Callous

The EMS call comes over the phone to us in the ED, ambulance in the field needs assistance. 5 month old, found down, not breathing for an unknown time, be advised CPR in progress. 1 round of epi through an intraosseous line, asystole is the presenting heart rhythm.

The three of us--intern, senior resident who answered the phone, and pediatric EM staff--calm down when we hear the story. This is not a rush, not a challenge, not a moment to shine. This is a moment to let death quietly come in. The chance of success bringing back a dead baby with no heart activity is near zero, and the chance of having a baby recognizable as a baby who smiles and coos is even smaller than that. But we are in a quiet, carpeted control room, not in a cramped ambulance performing CPR on a tiny infant with family looking on. It's easy for us to assess the situation at a distance. Easy for us to be 'objective'.

More details are relayed--impaired status at baseline, crack mom, baby now living with grandma who wants everything done. 2 rounds of epi, aystole in three leads. Intubation fails. Bagging, doing compressions. As I listen, the paramedics relay updates in brief chunks of speech with long pauses.

The senior resident asks for signs of lividity or prolonged downtime. A long pause. We're dealing with an african-american baby, hard to tell, comes the answer. One sign of lividity is pooling of blood by gravity, which is easier to see in a caucasian baby, but that's not why they answer that way.

Third round of epi. Asysto--wait, one beat. Another beat. Long pauses.

The pediatric staff puts her hand to the bridge of her nose, squeezing. I hate the third round of epi, she says. You can get a beat from a stone with enough epi, the senior resident says.

Ask them if there's a pulse. Cajole them. Push them to call off their efforts, it's the right thing to do. We're in the carpeted room. The situation is clear to us. We're not the ones compressing the tiny chest, feeling the ribs recoil, suctioning out the mouth, bagging, watching the limbs jump with the compressions. We're not the ones willing return of circulation. Not the ones chasing the fairy tale ending.

No pulse. Asystole. Stop.

I Will Never Diagnose Constipation

I will never diagnose constipation. I will never diagnose gastroenteritis. You have abdominal pain. You have nausea and vomiting. I may have to diagnose viral syndrome, due to the overwhelming crush of well-appearing sniffly children, but I draw the line after that.

To say 'constipation' or 'gastroenteritis' is to say 'there is no chance that you have badness currently occurring'. That is NOT how I have learned to think. This was reinforced a few days ago.

A 14-yo boy w/hx of constipation written suggestively in the nursing notes comes in with RLQ pain for only 2 hours that came on suddenly. I went to see him. His story was correct in sequence for an appy--pain first, central migrating to RLQ, with nausea. One tiny loose stool that did not relieve the pain. His exam was correct; he was tender maximally over McBurney's point, the magic spot for the appy. There was one more detail; there was something behind his eyes that told me he was sick. This is not scientific. It isn't always there. When it is, I have found it very reliable.

I went to staff the patient, told the story, and the attending, who is quite good, said, if you told a surgeon this story, they would laugh at you. No way appendicitis starts and progresses in only 2 hours. But, you're right, he's hooked us with his exam.

We tried a KUB which showed some stool. We tried a fleets enema, and it initially seemed to work. I actually filled out the paperwork for constipation before I went back in to re-examine him on my own, because the nurse said it made him feel better. Just before I went in, my staff went in, and came out. His exam was unchanged. CT showed a 1 cm dilated appendix with peri-appendiceal fat stranding (inflammation) and I called surgery for an acute appy, put in a line, gave him some morphine.

Constipation is a sign and a symptom, not a diagnosis. Yes, there are LOLs who come in with impaction, but it is due to something--inactivity, opioids, or, scary terrible inflammation in the gut that is waiting to kill them.

Gastroenteritis and constipation are dangerous, dangerous diagnoses--moreso becuase they are so common, and usually we will get away with these diagnoses if we are confident, or maybe foolhardy, enough to use them. The author of RENT, 3 days before he died in his apartment of a ruptured aortic aneurysm, was diagnosed with gastroenteritis. Is that common? No, or people would be dying in droves. But COMMON isn't what I'm looking for. I'm looking for 'zebras', what we call rare diseases. For a medicine doc or a pediatrician, that's usually some obscure genetic disorder. I look for enormous zebras with big teeth waiting to kill you--the aortic dissection, the coronary artery aneurysm from KD, the inferior MI that shows up as weakness.

It felt good to be right about this kid. He got helped. But how many have I sent? How many will I send? Only paranoia can save me from the abyss.

Heroes

At the program I train with, we are required to do EMS ride-alongs, and we have the option to do helicopter medicine. I am all in on the flying, but I learned the most real-world perspective from two or three ride-alongs. EMS folks live in a different world than anyone else. They take the fight to save the patient from themselves into the erstwhile lair of the patient themselves, and all their crack-addled neighbors.

Imagine intubating on the kitchen floor while your partner stomps the roaches to keep them from crawling into your field of view. Or starting an IV in a moving truck.

ER docs do good. But we work as a team. Next time EMS rolls in, whether they've done a banner job or not, I think we should keep in mind where they were and what they do on a daily basis. Coffee's always around for y'all, you do good work.

Why this post? Good new EMS blog here.

Respect the SS

Sickle-cell anemia comes in a couple of forms, but in general SC disease is more trait-like, and SS disease is more severe, with pain crises, strokes at young ages, autoinfarction of the spleen, and so on. So, typically we're more careful with SS patients than with others.

A 13 year old girl with SS comes in with a sore throat for about six hours and feeling a bit tired. She has friends who have strep. Her exam isn't scary; she does have a fever, and a bit of a fast heart rate (116), but otherwise, her throat isn't bad, she's not in respiratory distress, she's appropriately alert. This is not like a normal crisis. She's having absolutely no chest pain or shortness of breath. Her neuro exam is normal. By protocol we sent off CBC, reticulocyte count, and blood cultures, but only by protocol.

Her anemia was so profound that her count of new blood cells being created in order to make up for her losses was almost higher than her blood count. Her hematocrit was 18 (normal is above 35) and her reticulocyte count was 17 (normal is, like 2). Oh, and her O2 saturation was 80.

We only got an oxygen saturation because she had sickle cell disease.

This kid scared me good. Respect the SS disease. She looked fine! No respiratory distress! Yes, she had a murmur--but a hematocrit of 18?!? And a pulse ox of 80%?!?

Oh, by the way, the strep was negative.

Is a Missing Lip an Emergency Condition?

The medblogs are buzzing about University of Chicago's decision to treat a boy attacked by a pitbull without surgery.

Shadowfax has posted multiple times, most recently here; WhiteCoat has picked up on it here; and Scalpel has replied with a vigorous, bracingly conservative ripost here.

These three and others have framed the question as an EMTALA violation; is this a patient dump, or not? Is it illegal, or not? I'm more interested in how it framed the plight of modern EDs. I don't think, from what I've read, that there was an EMTALA violation. The boy was 'treated', and although his cosmetic outcome may well have been better, according to Dr. Grevious (no joke) once mom carted him across Chicago for immediate surgery, I think UCMC has a case.

More interestingly, the question is how can overwhelmed EDs possibly respond to crushing patient loads, the loss of subspecialty coverage, the mandate to see any and all regardless of pay, and all of this increasing as more and more EDs close and the federal government that forces us to see everyone subsidizes less and less? This on top of California's recent court decision that legally prevents EM groups from seeking additional compensation for services rendered from the patient. From our perspective, what exactly are we supposed to do? Chicago was trying to dispo out people who don't need emergency care. That's OK with me; tons of people abuse the ED although they are overall the minority. I think they picked a horrible time to do it with this kid--but, then, maybe they did it on purpose. No plastics available? Fine. No subspecialty care? Fine. America, this is what you get from us, they are (possibly) saying. You get the care you pay for. And when co-pays in the ED are zero, medicare reduces payments towards zero, states disallow collection of fees, we all end up with...well, zero happy stakeholders.

It's easy for me to say I care about cosmesis and wound outcomes and I'll fix a lot. I didn't see the kid, it might well have been beyond me, and besides, I work in a pediatric ED sometimes with triple attending coverage and three or four residents for twenty rooms, and we still have visit times up around four or five hours. I can see UCMC's side, easy--even if I also feel for that poor kid who couldn't get his lip sewn after he was a chew toy for a pit bull. If we can't take care of that, we're in trouble. Maybe UCMC is just pointing that out to society.

Undue Influence?

Thought this was a great shot. On anesthesia at the VA, one of the retiring PAs brought in his pen mug from his office and these were my top choices for classics. Interesting how long big pharma has been plying MDs with free pens--not that we should be interested, it seems like we could afford our own pens. I still don't understand why MDs are interested in these. The trip to Hawaii I understand.

I've taken an oath here to avoid pharma influence. So far it's been easy. The county where I went to medical school outlawed drug reps, and my residency program has a policy of not taking any money or gifts from pharma. Just wait for the community, right?

I think the Versed pen is my favorite. I was tempted to take it, I admit.

Rant

This is a rant. Fair warning.

OK. Reasons NOT to bring your kid into the spanking new high-quality 20 bed pediatric only ED with 6 resuscitation rooms and triple attending coverage.

Number 1. My kid's foot jerks in his sleep sometimes. I videotaped it. It happens, like, every five minutes. He keeps sleeping but he, oh my GOD, like rolls over. I brought him in here, not so you ED docs could look at him because you don't know what seizures are, but so he could get an MRI and a STAT Neurology consult (I didn't tell her that was an oxymoron). Yes he has a fever. Yes he has a cold. Yes he's 18 months. So, A, that's not a seizure, it's sleep myoclonus, and B, even if it were a seizure and it were generalized, even up to 3 or four minutes, it would be a febrile seizure and he wouldn't need an MR. Let's say you're right and he is having focal seizures, just for the sake of argument; if that were the case, he has a fever so I have to 1, CT him, which is radiation which you don't want, and 2,tap him which you obviously won't like if it bothers you that his itty bitty widdle foot twitches in his sleep. Honestly. I'm not trying to deprive you of your God-given right to a stat MR for sleep myoclonus. I'm trying to avoid giving your kid leukemia (now thought to be perhaps as high as 1 in 1000 for early CT exposure). Sigh.

Number 2. My otherwise well kid really didn't sleep well last night and he has a runny nose. Guess what? My kid didn't sleep last night either, because despite stripping at the door and sprinting to the bathroom to wash my hands, I still am covered with stinky-germ-goo from people like you and all my kids, my wife, and I, are sick. I still came to work. My kid is at home. He woke up ten times too. My wife, who feels sick, is at home taking care of three sick kids so I can have the joy of telling you it's a virus and you should, like, suction his nose and let him rest. Christ.

Number 3. On to annoying primary docs (many are good, I'm not yelling at them). My patient is totally fine, but she has a bump on the back of her leg that doesn't hurt at all. She fell a MONTH ago on her shin and couldn't walk for a day and now is better. She has NO feverchillseasybruisinglossofappetitenauseavomitingdiarrheacoughheadachemalaise. You, smart PMD, told this poor lady and her two kids to come DIRECTLY to the ED for EMERGENCY hematology consult and EMERGENCY orthopedic consult. Apparently small, painless, barely noticeable calf bumps are outside the scope of practice for this particular generalist pediatrician.

Number 4, a special shout out to the receptionist. Thank you, oh thank you, for telling the chronic abdominal pain patient who, to their credit, is not requesting drugs or mega work-up, to come DIRECTLY to the EMERGENCY DEPARTMENT (so named because it is for emergencies, not clinic visits) so that we EM docs can arrange for your doctor to see you in the ED because he's over at the hospital today. Please, please don't tell the patient they can be seen in clinic by one of the doc's colleagues. Please, please don't tell them to make an appointment, God forbid, tomorrow when the doc is back in clinic. No, no. Send them directly here. I'll see them right after the runny nose, the calf bump, and the jerking foot kid.

Airway Tip O' The Day

A colleague on flight had a horrendous trip the other day to a blast site. One victim was talking, had normal vital signs, but was hoarse and covered in black soot from the neck up due to the blast.

An indication for a tube if ever there was one; it had only been sixty minutes or so from the time of the blast and already she was unable to pass a tube a full size smaller than needed, and saved his life with a rescue device instead (a King LT). Which leads to the airway tip o' the day.

A bougie is a long, flexible plastic thingee used to find the trachea by feel and by the bend at its end, over which you can then pass a tube. Usually I think of it as a means to improve an airway with a bad view. She had a great view; he was just too swollen.

The tip is to use a bougie even with a great view in the setting of airway edema; if you can't pass a tube over the bougie, leave it in place, go one size down, continuing until you pass something.

Of course, this being the great frozen north, it was seven degrees where she was trying to intubate without the windchill, so the bougie probably would've snapped. The O2 tubing had already frozen. Sweet. Can't wait to start flying.

GCS of Seven

Most kids aren't that sick in the ED. Some are downright well. After working there for a while, you're sicker than most of them because they've given you GI junk and URI junk and maybe some rash junk, too.

When they ARE sick, good God, it's scary. We had an ambulance call, not a trauma call, come in the other day, of a 3 year old, head versus TV, and 'altered'.

To prepare in my head, though I would never be the one to do it as an Intern, I reviewed RSI doses--0.2 mg/kg etomidate, 2 mg/kg succinylcholine, estimate for a 3 year old about 15 Kg, so 3 mg and 30 mg.

He came in moaning, not in a C-collar, his right arm flexed, eyes closed. GCS? 1 for eyes, 3 for pediatric moaning, 3 for flexion posture--seven. Needed a tube.

We took him into the trauma bay, and held C-spine precautions while I realized I didn't know how to work the C-collars we have at children's because I've never done it. Having never done a peds trauma resuscitation, I was sort of useless--I could hold the bag on and do the ATLS algorithm in my head, but so what?

IV in 2 minutes, intubated in 5, CT scanner in 10. Pretty good. The kids are so small and everyone is so intense, pediatric traumas are frenetic. Everyone is close together. The sphincter tone in the room is incredible.

His CT scan showed a skull fracture and air all over, with 2 mm of midline shift. Hopefully he'll do better.

That's Peds EM this month--95% BS snot and wheezing or their leg looks funny but doesn't hurt, and 5% holy crap.