Saturday, May 30, 2009

Foreign body (in more ways than one)

This is a story from a little while back. We admitted a 17 year old female with abdominal pain. As part of the admission tests, we got an abdominal x-ray (a KUB). This is what it looked like:

When we saw the x-ray, we all wondered what those radio-opaque circular objects were. During morning rounds, we stood around the computer screen wondering if she might have inadvertently (or purposely) swallowed something, or were they foreign bodies or calcium crystals or pigments from a tatoo. Finally, since this was a patient I had admitted, I was elected to go into the room and ask her. As diplomatically as I could, I asked our little miss if there was something she might want to tell us. I told her I needed to examine her lower back. She dutifully turned onto her stomach and let me pull me the sheets down. I was all prepared to find a tatoo of some sort on her lower back skin but what I saw stopped me in my tracks and instantly provided the answer to our radiologic dilemma. I turned beet red as I saw a pretty pink thong with artificial gems studded in the pattern of a butterfuly on the triangular piece of thong. My colleagues all had a good laugh at me because I was obviously embarrassed by my finding. We all had an even bigger laugh when the radiologist's official read of the x-ray came back as:
"there are multiple radiopaque densities projected in the central aspect of the lower pelvis, probably at the rectosigmoid junction. I presume that this represents residua from suppository or previously-injected material."
Should we tell him?

Thursday, May 21, 2009

Tortured thoughts....

Perhaps my turn of thoughts is because I am still recovering in some form from a recent illness.


Last night, I sat at the nurses station on Peds trying to finish some paperwork. From down the hall, I heard the sound of a child wailing and crying. I could not bear it. I asked who this was and was told that this neurodevelopmentally delayed 11 year old cries unconsoleable like this every night. Incredulous, I walked determined down the corridor to see who this patient was and why she cried like this.

LW is 11 years old. She was born to a mother who drank during her pregnancy. After a period of failing to meet developmental milestones and some physical and mental signs of cerebral palsy, she was diagnosed as having a 'chromosome 8 inversion' abnormality and consequent severe cognitive impairment. In my years as a scientist, cheering excitedly and participating in the revolutionary sequencing of DNA and the human genome, I had never envisioned the face I saw last night. There is no way to fix a 'chromosome 8 inversion'. It occurs in every one of the billions of cell in this little girl's body. It is a life sentence. The ramifications and effects are not completely known. Few people have this.

Needless to say, LW is in a foster home. Not many individuals have the emotional and physical resources to care for such children. They are high risk for abuse and neglect. Sitting in her room, watching her wail and cry, frustration and anger burned within me. Why was she crying? How could I stop it? What was I missing?

Her nurse and me checked her daiper, repositioned her, tried to soothe her, turned the tv on and then off, turned the lights on then off, tried everything we could think of. No effect. I tried a mild sedative, then another -- no effect. The crying continued. I sat at her bedside, making eye contact, trying to look into the window of her soul, praying for insight, a connection, a solution. I can only imagine what parents and caregivers must go through, year after year, night after night. I searched the literature on sleep and behavior disorders among those with cerebral palsy and neurodegenerative disorders. I found lots of articles that talk about the toll it takes on caregivers, things tried and failed. I read her medical records and found that this problem had been going on for a while and several solutions were tried unsuccessfully.

This patient came to us with a horrible wound at the back of her head and neck. We are unsure what it is, how it got there and exactly how to make it better. At about 4 am in the morning, I thought I would try giving her something for pain. A little bit of morphine put her into much needed sleep! There was no aha moment. Maybe this was pain. Maybe she was exhausted. Maybe she was just done for the night. Who knows? But she slept.

What does the wailing and crying of someone with 'severe cognitive impairment' mean? Is it pain? Is it just the behavior of a disorganized and disregulated brain that cannot calm itself? The patient cannot communicate verbally and does not appear to follow verbal commands, so who knows? As I sat beside her trying to calm her and soothe her, I felt like I was listening to a scrambled brain cry out. In a dark moment of frustration and despair, I found myself thinking, " why do we prolong such a life? Are we really making any difference with what we do?" Dark, scary thoughts that come not from impatience with the patient, but from a mourning heart and mind that cannot think of an answer to make the suffering better.

We live to fight another day. It is morning again. I hear that she slept for a couple of hours and is up and quieted down... for now. My heart is still in knots. I hear the sound of a scrambled brain in a spastic body crying and I don't know what to do. I am driven to find answers. I love what I do. I am haunted by what I do. I want to be better, smarter, wiser.


It was Monday, the first day of the work week. I had feeling unwell all weekend and dragged myself into work Monday. After a busy clinic, I was feeling really run down. My nose dripped, my eyes were red and itchy and my body ached. As the night wore on, I found myself getting sicker. Fortunately, it is near the end of the academic year and the intern I was on call with was more than willing, and able to step up to the plate and field most of the calls. Still, as I lay on the couch in the residents' room feeling miserable and useless, I was overcome by guilt at leaving him alone to 'do it all'. I was afraid to go into the Pediatric ICU or the Oncology sections where our sickest patients with the most compromised immune systems lay, lest I infect them with whatever I had.

The next afternoon, after returning home, I felt I was getting worse. I agonized over the decision: should I go in to work or beg off sick. Healthcare workers are a strange breed. When we are sick, we feel guilt and dismay at not showing up for our patients and leaving our overworked and tired colleagues to take up the slack. And yet, who knows more the risks of exposing the sick to more sources of infection from the ones they come to for help and care?

I called in sick. I did present to the Urgent Care and was dutifully swabbed for swine flu, and the two common forms of seasonal flu. Fortunately, I was negative for all three. Fortified by this knowledge, I was able to return to work last night -- no runny nose, a minimum cough and a healing body. Perhaps one of the benefits of working with sickness is the constant exposure and 'education' our immune systems get, and the ability to consequently heal a little faster.

A colleague took my night of call. I shall have to 'pay her back' by taking her call in the future sometime. While I would not let such a good deed unnoticed or want her to gratuitously do my work, I do feel bad that our system does not allow for sickness. Maybe it does, but there is no equitable trade. I'm better and back on the other side of the sick bed, where I belong. By the way, those swabs hurt! OUCH! I guess I know how my patients feel when I order these tests...

Saturday, May 02, 2009

A strange night of call in Pediatrics - Part 2

We were only getting started.

We received a 6-month old little girl as a transfer from another hospital in a nearby town. While the story was not clear, apparently, her mother and 2 and 3 year old siblings were all dead of gunshots to the head. Her father sat dazed in their home, with the furnace running full and the vents shut off. There was a strong smell of gasoline and natural gas in the home as well as on the baby. Police rescued the little girl and seeing how she smelt of gas -- it came from her breath as well -- arranged for her transfer to us. The transferring physicians wanted her closer to access to a Pediatric ICU if she needed it. Ours is about 50 feet walking distance from our wards. A urine drug screen was positive for sedatives. The little girl was screaming, agitated and wouldn't take a bottle initially.

We activated the CAN (Child Abuse and Neglect) workup.

There was a lull from 1 am to 5 am (no admissions). At 5:45 am we received a little girl with a right eye swollen shut and some steristrips holding lacerated skin together at her right eyebrow. The family had had a picnic in the park the day before and encountered a dog without tags. He seemed friendly enough and came and sat under their picnic table. During the course of the picnic, the family made friends with the dog. Feeling sorry that no owner was in sight and no identifying tags were evident, they called the Humane Society to come and 'rescue' the homeless animal. A Society van was pulling up to the edge of the park. The little girl went to pet the dog goodbye and he bit her on the face, narrowly missing the eye but tearing open the skin of the eyebrow.

The rabies status of the dog is unknown. The girl became sick with a fever several hours later. A bite to the head from a dog of questionable rabies history, now showing signs of systemic illness, fever and increasing swelling and redness closing off the eye is cause for concern. I wrote admit orders and quickly examined the girl before rushing to make the 6:00 am signout to the incoming team.

What a night!

A strange night of call in Pediatrics - Part 1

I was Ward Chief in Pediatrics Wards last month. That meant that I did not have any night or weekends call (I know, great, isn't it?). My last day on service, I switched call with a colleague who desperately needed the time off. What a night it would prove to be...

1. We had a young teenager on the service that had transferred out of the Pediatric ICU just that morning. She had been admitted for a suicide attempt (not her first). She had ingested some sedatives and ADHD meds and we were monitoring her for side-effects, with the intention to transfer her to a mental health facility in the morning. She had been 'chaptered' -- meaning that a sheriff's department had activated Chapter 51 of Wisconsin state law: detention against one's will for declaring intent to harm oneself or another. Towards evening, she became irritable, wanting to do things she was not allowed to -- these restrictions being part of a suicide watch. The 'sitter' (person who sits in the room and watches the patient who is on suicide precautions) called for help. The patient had tried to wrap the curtain in the room around her neck and shouted "I want to die!". Nursing responded. Apparently, the patient had a history of explosive rage disorder -- something we were not familiar with. Unfortunately, we were about to find out. She 'lost it' and began screaming at the top of her lungs. She attempted to leave the room. Her nurse attempted to restrain her physically and was bitten, hit and kicked. There was pandemonium. I rushed in.

Okay, time-out.

Medically, here's the situation. She had ingested an amphetamine and a benzodiazapine (to those of you to whom this means anything). We were monitoring for side-effects of the ingestion -- heart arrythmias, respiratory distress, altered mental status. I had to make a decision: am I going to give Haldol (drug that could cause or summated with the previously ingested meds, precipitate a life-threatening cardiac arrythmia) or not?

Back to the scene.

I added my weight (literally) to the bodies trying to physically restrain this large teenage (who weighed more than some of the adults in the room). I made my decision: I called for Haldol and repeated the dose three times, including adding a sedative as well. Since the patient had chewed off her IV, all these meds were given intramuscularly. The needles did not add to the patient's state.

Within minutes, the patient was quietly asleep. No cardiac arrhythmias, no respiratory depression. Just calm. Our nurse was sent to the ER for antibiotics. We were all rattled.

Peds is usually a lovely place to be: there is a little Winnie the Pooh forest, and pictures of doggies, brightly colored beach balls, flowers and toys painted on the walls. Most of our patients are cute, cuddly and make you smile.

Fearful and tearful, mom stood behind the scenes. Grandma stood next to her with fire in her eyes. There would be long conversations with them afterward.