Sick-kid Season

I love kids. Always have and always will. And when it comes to sick kids, I feel fortunate to have been trained in a demanding EM residency program where the pediatric emergency department was directly attached to the main trauma center. As a result of such exposure, treating ill kids became as natural to me as treating ill adults. Those little buggers, with their fevers, snotty noses, abdominal pain, and piercing shrills, don't scare me. Some get an "A" for effort, though, pulling out all of the stops in their vain attempt to get me out of their room. Regardless, because of my comfort, I try to see the really sick kids that come through our doors during my shift.

Over the holidays, with the flu season in full swing, I treated many children who were swept up in the epidemic. Some parents simply needed reassurances that they were giving their little Johnnie and Susie all the proper care, while other parents, with their heavy concerns, were right to bring their children in for a workup, including some IV hydration and anti-emetic medication. All-in-all, there was a much heavier flow of pediatrics than what we typically see.

Walking into Room 22, then, thanks to an alert by the nurse, I knew I was about to face another sick child. "This one is 'punky', Doc," she had said, "he hardly flinched when I started his IV." Never a good sign.

I quietly pulled back the curtain to the room and entered, finding a fatigued two-year-old boy sprawled on his back on the medical cot with his cotton sheet kicked into a ball at his feet. His oversized hospital gown had one loose tie in front, opened to reveal his skinny frame. His blond bangs were sweaty, matted to his forehead, and his skin was pale. Before introducing myself to his parents, I walked up to him and felt his forehead with the back of my hand. He was "burning up," as we say and, more importantly, didn't even shrug to a stranger's touch.

I shifted my focus to his parents, walking up to the young mother sitting in a chair alongside her son's cot. She looked as wiped-out as her son, the livelihood of her existence threatened by her son's illness. She was tearful, a mother's angst clearly etched into her face. I took her right hand in the both of mine, squeezing it reassuringly. "We'll get him feeling, better," I said, nodding to her sleeping son as I spoke. She dabbed her eyes with a Kleenex and gave me a feeble smile.

Next, I walked up to the father, his disheveled baseball cap barely clinging to his head as he paced three steps back and forth in a tight corner of the room. We shook hands and I held his gaze for a few extra seconds, trying to silently reassure his concerns. He, like the mother, was young, worried, and quite upset over his son's circumstances. He looked me in the eyes and took a deep breath. "Can you really make him better, Doctor?" he asked, a glimmer of hope escaping his watchful eyes.

"Let me talk to you both, do a thorough exam of your son, and order some tests and treatment for him, okay? But yes, I do think we'll get your son to feel better by the time we are done treating him." Their son looked like several other patients we had recently treated for influenza.

Between the two of them, I learned that they were first-time parents and married. Although neither of them were ill, their son went to daycare two days a week, where they thought "a bug" was going around. He had been born full-term and was up-to-date on his immunizations. This was his first major illness, barring a few past ear infections. Over the past few days, they watched their son eat and drink less, urinate less, become less active, and start a fever that they couldn't control. Eventually, all of their son's symptoms worsened and became boggled in their minds, totally confusing them (like any first-time parents) as to what symptoms were most serious and needed addressed immediately.

That's where we came in.

After a thorough exam on this patient, I had no suspicions for focal illnesses (such as pneumonia, bronchitis, or strep throat) on this patient. His temperature was quite high (103.7) and he appeared clinically dehydrated, so we treated him with a Tylenol suppository, aggressive IV hydration, and some IV Zofran, a God-sent anti-emetic that helps control nausea and vomiting. Then we sat back and waited--one, to see how the child would respond to our interventions and two, to review the results of our blood and urine tests as they returned.

Within the hour, I was walking into my work station with another patient chart only to find Dad standing at the counter, waiting to talk to me. He was smiling.

"He's doing better already?" I asked. "Come take a look," Dad said, practically grabbing my hand and pulling me towards his son's room.

We got back to his son's room and, before opening the curtain, the father stepped aside, sweeping his arms as if welcoming me to step into his home.

Pushing aside the curtain, I was extremely happy to find their son sitting upright in bed, licking an Italian ice while watching a cartoon on the TV. He looked at me with apprehension, turned to his mother who gave him a reassuring wink, before turning his attention back toward the TV, continuing to lick his popsicle. He was a new kid.

The mother jumped from her chair, then, and rushed me, giving me a big, grateful hug. "I can't believe how good he looks," she said, muffling her words into my shoulder. "Yes," I said, happily agreeing with her, "he looks great!" She left my side and went back to her cot-side chair, sitting clumsily down before wrapping her hands back around her son's torso. Her face held the most genuine expression of thankfulness and love that could ever be.

Within the next hour, as the patient's labs returned with adequate results, the nurse and I took turns going into the room to educate the parents and answer their questions.

How frequently are they supposed to use Tylenol and ibuprofen?
What doses of Tylenol and ibuprofen are they supposed to use?
How should they use the Zofran prescription we'd be sending them home with?
What type of fluids should they give their son?
What foods would be okay to reintroduce back into his diet?
How much sleep should they let their son get?

It's easy to see how confusing it can get the first time your child has a serious illness. Their questions for us were endless and repeated several times, but we, in the medical field, all know that education and knowledge is most empowering to recover from an illness. Our patience in the parent's education is paramount. Besides making sure each of their questions were answered, we also wrote down their instructions for them to take home.

By the time we were ready to discharge this patient, he was a new kid, running around his room, drinking watered-down juice, coloring the staff pictures, and covering himself in the stickers we gave him.

To us, another successful but predicted response to our interventions with a child with the flu. To the parents, though, this was nothing short of a miracle. The clouds had parted, the rays of sunshine had dispersed before refocusing on the head of their sick child, and the gods had sung. Anyone who has had a sick child recover knows these feelings of exhilaration that follow the many pangs of doubts that haunt us during our child's illness.

I've been there...have you?

The nurse and I stood together at the counter and watched this young family walk out of our ER after being discharged. Three big smiles, plus two more if you count ours.

It was another good day in the ER...

As always, big thanks for reading. I appreciate the nominations and support for the 2010 Medgadget awards for best medical weblogs...thank you, thank you. I hope this finds you well...

The Saving Brother

I heard the patient's agonizing scream emanate from Room 31 just seconds before Nurse Carla ran up to me. "Dr. Jim," she said, grabbing me by my arm, "I need you in 31 right away." Her face was flushed, her voice edged with concern. Carla, usually calm and collected, had me worried with her nervousness.

As we hurried down the hallway toward the room, we were greeted by yet another gut-wrenching scream. Somebody was hurting. And hurting bad. We hear many types of screams in the ER--demented screams, angry screams, excited screams, drunken screams, etc.--but this primal scream from being in extreme pain was by far the worst.

"What's going on, Carla?" I asked her, intrigued as to what I was going to find when I walked through Room 31's doors.

"Bad burns," she said, "and trust me, your heart's going to drop over this one."

We walked into the room and I was surprised to find an eighteen year-old male patient sitting upright in his cot, completely naked. He was alone and crying. He was thinly-built with shoulder-length blond hair, his face painfully scrunched-up as a result of his despair. His hands were alternating between flailing and holding his genitals. The nauseating smell of burnt skin and hair permeated the room.

I rushed to his side while Carla assumed position on his other side, preparing to start an IV. On a quick, cursory exam, I saw that he had apparent burns to his lower abdomen, his inguinal areas, and his penis and scrotum. Poor kid.

I quickly introduced myself to him. Through abbreviated, gasping words, he told me his name was Matthew.

"Matthew," I said, "we are going to start an IV and give you some pain medication to make you more comfortable, okay?" He nodded his agreement while grimacing from his discomfort. I continued. "After we get you a little more comfortable, we'll talk about what happened. In the meantime, I need to perform a physical exam to see what the extent of your burns are."

Carla had an IV established before I was even done talking. "Morphine?" she asked. "Morphine," I answered, "and lots of it." After giving her some further orders for IV fluid hydration, she hurriedly left the room.

I looked closely at Matthew's head and face. He had no singed nasal hairs, no burnt eyebrows or lashes. I had him spit in a container. His sputum was clear. He had no stridor or difficulty breathing. All good findings to suggest his burns didn't affect his airway. His heart sounds were excellent. His lung sounds were clear. His abdomen, barring the lower skin burns, was soft and without pain. His extremities revealed him to have redness and blistering to the palms of both hands.

Next, as Carla administered the morphine, I focused on his burned privates. His entire penis was red and blistered but, thankfully, the burns were not circumferential. A band of burns that completely encircled the penis would have had potential to cut off the blood-supply to the distal part and that would have been very bad. Matthew's scrotum was also burned, red with significant blistering covering its entire surface. His groin area and proximal thighs on both sides were also a bright, angry red and blister-filled. His anus and rectal area had been spared.

Because of the location of his partial-thickness and potentially full-thickness burns, Matthew needed to be emergently transferred to a burn-unit with his injuries.

After making quick arrangements for his transfer, I returned to Room 31 to find a much more comfortable patient. Several nurses, including Carla, were bent over Matthew tending to his burns.

"Matthew," I said, "do you feel better." Groggy from the pain medications, he smiled a goofy grin at me. "I sure do, Doctor. Thank you."

He then went on to explain to me how he had received his burns. His younger ten year-old brother had been playing with fireworks when Matthew had happened upon him. His younger brother, Matthew continued, was holding an M-80 in his hands, lit, and was trying to slide it down a tube that wasn't wide enough. Matthew, watching with horror, saw the wick of the firework burn down to almost nothing and he decided to act.

"I ran up to my brother, Doctor, and grabbed the tube with the M-80 sticking out of it. I thought it was going to blow up in his face, so I snatched the tube and held it against my belly so it wouldn't hurt him."

As you can probably guess, the M-80 blew while Matthew was pressing it against himself. Although the force of the M-80 missed causing him significant injury, Matthew's clothes caught on fire, resulting in his burns. Matthew was a hero.

"Is your little brother okay?" I asked. "I think so," he answered, "he and my mom should be here soon."

I liked this young man. Here was a respectful, saving brother who risked his manhood, his life actually, to keep his younger brother out of harm's way. I had no doubt that if the exact scenario repeated itself, he would do the same thing.

Within minutes after our discussion, I greeted Matthew's mother and younger brother in the hallway outside of his room. They were both distraught and crying, their tear-stained faces looking expectantly at me for some good news. Especially the younger brother.

I put my arm around his trembling shoulders while I addressed them both. "Matthew is much more comfortable now," I reassured them, "but I have some concerns about how bad his burns may be. We're going to transfer him to the regional burn center so he will get the best available care possible for his burns."

The mother nodded. "Please do whatever you have to do to get Matthew better, Doctor."

I escorted them into Matthew's room, where the younger brother immediately bolted to Matthew's side, hugging him. "It's all my fault," he muttered between his free-flowing tears. "I'm sorry, Matt." The guilty weight of the younger brother was heartbreakingly evident. Matthew, as I knew he would, put his protective arm around his younger brother. "It's alright, bro. I'm just glad that you are okay." Mom came up then, wrapping her arms around both of her sons. Carla and I stepped out to give them some privacy.

We transferred Matthew to the burn unit without incident. Prior to his leaving, we wished him well and told his mother to please keep us posted as to his recovery. We all wanted Matthew to have the best of outcomes.

A few weeks later, waiting in my work mailbox, was an update letter from the receiving burn unit regarding Matthew's condition. I eagerly ripped it open, nervous about the news it contained. Thankfully, it held the best news possible. Matthew hadn't required any skin grafting and, although his burns were significant, they expected a full recovery without any permanent injury or damage.

Sometimes, things turn out just the way you hope they will. Cheers to Matthew.

As always, big thanks for reading. See you Friday...