Cecelia is Crying
Thursday, January 08, 2009
Sean Donahue, DO
It’s 3 AM. Only 3 hours left. It’s about time for one more cup of coffee. Suddenly the calmness of my overnight Pediatric shift is broken by the wailing of a crying baby. The family walks past me-looking exhausted, feet dragging, bewildered, holding a screaming child. They are quickly registered, and the chief complaint flashes on the computer screen before me: 4 month old female, “crying.” Ah, the crying 4 month old problem. Is there a more challenging dilemma for the emergency Room Physician? It’s 3 AM, there is a crying baby in my department, time to put on the old thinking cap, this is one of the toughies.
I entered the room to find a pleasant Hispanic couple rocking their 4 month old daughter Cecelia. They were new parents. Cecelia had been crying, and crying, and crying. Usually a very “tranquil” baby, she had turned into a monster over the past 6 hours: “she has not stopped crying,” stated the mother. “This is so unusual…” OK, Pediatric ER Rule number one…always listen to the mother. If she says something is “different”, you can guarantee something is up. The mother states she went to bed at 8PM, “and was feeling fine,” only to wake up at 1100 screaming. She thought maybe she was wet, or hungry-but was neither. She had taken her temperature (rectally…what a good mom!), no fever.
I asked the usual litany of pediatric history centered questions: did she have a normal birth, any extra hospital days, what is she eating, how often, any changes in diet, is she pooping, and peeing normally, is she vaccinated? All normal, no extra clues…the plot thickens. My usual list had been extinguished. Usually I can come up with something…”oh we changed her formula, she hasn’t had a bowel movement in days...” Now I’m going to start thinking of the rarer things….
“Any recent trauma, or falls,” I ask. The parents look at each other, “no,” they respond in unison; meanwhile Cecelia continues to wale. You always have to ask this question. One might be surprised at both the incidence of random accidental and non-accidental trauma that turns up in the ER. No red flags here.
Is she
colicky? It would be really rare, she is older, and this seemed to start so suddenly. I remember back to med school, and learning the “rule of three’s,” for colicky infants: usually by three months, lasting longer than 3 hours a day, three days a week for more than three weeks…possible…”severe first time colic episode…” strange ring to it…moving on…
Is this an
intussusception, or a telescoping of bowel into itself? She is in the right age range, 3-12 months, but she has no vomiting, the pain is constant, not intermittent, she has normal poops-no blood. Hmmm, I ponder, possibly, we’ll keep this one on the back burner….let’s check this kid out.
We had Cecelia undress, and laid her on the bed. She appeared healthy, just really pissed off. No rashes, no jaundice. I listen to her heart and lungs…good luck with that one; I would have had better luck hearing a mouse fart in a hurricane. I proceed to diligently examine every nook and cranny on her little body. Her head, face, eyes, nose, ears, neck, arms, legs, genitals, buttocks, legs, toes. Looking for any clues: did something get lodged in her nose or ears, does she have a “
hair tourniquet,” or a piece of hair or string, stuck around and appendage? No, no, and no. I stand back and watch her pattern of crying. Between the wales, her hands move towards her face….her eyes. Strange….a few moments go by….she does it again…..her eyes.
I proceed to check her eyes. Her right eye looks red, slightly blood shot at the corner...I missed that the first time around. I ask if she has had any eye trauma….”no, I do not think so,” the mama responds. I look again at her tiny fingers….wow talk about Dracula nails. Suddenly I know the answer to the mystery. I leave the room and return with fluorescein, a gentle stain for the eye. This stuff lights up any scratch on the cornea, or the clear skin layer that overlies the colored part of the eye (iris) like a Christmas tree.
I place the stain, and look with an ultraviolet light…BEHOLD: a dazzling streak that looks like a green light saber streaks right across Cecelia’s little
cornea! At some time during the night she mauled her eye with one of her Dracula nails. Talk about an owie!
The nurse gently shows the parents how to cut Cecelia’s nails, and we prescribed them an antibiotic ointment, and gave them a follow up appointment with the Pediatric Ophthalmologist. I was feeling pretty good about myself. Heck, not a bad find for 3 AM. A couple of rules I have learned to live by: In the ER you have to be sharp 24/7, and crying babies command attention to detail.
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Let pain be your guide
Sunday, November 30, 2008
Anil
As a resident, I am constantly learning. And, I think, so are most of the attendings that help guide me. Every so often there comes a case that is as startling as a splash of cold water. The dangerous disease lurking behind the benign presentation can keep the hairs on the back of your neck erect for months. Something very similar happened just yesterday.
In room 7 waited a 54 yo man with a history of
kidney stones and a complaint of pain in his lower back. I've never had a kidney stone and from what I have seen I am happy not to experience that pain. This man held his lower back with his left hand and grimaced in pain, so I quickly put in orders for medication and told the radiologist to keep him in the cue for a CT scan. We usually do not give
contrast when we look for a kidney stone, which means that there is no dye running through his vessels, and the stone often appears as a
bright rock in the
ureter.
After about an hour, when the scan was completed, that bright rock never appeared in any of the images. And, despite receiving a heafty dose of
Dilaudid, he still complained of a severe pain and clutched his lower back which was very tender to touch. A healthy, middle aged man, with normal lab tests, and a normal non-contrast CT scan is usually pretty safe. Nonetheless, his level of pain seemed to indicate something different.
Though my experience indicated that this patient was probably just fine, my intuition and his pain drove me to keep searching. I checked his abdomen with an ultrasound, looking at his gall bladder which seemed normal, and I moved closer to his left, where his pain was, to look at his aorta which also appeared to be normal. A constrast CT would inject dye thorugh his vessels and allows the scan to show more subtle findings such as a
tear in the aorta. We agreed to do this study and discovered that he did, indeed, have such a tear.
As I reflect on his case, I feel relieved that he is now doing well in the hospital and I am glad that we kept digging. Sometimes pain is hard to control, but it is always our best guide to finding disease in any individual.
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Taming The Jealous Mistress
Sunday, November 16, 2008
Sean Donahue, DO
“Medicine can be like a jealous mistress if you are not careful Sean….” These words were spoken to me 10 years ago by a much older, and at the time, possibly wiser Orthopedic Surgeon. The man was in the waning days of his career, and at 65 years old was currently working on his third marriage and had a 3 year old son. I listened to his words, but I could not fully appreciate the gravity of my chosen career. I remembered thinking, “this guy must be crazy…he is still working 80 hours a week, he failed 2 prior marriages, he is now remarried…and has a small child….and he is telling me about how Medicine is like a jealous mistress…” But as time went on, I realized a specific pattern starting to develop in my associations with other physicians: many of my father’s friends who were physicians were divorced. Many of the physicians I was starting to work with were divorced. Some had remarried; some were working on their 3rd or 4th marriage-starting anew. Many were estranged from their own children. A few even had problems with drugs and alcohol. Maybe there was something to the “jealous mistress” thing. Could the job really be the only blame? Of course not, but my chosen career, like many other jobs which require a high degree of self sacrifice can, if one is not careful, become really like that other person in your life.
I have reflected on my life over the past 10 years since starting my career in Medicine. For the most part I have given up the luxury of weekends off and 9 hour work days. I cannot even count the times I left the house at 600 AM, only to return exhausted at 900 PM, for 6 days straight. I used to think medical school was rough-only to find Residency 30-grit rougher. Not only is Medicine the ultimate time monger, but our work also involves great personal sacrifice…caring for others in need. It is very difficult to place into words how mentally and emotionally draining this care can be…particularly in the Emergency Department. Day in and day out we work in a fast paced pressure cooker. Here, our patients do not care about the type of day we are having; a dying patient need not to know that you are having marital problems, or that your kid is failing school. Many physicians have to completely compartmentalize their life from their work-your normal life gets shoved to the dark recesses of your mind for 12 hours. When leaving work after a draining shift-the reality of medicine, and the stress of your day dissipates, only to be met by your life’s real problems. As many physicians with problems outside of work admit-whether it is marital, drug or alcohol abuse,” they just do not have the energy to deal with their real problems.” They either turn to something else, or dig in deeper to their career. Everything about her is seductive: the time, the pressure, the stress, and the commitment.
I think this is where the notion that Medicine is like a jealous mistress begins…and ends. I have come to realize that I, or any other physician, cannot blame our career on our life’s troubles. Sure the job demands much more than the average, but it is our choices which ultimately determine our happiness. I am reminded of a quote by the late John Candy: “Like your work, Love your wife.” Amen. I recently have had many new aspiring physicians ask me “how do you balance work and home life?” It is not easy. But priorities are paramount. I vowed early on that my wife and children will always be paramount-they are my number one, and my job will never replace them. I tell newer colleagues if they want to be surgeons, if they want to do research, if they want to be leaders of their chosen profession, that is wonderful….but these aspirations will require great sacrifice. Just do not sacrifice what is truly important-the ones who love you. Very few, tread in these waters and maintain the harmony between work and family life they or their families expect.
“Medicine can be like a jealous mistress if you are not careful Sean.” He was right, you do have to be careful, but we are in control of our own destiny. We choose our own priorities, and these dictate the life will lead. After a grueling 12 hour day in the Emergency Room-after the stress, the chaos, the heartache, and triumph-I know at the end of it all, my wife and child are waiting. Everything else melts away. The mistress once again gets the boot.
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Desert Halloween
Saturday, November 01, 2008
Anil
Today is Halloween and I am celebrating it with a costume made of bandages. One roll of elastic tape can make you look like the mummy, a creature from Pans Labyrinth or just Robin. I am also celebrating it with over one hundred competitors from the race. Sometime between yesterday at 10 p.m. and today at 2 p.m., they finished a 54 segment of the race. That makes four marathons and one double-marathon. At the end, most runners successfully completed the race. The things that stopped a few were stress fractures, torn ligaments, and severe dehydration.
A surprising number of runners with IT band injuries pushed on for miles through the pain. The iliotibial band runs from your hip on the lateral side (outside) of your thigh to an insertion point near your knee. With strain and asymmetry, it gets tighter and begins to rub against the bone. This creates a sharp knee pain with running that is only relieved with stretching, rest (sometimes for months), ice anti-inflammatory medication, and massage. Unfortunately, most did not rest or have time to stretch, thus aggravating the problem.
The runners I've treated struggled with IT band pain for months, to even a year, with intense efforts at rehab. After rest cures the pain and running is ceased, the underlying problem requires a more relaxed muscle. That can only be achieved with stretching and rolling. The foam roller is a simple invention that amazes me. A cylindrical piece of foam, in the proper hands, doubles as an expert and powerful masseuse. By placing the roller and body weight on the latter-lying IT band, a back and forth movement can slowly roll out the leg. This is one of the few things I have seen really cure this injury.
I don't expect to see any of the desert. It is over 100 degrees here again, with endless sand dunes and at least a cool breeze. In the end, all these days in the desert are unforgettable. Despite the heat, lack of shower or clean clothes, nights without light pollution, and with stars that beam brighter than any location I have been—all this has burned into my memory. The runners' triumphs have also been inspiring. One Korean runner completed the race without seeing the sights because he was blind. He had someone lead him through the course by rope, and finished with great speed.
I am ready to head to the trail myself now when I get back.
Anil
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The Roaming ER
Wednesday, October 29, 2008
Anil
It appears that life is more than blisters and foot care. Though that is an important part of a race that keeps people pounding their feet in 100 degree weather for most of the day. In my travels, I've noticed a need for medical care in the villages and for locals.
Here, in the
Sahara Desert, the Bedouins comprise most of the population and are isolated from the major hospitals in Cairo. At our medical tent, located at the overnight camp of racers, the locals stopped by together. The medical complaints were varied from abdominal pain to runny noses. Most of the complaints were bread and butter emergency medicine but complicated by our lack of diagnostic and therapeutic tools. Just read Dr. Auerbach's blog for a sample.
Interestingly, one policeman with abdominal pain had a belly that was so tender to touch that it seemed like appendicitis. Another doctor on my team saw him and urged him to make the long drive to a nearby hospital for evaluation. There, his appendix was taken out without a CT scan and the doctors concluded that he did have appendicitis. It was good that we were able to diagnose him early because untreated appendicitis can have a mortality rate upwards of 15%.
I'm getting used to my new ER, located among limestone towers, cashmere soft sand, and racing tents. Though I spend much of the time working, I don't have any complaints.
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