Stickers are like gold in the pediatric E.D. I don't remember ever being that excited about them when I was growing up. Around 5th or 6th grade, I got into the girly "Hello Kitty" thing with the cute pencils and erasers (mind you this was the first "Hello Kitty" era in the late 1970's.) But, I really don't remember having a thing for stickers. Kids today, though, love them and actively seek out their favorites.
Unfortunately, we can't heal everyone with stickers, but sometimes it's the best gesture you can make after what these kids go through.
#1 - Foreign body in nose: "I wanted an adventure." 4 year old that decided to stick a rock up his nose. A few problems with this:
a) he lost the rock in the nose and couldn't get it out
b) he didn't like the idea of my sticking a tube in his nose to get it out
c) the "rock" turned out to have been made by a rabbit
- Sponge Bob stickers for him and some antibiotic ointment for his nose
#2 - Hand injury: 13 year old that got beaten up in front of her house by the neighborhood female bully. Supposedly. she lives in a very bad neighborhood, and there's a family that moved in that has caused a lot of problems. This is just the latest. The police report showed that after the girls started fighting, a social worker tried to pull them apart and she was struck and injured, and then more family members jumped in and there was a bigger altercation. Not to mention the reason why there was a social worker at the house: the mother is, to quote one of the ED RNs "Dumb as dirt." There are 4 other children in the house, one of which has cancer, and the mother can't be counted on to assist in his treatment (ie: remember to give him his medications and get him to doctor's appointments for chemo.)
- Princess stickers will help this poor girl feel maybe a little like a kid; she's having to grow up very fast.
#3 - chest wall contusion: 16 year old playing basketball got hit with a knee in the chest as he was bending to pick up a basketball during a game. No stickers for him; he's a little too old for them, althoughI might have given him the Spiderman one just cause.
#4 - possible sexual abuse: this was the hardest case of my night. I had to talk to and exam a 2 year old whose family was suspecting sexual abuse. Seems the little girl spends 2 weeks at her father's and 2 weeks at her mother's. Her mother has a boyfriend, and the father's family was concerned that this was the person abusing her. I had to take statements, do an exam, and call in a report to Child Protective Services. I don't know if I can follow-up with a case worker or not, so I will just have to follow her medical records to see if she pops up again.
- No number of Princess or Dora stickers could make up for the fact that I had to do a vaginal exam on a child already suspicious of anyone trying to have anything to do with that area. I can only be comforted by the fact that she's safe... at least for 2 weeks while at her father's.
#5 - #10: The usual montage of diarrhea, constipation, vomiting and diarrhea, etc. I do have to make one comment: if you're going to tell me that your child hasn't been able to eat or drink anything for two day because they throw everything up, do not hand your child a soda bottle and allow them to drink half the contents in front of me while you are telling me this. I might not believe you. And, when I ask if the child seems to be doing better, don't tell me, "No, she spits up everything she drinks down, " while the child is happily swinging her legs in the chair, sucking down her bottle of pop, and play burping along with me. Seriously, I'll wonder why you came, and you'll be left wondering why I am not doing a million dollar work-up on your child.
This was our ED whiteboard at 2030: we didn't clear it until almost 2 in the morning - and this is with 20 rooms, 2 surgical rooms, a trauma room, and an ortho room - all full.
Ok. Enough of being a vampire. Tomorrow is Grand Rounds Wednesday, and I am presenting the chapter on Pediatric Cellulitis to my reading group, so I better go read it. Back to the E.D. fun on Thursday.
Save the Seals!:
I bought a bunch of these small notebooks when I started this residency. Actually, a total of 6, two in each color. This is the first one, and I have its mate sitting in my white coat out in the car. As a part of our residency program we have to do a "follow up" on a certain number of patients that we see in the emergency department. We want to see "how well we did" in managing their care.
So, I carry my notebook, and every patient I see goes into it. I log down what their presenting complaint was (why they came into the E.D.), what I did (labs, x-rays, etc.), and what their dispo was (dispo = disposition: admitted or discharged.) It's also where I keep track of any procedures I performed: suturing, chest tubes, central lines, intubations, all of my 16 deliveries, etc. We have to have a certain number of procedures to be deemed "certified" and able to perform on our own without supervision.
Usually, I have my little book next to me when I am blogging the past shift's events, but... I left it out in the car, in my white coat, and I am feeling very lazy. So, I thought I would give some general comments about my shift last night:
- again, we were very busy. I think around 3 in the morning, we finally had no patients waiting in triage. Then around 0305 the next patient arrived.
- I am starting to feel like all pediatric thermometers are set at 103.something. I had 2 patients yesterday, and have seen several others, who all had home reported temps > 103 and who had temps of 99, 100, 101 by the time they arrived in triage. Ok, so maybe the Tylenol or Motrin finally kicked in, maybe the fever was at its peak and broke, maybe the trip to the ED in the crisp cool Buffalo air brought the fever down, but still. The kids shouldn't be nice and dry, playful and alert, etc. if they've had that high a fever. Of these two patients, one ended up with a respiratory viral syndrome, and the other I will have to find out about today as I had to sign them out when I left last night.
- I have come to realize that I am no good at math. Everything in pediatrics is mg/kg or ml/kg. Aside fromthe fact we're working in the metric system, and I have to consciously convert Centigrade to Fahrenheit, I just seem to have a mental block when it comes to simple multiplication. Not to mention that I also don't know, off the top of my head, the maximum doses of all of the medications we give (luckily I have my attending and a slew of nurses to remind me). So, it's been quite the challenge when I am called to give a medication order. Which I do, obviously, quite often. Sigh...
- If you're jumped while leaving a bar at 3 in the morning and knocked unconscious, you probably should come into the ED. When your face swells up and looks like Quasimodo's, probably a good time to get that checked out. You shouldn't pop a couple of your buddy's 'pain pills" and then go out to a BBQ with your blurry vision and massive headache. Just not a good idea. Luckily, when his parents finally found out, via an uncle who went to the same BBQ, they made their son come in to be evaluated. Luckily, the CT scan only showed a small fracture in one of the nasal bones, but things could have been much worse. My excitement, of course, was in dealing with something other than vomiting, fever, diarrhea, and, "oh, what's this rash?"
- when you come to the E.D., it is not necessary to bring your "posse" or "entourage" with you. The rooms are small, I am trying to get information, and I don't really need a running commentary or additional information from your supporting cast. There's a rule that only 2 people should accompany any one patient, but somehow others always seem to slip past the front desk, and usually our staff is too busy to notice the comings and goings and exchanges. I don't mind playing to an audience, just not while I am trying to take a history.
- little boys seem to get constipated an awful lot more than girls
- and, finally, there's something about sitting back during those brief moments of "down time" and listening to the "war stories" the nurses exchange with each other. Last night, the comments focused on pregnancy and all of the events that had been witnessed: some funny, some sad, some a testament to my sometimes thoughts that we should adopt a national "contraceptive" vaccine that doesn't allow you to procreate until you've reached a certain age, achieved a passing score on the "baby test" (kinda like your driver'stest, but you're only allowed to fail it once), and passed several rigorous written exams; after which you present with a folder of references and recommendations by others who are nationally certified to procreate. If only...
Ok, off to my last night of being a vampire for a while. We'll see what the evening brings...
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?
Ok, so let's jump right into this:
The E.D. was busy and "standing room only" when I got there. We had so many providers (attendings, residents, and PA's) that I actually didn't pick up a chart for 1/2 hour. I got my bag settled under the counter (we don't get lockers, so it's first come, first served space), filled my lab coat pockets (scripts, pens, penlight, stethoscope, pregnancy wheel, etc), and pulled out the newest EM journal I brought to read "in case things were, hmm, not the S word or the Q word, umm.. "calmer" later in the evening.
Finally, I picked up my first chart: "toothache." Great. I looked at the clock. Six thirty p.m. on a Friday night is not a good time to be coming into the ED for a tooth complaint. I went off to see the extent of the damage and wondered what I might be able to offer.
It was a 7 year old who's mom had tried to get her into a dentist's office, but wouldn't be able to for another couple of weeks. She a had a cavity in one of her back molars that went all the way into the pulp of the tooth. Very painful. I went off to find my attending and to see what was able to be offered. Luckily, WCHOB has a dental service, and so I was able to consult the dental resident who came down and prescribed antibiotics, pain relief, and got her an earlier appointment. One down, nine more hours to go.
Since I am running late, I will briefly highlight what I saw last night:
13 month old who fell and bumped his head. Dad works in the neuroradiology department and sees what can happen with even minor head trauma. I examined the child, gave the parents assurances, and sent them on their way - Dx (means diagnosis) = minor head injury.
10 year old with left arm pain after falling while playing soccer. Dx = left distal radial buckle fracture. She broke her forearm bone close to the wrist. Splint for her, and she will follow up with ortho for a cast. No gym for 10 weeks.
13 year old with "nipple swelling" and left arm pain after getting into a fight at school. The nipple swelling was normal due to hormones. Dx = gynecomastia. The x-rays didn't show a fracture. Dx = left wristsprain. Ace wrap and ibuprofen.
18 month old with "nipple swelling." Actually, this little one did have an abnormal breast mass. By this time, it was almost 10 p.m. We didn't have an ultrasound tech in-house, and this wasn't an emergency. She will definitely need to have follow-up and probably a biopsy of the mass. We sent her out with instructions for follow-up with her pediatrician. If I get any follow-up I will let you know. Dx = breast mass.
3 year old with a severe asthma attack. This was my longest patient in the E.D. in terms of disposition. He ended up receiving 3 rounds of nebulizer treatments and his oxygen saturations never got any better than the low 90's. He ended up having to be admitted. Dx: hypoxia, asthma exacerbation.
2 year old who mother reports wasn't "drinking enough." We gave him some pain control since he'd recently had a tooth pulled, and then gave him something to drink, he did, so he went home. I honestly don't know the diagnosis since my attending was "cleaning house" when he came on shift and discharged the patient on his own.
18 year old with cramping and vaginal bleeding. She was just about 7 weeks pregnant. After no seeing anything on the ultrasounds and finding a lot of clots on my vaginal exam, we drew some blood levels and sent her home with instructions to return on Monday for a second set of lab draws. If the numbers go up, the pregnancy is still viable, if they go down, she most likely miscarried. Dx: threatened miscarriage.
And, finally, 20 year old with concern about STD exposure. Sex with Boy A who had a history of an STD. Then sex with Boy B about a month later. A couple of days ago Boy B said she'd given him an STD. I took cultures and treated her for STD's. I also advised her on the importance of wearing condoms and birth control.
And, that was it for patients. I am running off for another night of fun with the chillin's. Also, Hockey USA is in town for several tournaments. I wonder how much ortho trauma we might be seeing tonight...
**on a side note: I want to thank "D" (Donna) for including my blog while doing a stint as Guest Editor on the Magic Smoke blogsite.
Thank you, D!
As stated previously, this is my "turn-around" day where I try to reset my clock to vampire mode for an upcoming 4 nights of shifts long weekend. I took a long nap this afternoon, flanked by cats, and am now trying to keep myself awake by doing odd and end things in my office.
Nothing much else, so I won't bore you with any further musings today...
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In case you have been following the seal counts, I was wondering what had happened to the HSUS.org website since they hadn't done any updates, and I found out today that the seal hunt is being suspended for 7 days while memorials are held for drowned crew members of an overturned boat.
The larger hunt is looming just over the horizon, and I know the totals will start sky-rocketing then. Again, "Don't Buy While Seals Die." There's a nice letter to give to your grocery store manager if their store is still on the list buying Canadian Seafood on the HSUS website.
So, officially March 30th is Doctor's Day. This morning, BGH celebrated Doctor's Day with a breakfast. Since residents normally start the day with stale bagels, cold coffee or lukewarm soda, the thought of a nice freshly made omelet or Belgian waffle with fresh fruit topping appealed to all of us. So, before our morning reading group, we ran to the cafeteria to grab something hot. Along with breakfast, the hospital higher-ups gave us a gift of a small coffee thermos with the hospital logo engraved on it. I like it.
And, essentially, that was the major event of the day. We had our normal Grand Rounds Wednesday with the addition of Journal Club. Once a month, a topic is chosen along with a series of journal articles, and we read then discuss the relevant issues. Normally, we focus on current medical studies related to Emergency Medicine. Today's focus was on domestic violence and how we, incorporating the local EMS system, can more effectively screen patients. We talked about the pros, cons, logistics, and pondered the potentials for the future.
Yes, very heady stuff for a Wednesday morning. I had no clinical duties today, and actually have tomorrow off. I work a 4 day weekend (Friday - Monday) on the night shift, so I probably will drop a quick note the next 2 days along with the de rigueur Seal Photo of the day to keep reminding you that the hunt continues. I will post the events of my next shift on Saturday morning after I get home, and before I fall asleep for the day as I switch to vampire mode, yet again.
Till then....
Ok, so I don't know a lot about pediatrics. I get that now. All of my attendings are right - they are not just "little adults."
So I had my first shift in the pediatric ED at WCHOB (Women & Children's Hospital of Buffalo.) It didn't start off well given that I was 20 minutes late due to a car accident on the highway, and somewhat poor planning on my part. There's a big difference between 5:30 in the morning traffic and 07:30 in the morning traffic headed downtown. Not a good first impression.
Given that the system in terms of signing up for patients is similar to that at the other hospitals, I jumped right in. I signed up for my first patient, "mouth sores." I thought, no problem. Probably something very benign. Of course, as soon as I started getting the history (patient had ITP and they weren't mouth sore but actually petechiae), I realized it wasn't just a simple case. However, I casually asked the parent when their last visit had been and what had been done, and I developed my plan from there: get a CBC (complete blood count) and see what the platelets are doing. I presented this to my attending, who agreed with the plan. Whew... after putting in the order I had a few minutes to sit and read about ITP and see what my treatment options would be when the results came back. I also was able to research the patient a little more and read about prior admissions and treatments. First one down.
My next patient was a little girl who'd had a febrile seizure. Somewhat common and you don't really do much except find the source of the fever. Of course, I wasn't sure what to do, and stumbled a bit during my presentation. My attending redirected me, and I sat and read about febrile seizures while I waited for lab results. She eventually got sent home with the diagnosis of bronchiolitis.
Next came a teeny 2 month old who wasn't breathing well. We gave him a breathing treatment which really didn't improve matters. We tested him for the common viral infections, which came back negative. We made sure he could eat and drink ok, and had actually thought to send him home, but he could not keep up his oxygenation saturations (O2 sats) and needed to be admitted. I will be following up on him.
My next patient had a rash. Great big wheals all over her body with no idea what had caused them. We went through all of the possible foods she'd had since the night before. We went through the list of laundry detergents, soaps, perfumes, new clothing, old clothing, possible chemicals she might have been exposed to, even possible pets. Nothing. She gets benadryl and was advised to keep an eye out for possible inciting causes. Will follow-up at some point and see if anything pops up.
The six-month-old I saw with "wheezing" was not wheezing by the time I saw her in the room. She smiled broadly at me with great big cheeks and let me examine her with no problem. I could smell the cigarette smoke on her parents' clothing as soon as I walked in the room. Of course, they "never smoke in the house." She was sent home with an inhaler and instructions on how to use it.
My last patient was a 16 year old with knee pain. I put his knee through all of its paces and could find nothing wrong on my exam. We did x-rays and found nothing obviously wrong. I sent him home with ibuprofen and recommendations for rest and ice packs. Sometimes you're just at a loss.
And, that's it for my first day. We actually had a lull of about an hour and a half with no new patients coming in, and we had plenty of providers with a senior ED resident, a Med-peds resident, myself, a peds resident, a family practice resident and two physician's assistants.
The only other thing of note is that one of my new duties is taking "Expect Notes." These are calls from doctor's offices or clinics when they are sending patients to the Emergency Department for further evaluation. Some of the patients from the calls that I took but did not see:
2 year old that got into his parent's medications - charcoal lavage and observation
2 month old that "fell off the bed" - came in with a skull fracture and a subdural hematoma. being admitted and Child Protective Services was contacted. One, 2 month olds don't roll, and they don't get subdural hematomas. Something is just a little hinky there.
16 year old whose robe caught on fire from a space heater and who was coming in with 2nd degree burns on their hands - he had just gotten there when I was leaving.
Several abdominal pains and upper respiratory infection patients as well.
The one interesting event was the invasion of the E.D. by a woman who was convinced that her 5 year old daughter had been brought into the E.D., and that we were hiding her there. She was ok initially, but then started trying to go from room to room opening doors and needed to be led away by security. One of the RN's recognized her as the mother of 2 children that had been sexually abused by their father. They commented on some possible psych issues regarding the mother. My understanding is that she was taken out of the hospital with a warning to not return.
Well, that's it for the first shift. Tomorrow is Grand Rounds Wednesday, so meetings all morning. Until then!
