La Comedie Tragique

So I have worked a couple of more shifts in the E.D. at WCHOB, and now I am on a string of swing shifts of a sort. My sleep schedule is a bit off, so I don't know whether to stay awake or sleep in. I've been doing a little bit of both.

Anyway, there was a fair bit of drama going on during my last shift. Some of it funny. Some of it sad. Hence, the title of my blog entry today. I'll share just a few of the scenes from today's episode of "Drama: Life in the E.D."

4 year old girl. Chief complaint: bloody stools. Seems this girl was sent from her pediatrician's office with several days' history of diarrhea. Over the last two, mom had noticed bright red blood in the stools. She took her to her pediatrician who immediately sent her to the E.D. I did a thorough exam as I ran through all the possible causes in my head. When I did the rectal exam, I thought, "Now this is strange."

Now, I've done lots of rectals (not something I admit readily in public). I've seen blood in its many forms before. This wasn't blood. I didn't want to say anything until I did a hemocult card. We put a small sample on the card, and then add developer. If there's blood, it turns a dark blue color. This didn't. I still didn't say anything. The parents were looking at me expectantly. I just said, "I don't think this is blood." There were two sighs of relief. I told them to hang on a second.

I grabbed another hemocult card and brought it back into the room. Mom had collected several samples. It looked red all right, just not blood red. I put some on the other card. Again, negative. I went out to tell my attending. We looked at the sample. We looked at the card. Dad wasn't convinced so I did it again with another sample. Still negative. "Do you believe 2 out of 3?" I asked him. He smiled and said, "Yes."

Now, onto the mystery of the red poops. I asked about foods. I asked about drinks. I asked about new pills or the antibiotics the patient was taking for a recent ear infection. Anything that could have a red color dye. The mom kept answering, "No, no, no..." Then her face changed, and she smiled. Vitamins. They had just changed vitamins a few days before, about the same time the patient had started having diarrhea. All the patient liked to take were the red ones. Mystery solved. Discharged to home.

9 month old patient. Chief complaint: ? seizure. Seems the little girl had been sick over the course of the day. She felt flushed and warm to the grandmother that was taking care of her. Because it was so cold, they had wrapped the child in heavy blankets. At some point she became stiff/limp, and the grandmother got scared. They ran the child to the bath and splashed cold water all over her. She recovered, and they brought her into the E.D.

I worked her up for a febrile seizure and felt that it was from an upper respiratory infection she had been developing during the day. I was talking to the Mom and Grandmom, and they started to tell me how the reason she'd been bundled so warmly had been because the landlord was not responding to calls to fix the heater. They had been using space heaters and turning on the oven to keep the apartment warm.

I found out that we can admit children to the hospital for social or welfare reasons. We were concerned about sending a baby back out into an apartment with no heat on a night when temperatures were going to reach the single digits. However, the family told me that they had somehow managed to get the heater working again in the time they were in the E.D. (about 5 hours or so), and the Grandmom told me that she would have taken the baby home with her if that hadn't been the case. We called their pediatrician and arranged for follow-up. Discharged to home.

10 year old. Chief complaint: rash ? chicken pox. Nowadays, with the chicken pox vaccination, we're seeing less of chicken pox. I had asked if all the immunizations were up to date, which the mother assured me they were. I asked about sick contacts. I asked about other kids at school being sick. No, no. I looked at the "rash." I asked if anyone else had it.

The mother turned to an older daughter, and she showed me her lesions. I asked about family pets. A rabbit. I asked about other people's pets. Some new puppies at a friend's house. The family looked at me as if I was strange. How can a pet give you chicken pox? I said I would be right back.

I went out of the room. My attending asked me, "So, is it chicken pox?" I said, "No, bed bugs." I described the characteristic "triple bite" pattern. He went to go look while I typed up the discharge information, and a sheet about treating insect bites. At least they don't have to get rid of their rabbit. Discharge to home.

The final case: I came on shift, and one of the pediatric residents came up to me and asked me how I would proceed on a case she had. It was a 13 year old girl with abdominal pain. The pregnancy test had come back positive, and the girl had vehemently denied being sexually active. I asked if she had talked about other possible circumstances which would allow the meeting of sperm and egg, and the resident said, no she hadn't asked.

I asked if she had done an ultrasound. She asked, "We can do that?" I told her that as E.D. residents we always put an ultrasound on anything we want a quick and easy answer for. I offered to do it for her. She said, "Yes." So I went into the room and introduced myself. I told them I was just looking to see if there were any obvious abnormalities.

The mother kept joking, albeit with more worry than laughter in her voice, about finding babies and how there had better not be any. The daughter kept saying, "No way" and then asking me if I was seeing anything abnormal. I told her that I didn't see anything abnormal, and that her resident still might want to do a more formal ultrasound. We got back the blood pregnancy test that confirmed there was a pregnancy. The number of the count was low, so too small for me to even see the beginnings of what is known as a gestational sac.

As the shift progressed, I asked the peds resident what had happened. Before sending the girl to ultrasound for a formal scan, she had told the girl that she was pregnant. The girl started crying and then admitted that she had a 16 year old boyfriend, and that they'd been having sex for 2 years. Something about the thought of an 11 year old girl having sex left me unsettled for some reason. I tried to think back to when I was 11; boys were still icky annoyances.

There was no badness on ultrasound (meaning no ectopic), and after OB-Gyn came down for a consult (pelvic and mom finding out the diagnosis) the patient was discharged to follow-up with her pediatrician and to get a prescription for chemical pregnancy termination. I won't discuss my thoughts on that issue, but suffice it to say that given what I see from day to day, I think it's the right decision for all involved. Sigh.

Time to get ready for another shift. Seriously, I am hoping to see something more interesting than colds and diarrhea. When is the RSV season over...?