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
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