Dr. Richards, the "little sister"

Most days at the hospital I feel like everyone's "little sister". There are a lot of very specialized doctors here, and most of the doctors are much older because they underwent more years of training than I did. For example, the pediatric neurosurgeon was in residency and fellowship for ~10 years, and the adult cardiologist was in residency and fellowship for 6 years; my 3 years of residency pale in comparison. While many of my counterparts are recently graduated from fellowship, most have more experience than I do, both in medicine and in wartime medicine. There are only three other docs at my level of experience (two internal medicine and one family physician), and of course they are all assigned to the hospital in the capacity for which they trained. I, on the other hand, am assigned as a general medical officer, a term for a doc of any training who is placed in a position to take care of soldiers. (GMOs do not exist in the Air Force - all USAF docs are assigned to a position in their specialty, whereas even the most specialized Army docs may be assigned as GMOs.) So not only am I less trained than many of my counterparts, but I also am tenuously assigned to the hospital in a catch-all slot - a slot which may be moved at any time to another facility likely to be far less comfortable and far less safe.

All of this contributes to something of an inferiority complex. Everyone else seems to be an expert in their field, while I am a relatively new pediatrician who has primarily been taking care of adults while at Bagram. It is constantly uncomfortable as I struggle to gain the knowledge that the adult docs have spent years upon years learning. Caring for pediatric patients is somewhat different in that I am more capable than the adult docs, but I still rank a distant 4th out of the 4 pediatrics-specialized docs (there is a peds neurosurgeon, a peds surgeon, and a peds ID doc here with me). All in all, there is very little here in which I might be considered an "expert", and I feel that I must always prove my worth in order to be "allowed" to stay at Bagram.

The one (and probably only) thing that I know more about than any of the other docs is newborn medicine. Of course, the other peds docs have done some newborn/neonatal care, but none have cared for new babies as much I have in the past year. (In fact, all I have done since graduation from residency last July is staff the newborn nursery!) Of course, we don't see many newborns in our hospital, so the fact that I can competently care for them is somewhat moot.

Or at least it was moot, until the newborn with the omphalocele was admitted a few days ago. (Read about the circumstances of the admission and his first days in our facility here.)

The pediatric surgeon has been running the show as far as surgical care is concerned, like when to decompress the belly and when to allow the baby to feed. (I completely defer to her for these types of issues, for she has far more experience with babies that have abdominal wounds.) Where I have been able to contribute most is in the area of nutrition for this small baby. We all knew that we would be unable to feed the baby formula or milk for a while after his surgery, and had discussed during his admission the probability of needing IV nutrition (also called TPN, or total parenteral nutrition). Unlike adults and older kids, small babies shouldn't go for days without some sort of nutrition, so when I heard this kid was coming to us, I immediately got to work on a TPN plan.

TPN hasn't been run in this facility for months and months; in fact, no one can even remember the last time a patient received TPN in our hospital. Understandably, there was a fair amount riding on the results of this "TPN trial", and I knew it wouldn't be easy given the lack of pediatric/neonatal resources in the hospital. All we have on the shelf is adult pre-mixed TPN, which has inappropriate amounts of nutrients for neonates. I gathered all of the information from the pharmacy about the pre-mixed TPN and vitamin/mineral solutions and set to work developing a plan. I estimate that it took 30-40 hours to investigate all of the neonatal nutritional requirements and determine if the TPN would even be safe, and an additional few hours to make the TPN the most nutritious possible given the child's clinical condition. Once I had a plan, I discussed it with a neonatal fellow at Bethesda Naval Hospital, who in turn passed it along to their pediatric pharmacist for review. We started the TPN yesterday through an IV running into the jugular vein.

Because of this child's blood sugar requirements, we actually have four solutions running into the vein: the TPN (which is 10% dextrose), some additional sugar water (25% dextrose), some additional sterile water without dextrose, and the fat concoction. It's a very complicated setup which requires vigilence on the parts of the doctors, the nurses, and the pharmacists simultaneously in order to NOT kill the patient.

The first test was the blood sugar: would the four solutions be able to keep a steady blood sugar in the baby? After the TPN started, we checked blood sugars every hour or two, and they remained quite stable. (Today I had to switch around the rates of the sugar-containing solutions a bit, but really it was a small bump in the road and has corrected easily.) This morning was the bigger and more important test: would the solutions provide the appropriate electrolytes for the baby? I nearly let out a scream of joy when I saw that the baby's blood labs this morning were completely normal! The TPN had worked!

This is the first time I have actually felt competent in something since I arrived in Afghanistan. I don't think any of my colleagues know exactly how much work went into developing TPN for this little one, nor just how complicated the plan is (I had to explain to the DCCS - a full-bird colonel and my ultimate boss - why the kid couldn't be transferred to the step-down unit today, and it was a mouthful). Nobody has been patting me on the back; I assure you that I will get no accolades for this achievement. But that's OK with me. It's enough just to see the baby thriving, breathing on his own, and taking a little bit of formula by mouth. :-)