L'il D

L'il D is a 2 month old. For reasons unknown, his soul was born to pain. His parents' story is that they were having a party and had too much to drink. L'il D was left on an ottoman, fell, and somehow acquired massive subdurals of different ages.

The human brainstem takes care of life for months. Early eating, sucking, and regulation rely on so-called 'primitive' reflexes but it's probably more fair to think of an operating system out of the box that takes care of basic tasks. After 2 to 3 months, the cortex should take over.

For this guy, his cortex can't take over. It's gone. He's cortically blind and deaf. He probably will never eat correctly. He's sort of all done.

For both of my last call shifts I've had to deal with him spiking temps or heart rates or both, and fussing. Babies fuss, that's OK, but they don't normally spike to a BP that would be hypertensive for a fifty-year-old smoking vet. And they don't fuss like D.

Last night, I held him. Now I have three kids, so I have the part of my brain that knows how to hold babies and wants them to feel better. Because I held him, I think, I now cry more for L'il D than almost any of the other remarkable patients I've had. You should see him. His head is a bit lopsided from all the swelling. His pupils are too big and usually lazily unequal. He has a tiny little NG tube in one nostril. All of his limbs are stiff and tonic because they don't have a brain to guide them. Despite all of it, he is, somehow, consolable. He likes to be held. His rates go down. He fusses but not as hard. His cries are miniature convulsions, eyes closed, bundled.

I don't know what happened to him. It may be his parents got drunk and he was hurt by someone else, he fell somehow. It doesn't matter. There is no justice for him. He's already gone, and yet still so vulnerable for the tail of soul he left behind when he was devestated.

Here's to him, and to the foster parents taking care of him when he goes home. L'il D, we love you. I hope your soul is more at rest the next time around.

Photo Credit: Not L'il D, of course, due to HIPAA.

See Below

There's been a lag, see below for two or three new posts that have been percolating for a while.

FMOE: Cope's Appendicitis

Ah, the appy. Every second-year med student can diagnose the acute onset of periumbilical pain that then localizes to the right lower quadrant. My first appy was a teenage girl who presented with pain, loss of appetite, fever, and dysuria for about twelve hours. Exam showed right lower quadrant tenderness. Labs were negative except for sterile pyuria. Even an obvious case like this one, where I walked out of the room and felt pretty sure, had a wrinkle, but sterile pyuria is a known associate, perhaps because the appendix can irritate either the ureter or the bladder.

But it's not until I read Cope that I look back on the appendicitis I missed in every single abdominal pain patient I've ever seen. Cope, incedentally, is the surgical bible of the acute abdomen. My surgery attending told us all to sit down and read it in a night, an 'easy read'. Perhaps, but to really absorb it...it's the book that keeps on giving. The following are some pearls to flesh out what we were taught in medical school.

History.

The 'march' of symptoms should be carefully sought, and is as follows: pain, followed by anorexia, nausea, or vomiting, followed by tenderness that is localizable but could be, according to Cope--and I love this--'somewhere in the abdomen or pelvis', followed by fever, followed by leukocytosis.

Put that in the context of what we think of as appendicitis. RLQ abdominal pain with a white count and fever. But a white count is the last finding. This march should be acute. Diagnosis of appendicitis should happen within 24 to 48 hours of onset, to avoid perforation. Fever first, nausea before pain, fifteen years of abdominal pain--these can make appendicitis less likely. Also, sudden onset of severe localizable pain, especially if it occurs in a 65-year old hypotensive veteran...perhaps not an appy.

Physical Exam.

This is the part of the reading that terrified me. The appendix can go anywhere in the abdominal cavity. Sweet. Frickin' awesome. I love that kind of a problem. If any localizable tenderness is found in the setting of a history that shows the above march, appendicitis should be on the list.

Of course McBurney's point must be palpated, and is perhaps the earliest localizable site of tenderness. Cope mentions light percussion as a very sensitive sign of parietal peritoneal irritation, which is what causes the tenderness--the switch from pain carried by the visceral peritoneal nerves to that carried by the parietal nerves. This can also cause hyperesthesia over the right lower quadrant to light touch. Test the psoas by rolling the patient to the left and extending the hip. Rovsing's sign is pain in the right with deep pressure on the left.

Perforation.

If the appendix does perforate, it can do so in a dizzying variety of ways. It can be localized or generalized, depending on whether it happens to be walled off or not. The most interesting difference, though, comes with rupture of an 'iliac' appendix versus the rupture of a 'pelvic' appendix.

The iliac appendix sits in the abdomen nestled against the pelvic girdle, while the pelvic appendix has dropped down behind the pelvic brim.

The iliac appendix should show a degree of guarding in the area we would expect, though, as in the case I started with, it can also produce urinary symptoms due to the proximity to the ureters. Overall, iliac appendiceal rupture should be found with a rudimentary exam of McBurney's point, which is reassuring since most people do that at least even when completing the intern's morning rounding exam (run in, stick stethoscope in the middle of the chest, push on tum, run out).

The pelvic appendix, though. Ah, the pelvic appendix. Much more terrifying. 'One of the most easily overlooked and therefore one of the most dangerous conditions that may occur in the abdomen'. Now that's saying a lot. A lot of badness can happen in one's abdomen. It's like a black box of poop-filled terror.

A perforated pelvic appendix may actually improve symptoms; the pain of distention is relieved (usually felt epigastrically) and the pus soup that was inside spills down deep in the pelvis, into the Pouch of Douglas.

So? SO, there will be little or no rigidity in the abdomen because the giant pus ball is in the pelvis. In fact, appendicitis can be misdiagnosed as PID, thereby lending insult--literally, if you're wrong and it's a young woman who is not sexually active--to injury. Things to watch for include pain with micturition, tenesmus, or diarrhea from inflammation. The cool maneuver here would be to rotate the hip internally to check for hypogastric pain, which would be wierd, right? Now, what if this is missed? It can go three or four days before the pus ball extends into the abdomen, and it tends to go to, wait for it, not the right, but the left side due to anatomy. Awesome.

See how I get paranoid? Now anyone who has abdominal pain in any location, with or without a fever, with our without nausea and vomiting, who may have diarrhea, pain with urination, pain with defacation, that has or has not been constant, probably has either early, late, missed, or atypical appendicitis and a giant collection of bacteria waiting to make them toxic and die.

This is how I think.

The Thirty

The thirty hour shift. The reason I didn't pick medicine other than, as stated before, endless metabolic work-ups, intact PTH draws, and anemia work-ups that make me want to stick a pen run dry from hand-written six page H&Ps in my eye. The reason we're losing so many primary care folks to specialization. The reason your primary won't come and see you in the hospital. Also, to listen to some of the old hands, one of the best learning experiences ever. What-everr, old dudes.

Hour 10. The normal work day is over. The rest of the team leaves. Have a good night, they say. See you tomorrow morning. They leave. The sunlight from the window kisses them hello as they escape into the world. The shadows in the hallway for the call taker lengthen, distort. The sounds of the hospital are eerily calm.

Hour 16.One or two admissions have occured by this time, perhaps accompanied by a hurried supper. It's past the kids' bedtime but still when a normal person might be awake. A bit of fatigue starts at this point but not too much. You can still assess a patient somewhat well. Skills are maintained at probably about 85% of normal. Cross-cover gets worse as the night nurses come on and re-evaluate sloppy day orders--this isn't a slam, just a point. Each nurse has their own style just as each doc does. We get better at writing PRN tylenol on peds, or 'beer at bedside' on trauma.

Hour 20. This was about when I got my favorite page of all time, from a senior I actually like. "Your night is about to blow up. Call me about the first of the admits." I'm now up way past my bedtime--I'm old, after all--and any hope of sleep is squashed, although it's best to assume it won't happen anyway. Total coffee--approaching 32 ounces for the day. Taking a history, now at about 2 or 3 am, I find myself pausing between questions, getting glassy-eyed. How many histories? I don't know. Three asthmatics. Two adrenal insufficiencies, one from CAH on cross-cover, one no one knows why. I close my eyes to listen to the heart sounds better and sway. One night, getting a kid at this time that was really sick with what we thought was Stevens-Johnson Syndrome, I was shocked awake by a six-month old pussing from his eyes and crying through secretions. The sick ones wake you up. Still, probably about 70% capacity.

Hour 24.One falls asleep finishing notes. The sun rises again. Somehow, that makes it better. I usually have time to spread out my admissions and finish up details around this time, as the morning team comes in. It takes me a minute to write a tylenol order without dropping a decimal point. Maybe 30% capacity. Differentials down to dead or not. What's wrong with them? I dunno. Can we figure it out tomorrow? Or at least later, when I'm gone?

Hour...um...the best is trying to be coherent on rounds. Usually I save a cup of coffee for this time, first to walk to the stall as a some sort of break, and second to be able to form sentences. It's just survival for the last hours.

Home, for recovery. This is the cruel part. It's the middle of the day. My kids are cute, my wife is gorgeous, the crock pot is aromatic, the sun is out and beaming across the kitchen. Despite that, despite all the reasons to stay up, all I can think of is bed. I sleep for 2 to 3 hours so hard that, per report, I'm sideways on the bed and I don't even notice getting moved.

The evening brings some post-nap attempt to stay awake in order to reset the clock. So I can go to bed, and get up early, and do it all again. The rounding. The anemai work-ups. And the pen in the eye. Suh-weeeet.

Photo Credit

FMOE: The Apathetic Adrenal

4-yo female, african-american with big bushy pigtails and a vacant stare, presented to an outside hospital today after mom noticed that she was unresponsive. Initial exam notable for altered mental status, hypothermia to 35.2, decreased respirations, bradycardia. Her blood sugar was urecordable; she got glucagon IM by EMS, then more glucagon in the ED, then D25, then a dose of 20 mg hydrocortisone with subsequent return to baseline.

Mom is present with the child and notable for flat affect and a poor recollection of when she was seen last, by whom, or the name of any of the specialists that take care of her. She knows her PMD who is an NP at a free clinic.

Her past medical history is notable for a stroke at the age of 3 with persistent right lower extremity weakness and some speech delay, adrenal insufficiency of unknown etiology, and multiple seizure episodes accompanied by hypoglycemia.

The differential for shock that presents as above includes adrenal crisis but also sepsis and dehydration. The prodrome, if history is obtained, may often include a recent illness. This girl, g-tube dependent from her stroke, had vomited twice over the last two days and had generally been 'tired'. Check.

Physical exam findings may support CAH--abnormal genitalia, vitiglio, or the like, which I've never seen. She had no such findings.

The most interesting part of the case is, first, the appeal of a 'fix-it' intervention for a shocky patient--the hydrocortisone brought her back to baseline relatively quickly--and the oddity of such an apathetic parent and child. Their main question on rounds has been 'when can I go home?' A genogram reveals lots of hypoglycemia and stillbirths in first-degree relatives but mom didn't really care. I mean, I know you are a primary care giver for a sick kid and that can be tough but sheesh.

The other part of it is home management. Like asthma, if a kid with known AI starts to get sick, or get fatigued, parents should give them a stress dose of steroids--2 to 3 times their normal dose of supplemental meds. Mom HAD that at home. Although it's easy to use the retrospectoscope on her, it would've saved her kid a lot of possible harm to just treat early. And she's had a STROKE at the age of FOUR in the past! I would think that would catch her attention.

The other explanation is that she's very aware just tired of residents. That's possible.

Still, good to keep on the differential for a cold, slow, shocky kid, especially with a non-specific, malaise-and-angst-laden prodrome or some flu-like illness.

Photo Credit.

Numbers

I saw 155 patients this month, in 21 shifts.

Shifts averaged about 11 hours, so 11 x 21 = 231 hours, give or take, in the department.

That's 0.67 patients per hour.

Slow things are beautiful, too. Turtles, for example. Gorgeous shells. No one complains about how slow the turtles are. They still manage to do everything they need to, right?