S is for So Many Patients to See

When I left the ED at 5 a.m. this morning (an hour late), there were still about 5 patients waiting to be seen.... and a full board. This was the result of the backlog that occurred from earlier in the day. And, the fact we went from 2 attendings down to 1. And, the fact we had numerous ortho injuries requiring procedural sedation, which I will explain later.

At start of shift at 6 p.m. yesterday, I had two patients which my colleague signed out to me as he finished his shift. As I picked up new patients, I felt like I was wallowing my way through a pool of mud and having a hard time reaching the other side. Just when I thought I was finally getting caught up, something else would come up to stop the process.

Things should move faster... but I am going to save my rants on the other residents for a day when I don't have clinical duties and can editorialize more fully. As for now, into the melee:

Dx: Torn frenulum - 20 month old who came in with bleeding from the mouth. If you pull up your top lip, there's a small piece of tissue that forms a connection from the back of the lip to the gumline. You might even be able to run your tongue right up the middle of your top teeth and over the gums and feel it. This is your frenulum, and I learned yesterday that it is common in children to sometimes pull or separate and then bleed. As soon as I opened this young one's mouth, I saw where the bleeding was coming from. And, yes Mom, these bleed a lot. Your head, not surprisingly has a lot of blood vessels, and they bleed a lot. Tx = treatment, place pressure until it stops bleeding.

Dx: Dehydration - 9 year old who had his tonsils removed and became nauseated so he couldn't eat or drink anything then started vomiting. It becomes a viscious cycle: nausea then not drinking, vomiting, not drinking, more vomiting, then you find you can't or don't want to drink and you get dehydrated. Tx: IV fluids and admission to the hospital.

Dx: Ankle sprain - 10 year old who fell off of his skateboard and landed on his ankle the wrong way. Tx: wrap the ankle with ace wrap, crutches for a few days, and no gym.

Dx: Shortness of breath - 10 year old who suddenly "couldn't breath" while watching television with her family. These are difficult cases because "there has to be something wrong." You go into the room, the patient has no clinical signs of being ill, the vitals are all normal, and, as the child begins to describe what happened, you start thinking in your head "panic attack" or "attention seeking" you know you are setting yourself up for catastrophe if you don't start really focusing more on the story. Luckily, that's where the attendings jump in as you're telling them the history and say, "yeah, probably from hyperventilating during her panic attack." However, you get the chest x-ray or blood sample just to, honestly, appease the parents, and maybe assure yourself, that there really isn't anything wrong. Tx: none, come back if it happens again.

Dx: FB (foreign body) removal. Actually, I think this was my feel-good, pat my own back, moment of the evening. A 4 year old shoved tissue paper in both ears. When the mom found out, she took her to the Family Medicine doctor who was unable to extract the tissue. They prescribed some ear drops for pain and gave them a referral to the ENT specialist. They came into the ED last night because the pain was becoming unbearable. One piece was very deep, and I was able to extract it. The second was easier. They were my trophies. No one else appreciated it, but I did my own little victory dance and praised my steady hands. Woohoo to me. I know you may think this wasn't much, but seriously, I needed a little fun in the sea of pediatric misery that was last night. Tx: counsel patient to not put anything bigger than their elbow into their ear.

Dx: Salter II, distal radius fracture. 10 year old out rollerskating at a friend's party who fell and broke his forearm at the wrist. He needed procedural sedation (used to be called conscious sedation - basically giving medications to place a patient in a "twilight" state so that they can have painful procedures performed with minimal discomfort. One of the drugs given actually has an amnesiac property, so the procedure part is usually never remembered) which my attending supervised. He got his cast and will be followed in the ortho clinic.

Dx: Pityriasis rosea - 18 year old with a "rash for a month." Her friendtold her it was scabies, which is a parasitic, highly-contagious disease, but I assured her it was a self-limiting rash that would get better on its own. Tx: Benadryl for the itching.

Dx: LWOBS - left without being seen. Some people just can't wait any longer... they'll be back I am sure.

Dx: Newly diagnosed diabetes mellitus - this was probably one of the more interesting cases last night. An 8 year old who suddenly started drinking large amount of water and was urinating "more than was possible for a little boy his size." He'd been doing so for about a week, but yesterday had suddenly become more tired and shaky. Given the story, we immediately suspected diabetes. A fingerstick glucose was >500, which is the meter's highest setting. The lab recorded his glucose level at 743. Given the top normal for a non-diabetic is about 120 for a fasting level, this was just a little high. Yeah. He was immediately (even before we got any labs or levels) started on the diabetic ketoacidosis protocol and given fluids. He was admitted to the endocrinology service who will get his blood sugars under control, give the family a lot of teaching and education, and start to learn how to live with the disease.

Dx: minor head injury. 10 month old who flipped himself out of his playpen and onto his head. No injury, just a little bump on the forehead. Tx: monitor for signs of further injury.

Dx: dehydration - 17 month old with vomiting and diarrhea for a week, and not able to eat or drink. Now, I have to editorialize just a little on this one. His parents both looked like they were in their very early 20's. Not together since this was "dad's week" with the young one. When I asked why they had waited so long to get medical care since this had been going on, and the baby hadn't been keeping anything down at all, the mother looked at the baby's father and said, "Because he just told me about this." They weren't able to tell me how many diapers the baby had wet, did he have tears when he cried, and when I asked if they had given any sort of Pedialyte, the dad answered, "Well, I gave him some sips of ginger ale." The dad's only concern was, "Can you give him something for the cough that will knock him out?" House would say, "Um, no, I'm going to give him some IV fluids so that his kidneys keep working, his heart is under less strain, and so his eyes stop having this reddened sunken in look." I, of course, tried to politely explain that ginger ale is not a good idea and Pedialyte is a better choice. Tx: IV fluids and parent education.

Dx: chronic otitis media, I think - I actually had to sign this one out to the senior resident when I left this morning. A 4 year old with cerebral palsy, chronic seizures, who went to another hospital with a fever of 103 and was found to have "some kind of infectious process" due to a high white cell count, who subsequently got transferred to us because "we're the experts." This poor mother had been up since the day before and would soon have to drive back home with her daughter since, when I left, we weren't planning to admit her. I'll have to see what happened.

Whew. That was my 10, no 11 hour shift last night/this morning. What I want you to realize, and I know I've said this before, is that I don't see the patients one at a time. I see one, present it, start the workup, then go see patient two, present it, start the workup, check if labs/films are back on patient one, go see patient three, call a consult on patient two, check labs on one, start admitting two, see patient four, etc.

Given that we were so busy last night, the time between seeing and presenting a patient was sometimes as long as 45 minutes. Meanwhile, I am not allowed to see another patient until I have presented my most current. This explains some of the wait encountered. I could have probably seen 3 patients while I was waiting for my attending to come out of the procedural sedation room, but we're just not allowed at this point in our training, which, really isn't a bad thing. I know I still have a lot to learn.

Patients overheard but not treated by me:
- a patient with Henoch-Schönlein Purpura which is a trio of rash, kidney involvement and arthritis that is caused by an autoimmune response.
- as predicted 2 or 3 victims of the Hockey USA tournament being held in Buffalo this weekend. I saw the films on one of the boys with a broken leg... ouch!
- a girl who'd been bitten by a dog. Plastic surgery was consulted to help repair the damage
- a child who might need an amputation of one or more of their fingers, I never heard the story, but our 2nd year on the hand service came in to take the consult (that will be me a year from now when I do my ortho hand rotation).

That's it... off to enjoy two more hours' of freedom before my shift tonight. At least it's Sunday night... right?

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