#metabolics

Coming in, I ran into one of the fellows. I am now only locuming at the institution at which I completed my fellowship, so the fellows don't see me often and I don't know this cohort as well as the prior cohort, but I've worked with this particular fellow for multiple shifts since I've moved.

"What are you doing here?" I asked. "Your shift doesn't start for a few hours."

She laughed. "I know, there was an issue with another resident's schedule so I volunteered to cover a few hours of their shift since I saw you'll be the staff on. I was just excited to work with you."

I was very flattered but of course Imposter Syndrome will never let us have nice things so I am simultaneously flattered and stressed.

Shortly after we received our department handover, I got a call about one of our patients presenting with a complicated pneumonia with multisystem dysfunction due to significant diarrhea and subsequent dehydration leading to acute kidney injury. As expected, their labs are an absolute mess, but everything is holding steady and the patient's on all the treatments needed to correct their underlying pathophysiology.

One of my biggest pet peeves about my fellowship institution is that the emergency department is essentially viewed as "lesser" than, and often our subspecialists speak to us like we're idiots. Unfortunately, this attitude is quite pervasive into our trainees as well, and so despite the fact that I completed the same training (and then some) as the senior pediatric residents that accept/refuse our consults, they will often be fairly condescending toward our department. (I have many feelings about the fact that my institution lets trainees REFUSE consults as it is abysmal for patient safety, but that's besides the point...)

All this to say that I'm sort of steeling myself for this discussion.

"Hi, it's Sabrina in the emerg, how can I help you?"

"Hi, I'm the senior peds resident calling about that patient. We are still talking to the PICU about them because we were thinking they probably need a bicarb infusion since their bicarb is still low."

"Ah! Okay, I see where you're coming from, but at this time the PICU will really not have anything additional to offer for this patient and therefore they would not be the appropriate admitting service. I understand what you're thinking about the low bicarb, but we have to realize that this patient has a mixed primary metabolic acidosis from their GI bicarb losses, but also a primary respiratory alkalosis from their pneumonia."

"Okay..."

"Giving this patient a bicarb infusion would actually be really dangerous, because once you rapidly increase that pH, then you can knock out the kiddo's respiratory drive and then we run into issues with respiratory failure and possible arrest."

"...Okay, but what about the low potassium?"

"Ah, yes, with the AKI this child has I understand that the potassium is not increasing despite the fluid repletion with potassium-containing fluids, but in this case the potassium is not low enough to put them at risk for cardiac arrhythmias or the like and therefore it's unfortunately a waiting game while their kidneys recover so they can actually hang onto their potassium again. I totally understand how stressful it is for the pediatrics ward when you have these complex multisystem issues given your limited resources, but thanks to all the teams, the management to correct the underlying pathophysiology is in process and at this point, repeating labs is really to ensure there is no deterioration rather than to monitor for improvement. We will probably start to see improvement after the next 12 hours or so, but for now, the fact that things are holding steady is actually exactly what we're hoping for."

"Yeah, okay..."

"You are doing such a great job keeping a close eye on the labs and for sure, if things actually get worse rather than hold steady, then it'd be very reasonable to discuss again with the PICU team. Let us know if there's anything we can do to support you in the meantime!"

...Interestingly, the patient was admitted and transferred up to the pediatric ward within 20 minutes of hanging up the phone.

Sometimes you really do feel like you can doctor! (Also: generalists and fellow emerg docs, don't let anyone ever tell you that you're dumb--you know things! You are a specialist in your own right and that's extremely powerful.) When the Imposter Syndrome comes calling... sometimes you just answer the phone like a badass.

tl;dr:

Me explaining to peds intake why we shouldn't give a bicarb infusion to this kid with a mixed primary resp alkalosis + metabolic acidosis: 🤌🏻 you'll give her a problem with the respiratory drive... And she'll arrest and it'll be bad

Also me: