broken boys and ala carte healthcare

I thought that I was in Pediatrics, and done with Trauma. In fact, I'm pretty sure I just got done with my 6 week stint at Legacy Emanuel Trauma. I shouldn't be seeing broken bones, at least acutely, right? I should be dealing with well child checks, runny noses, and maybe dealing with asthma.

maybe not...

a couple of days ago, I stitched up the toe of a girl who managed to slice it on a mirror. I don't know if she saw her reflection, and like a young kitten, not knowing it was her in the mirror, freaked out.... hissed and batted at it like a flurry of right and left crosses, then somehow in the chaos sliced her toe.

or maybe she was practicing her karate kicks in the mirror, and got a little too close. in any case, I stitched her up.

And on the same day, I stitched up another kiddo's knee after a horrible recess time football accident. It was gruesome.... after three sutures, I realized we were in the clear, and we wouldn't have to amputate.

He was thankful.

Then, just this Monday I saw a 17 year old guy who was in an MVC, going about 30, went into a ditch. He went to the ER that night, Saturday, and got worked up and sent home. They told him to follow up with his PCP on Monday. They gave him a clean bill of health after, what I can gather, a few x-rays. He said that everything came back negative.

He still had low back pain, and noticed a bump on his head. He didn't lose consciousness, nor did he remember smacking his head. He was belted, and there wasn't too much damage to the car.

He didn't have any pain other than in his lower back... he moved around the room slowly and deliberately. He had a limited range of motion as I watched him move.

At Emanuel, they would always feel the spine before sliding the folks into the CT scanner, looking for step-offs and other deformities of the spine, as well as trying to illicit any pain response from the patient. These things being clues for a fracture. What you really look for, as far as the pain response is concerned, is tenderness on the bone, not in the muscles, but right on the bone.

At Emanuel, the surgical resident or the trauma PA did this... not me. So I didn't feel the patient react to pushing on their back, but I saw it.

I've done plenty of back pain exams now, in the ER and in clinic, and that's something you always check for.... that spinal tenderness. I've never had a patient react in such a way that I've been concerned that they have a broken back. Even the whiners.... it's just never been impressive.

"Does it hurt when I push here?"

"OHHHHH... uhhhhh, ahhhhh..... yeaaaa...."

"How about here?"

"Ehhhhhhhhhhh, yes." they'll groan.

No real reaction.

But this kid..... I have him sitting on the exam table and start pushing on his spine.... around L1... working my way down.

"Tell me if it hurts anywhere."

As I'm pushing, and working my way down his spine, I get to about L4, and he doesn't have to say a word... I push, and he JUMPS away from me. He moved faster than he had the entire time he'd been in there with me. I had pushed right on the spinous process of L4 and he was through the roof.

Anywhere else I pressed didn't bother him.... The muscles surrounding L4, the other spinous processes... nothing. No pain, no reaction.

ooooops.

"So, in the ER, did they do any CT's? You know, where you lay down on a table and they slide you into what looks like a huge doughnut?"

"Nope. They did X-rays."

"Well, you're gunna get one today."

He does... and the results came back via phone call from the radiologist.

L4 compression fracture with no posterior involvement (which is good) but with some anterior wedging/displacement.

It's basically stable, and there's not really any worry for this type of fracture paralyzing this kid. But it still warrants a spine-guy consult. Which we get all set up for him.

another little kiddo, well, about 11 years old, strolled in around the same time. He fell playing basketball, and hurt his arm... a quick x-ray later, we found that he had a torus fracture. we splinted him, then sent him off, only to come back in a week so we can cast him up once the swelling dissipates.

so, i've discovered that pediatrics can be more interesting, and varied, than i thought. i should have realized that kids tend to get hurt.

some kids that come in however, are not hurt, but act like it.

we had a teenage girl come in with her mom. She had been seen in the pediatric night clinic... (like urgent care, for kids) and was diagnosed with a sinus infection. she was given antibiotics and sent home. though, at the clinic, she and her mom were asking for an IV.

"I know my kids, they crash fast. and this one, she'll perk right up when she gets filled up. I mean, I know they do it for athletes, it's not a big deal. She did this the last time too, and Lisa gave her an IV, and she popped right back up! We asked for an IV last night, but they wouldn't give her one."

I'm thinking, as she's saying this, "she does NOT need an IV. that's just a waste of time, money and resources. It's an unnecessary risk (albeit a small one) for a placebo effect, and to appease the mother and child. This is NOT a McDonald's... you can't just order what you want!"

Or, i guess you can.

i should have known... well i did know. but it bothers me.

So I present the patient to the preceptor and say that they came in with the hopes of getting an IV, anything less than that will leave them upset. So, we bolus the girl with 1 Liter of NS. the NON-dehydrated girl.... and all was well in their world. It's amazing how a liter of salt water can make a sinus infection better. i guess i should have checked UpToDate... it's the preferred treatment, after all!

well, i've made a short story long, but.... turns out, i like peds more than i thought i would. even despite some of the silliness that is made-to-order medicine. That's just the way it is, in every field. It's not Doctor knows best, it's, "what can I do for you today? no matter if it's unwise, dangerous or just silly, it's your care! let's do it!"

In my practice, I won't fold so easily, I won't enable this kind of behavior. But, I'm just a student in a 6 week rotation. I'm not out to change a practice. I'm just out to practice.

cn

catlike speed and reflexes...

A naked baby is a dangerous baby. The business end is ready to blow at any time. It's simply frightening to see a diaperless baby for any length of time. When I do well child exams, I make sure to be quick when it comes to diaperless baby time. I'd rather not get pooped or peed on, if at all possible.

I am constantly reminded of the fragility of my non-poop-covered clothes. In pushing on a the belly of a little 2 month old the other day, I created such an uproar inside her, that a gurgle turned into a largre rumble and a quite adult sized fart.

Yes, we all had a good laugh, mom, myself and the child. but the consequenses would have been dire had she not been wearing that huggies. I was right in the line of fire.

But I'm really only fooling myself if I think I'm going to make it out unscathed. I've already been soiled in other rotations, and in this one. So what I should really be practicing (other than my body-washing technique) is my speed and reflexes.

Anticipate that the little baby boy is going to try pee on you when the flippin' thing is aiming right at you like a little flesh colored fire hose. (with seemingly the same amount of power. It could definetely clear a rowdy crowd nearly as well as the conventional fire hose.)

I need to know that blank look of confusion and anticipation that appears on the face of a snot covered three year old just before they sneeze right in your face. Cover up, be damned!

I need to be like Neo, in The Matrix, time needs to slow down, just a bit, for me. I need to recognize the signs of impending disgusting, and maneuver through the air in such a way to avoid all the contaminated fluid flying my way.

So here I come, with my catlike speed an reflexes, I'm betting this kid has strep, but to be sure I need to shove that horrible, long q-tip down his throat and make him gag.

I should get a face shield... like that of a fire-fighter.

I don't.

"Hey there you little germ monger... I"m gunna cram this thing down your throat, and it's gunna make you gag... I know, I know, it sucks. I HATED this as a kid, but it's quick, and then it's all done. Just try not to barf on me."

Now I don't say this, in so many words, but close. I'm definetely thinking it.

In goes the q-tip, and here comes the gag.... and an instantaneous cough... I feel my face peppered with spit.

crap.

shoulda worn the fire-fighter helmet.

4 mintues later, I find out that the cough shrapnal was indeed teeming with strep.

excellent.

I had already washed off my face, and hands.... but, alas, it was too late. the next day... with my sinuses plugged, sore throat, and headache, I headed back for more.

you got me, kid, you got me. if it wasn't you, it was one of the other 20 something i see per day. but you know what... I like it.

I just need to work on my matrix moves. I need to be more like Neo, and less like Chris Farley in 'Tommy Boy'.

"I was checking the a ... specs on the end line.... for the rotary...... girder. I'm retarded."

http://www.youtube.com/watch?v=K9mBn9bMB-g