Friday, April 11, 2008
Some Really Sick Kids...
So, my shifts are 10 hours' long. Usually I come in at the beginning of the shift and pick up a chart and get to work. Within the first hour I have 3 or 4 patients I am working on, and over the next several hours, I discharge one, admit one, pick up another one, etc. I had 3 patients that I picked up within that first hour that I worked on over the next 5 hours.
The first was a little seven month old that needed to be evaluated for seizures. He had been having tremors or shaking spells for his entire life. He was born a few days late. His mother "failed to progress" after being induced and had to go for a C-section. When they finally performed the C-section, it was noted that there was a knot in his cord. How long the not had been there is not known, but there was some underlying concern for poor oxygenation during the end of the pregnancy.
His orders: CT scan of the head, basic labs, neurology consult. Seven hours later, I discharged him home with a normal CT scan, normal labs, and he will follow-up with neurology in the morning after he gets the results of an EEG (brain wave analysis) which was performed prior to his being discharged from the ED. Dx: seizures. Even though it's not official, we still have to call them that based on the description.
My next little 4 year old was having problems breathing. I got labs, put him on oxygen and we got a chest x-ray. His chest x-ray showed that his lungs were hyper-inflated (over-inflated) meaning that his airways weren't open enough to allow air out. He got a breathing treatment, but he still could not maintain an oxygen saturation above 92%. You need a 95 or 96% to be allowed to go home. And, he just looked sick. He got admitted.
Next came the 5 year old, also with low oxygen saturations. She had just not been feeling well for 3 - 4 days and went to see her doctor on Thursday after having a fever of 103 on Wednesday night. She had an oxygen saturation of 95%, and a chest x-ray was obtained. It showed a right middle lobe pneumonia. She was given antibiotics and sent home. As soon as she took the first antibiotic, she started throwing up and continued to do so all night and into this morning. They called their pediatrician who said to go to the E.D.
My expectation, and my attendings, was to get a repeat chest x-ray, give her some fluids and a dose of antibiotics. As soon as we saw the chest x-ray, we knew things were much worse. She had a fulminant pneumonia which covered about 2/3 of her lung, but worse, she had an effusion (fluid collection) as well. So, she was pretty much functioning on only 1 lung. We then had to go back and draw labs, blood cultures, and I got her admitted. We ended up doing a CT scan which showed a LOT of fluid around her lungs; so much that part of the lung was being compressed and damaged. I consulted the surgery service, and they will most likely need to go in and drain an empyema (infected fluid collection around the lung.) Very cool to do, but will not be much fun for this little one.
I also saw:
*wrist and elbow fracture - splinted and sent home
*sickle cell patient with pain in a shoulder after an immunization - antibiotics for possible infection, pain meds and sent home
*teen with abdominal pain that had been going on for 6 weeks and had undergone multiple CT scan, ultrasounds, and even exploratory laparoscopy with no diagnosis. When I left they were considering appendicitis, and she was going to be admitted after she underwent ANOTHER CT scan.
And, I think that's about it. Not a lot of patients by any means, but sometimes it's the quality and not the quantity that makes for good learning experiences. And, I have to admit, I am learning A LOT on this rotation. Off to sleep and back again tomorrow. We'll see what a rainy Saturday afternoon has in store.