The little girl - three and a half years old, this one, nearly four, and sharp as an everloving tack. She came into the ER with - as BM reported it later - a chief complaint of headache, vomiting, and fever. These, O Best Beloved, are warning signs of meningitis. Especially when we've seen so many kids on the floor with meningitis already. But she had a past history of kidney infections, and the ER people got some CVA tenderness (pound over the kidneys and see if it hurts), and the urinalysis showed a little bit of whites and bacteria, so they admitted her to us with a diagnosis of pyelonephritis.
In the middle of the night, BM admitted her and took the history again. And he was struck by the way her mother described her presentation, especially the bit about how her head hurt so bad. From any other little girl of 3 1/2 years old, we might have brushed it off, but this girl is bright - extremely so, and disturbingly coherent. He was struck enough that the next morning we decided to do an LP (a spinal tap) on her to look for meningitis.
In infants, you do an LP by getting someone to pin the baby down in an arched-back position, and really don't use much in the way of anaesthetic. In adults, you numb them up good and get their cooperation. From kids D's age, you do conscious sedation. We gave her Versed and morphine. A lot of Versed and morphine. Enough to knock most kids out completely. It still took three of us to hold her down and both residents to do the tap. This kid is an absolute tiger. And even as drugged as she was, she was still conscious enough to ask "why are you doing this to me?" and to listen as I tried to explain it. Didn't matter, she didn't want us to hurt her.
I went to see her after the results of the LP were back in - 150 white cells, a clear-cut case of meningitis - and she remembered me. And she listened when I said I wasn't going to hurt her, I just wanted to talk to her and poke and prod a bit. She told us the history of her headaches, and she told us about how bending her neck had hurt in the ER but it didn't now, and she was patient and offered to wake her mom up if we wanted. This is one of the smartest 3 1/2 year old kids I've ever seen.
She'll be fine, the LP was entirely a viral meningitis - but it was still an interesting sort of case. We can't figure out how the ER staff got pyelo. But as long as she's in the hospital we're going to work up those two old kidney infections. Any kid who gets a urinary tract infection before the age of 4 should have at least a renal ultrasound.
Had an 8-month-old baby with a spiral fracture of the femur. Even walking children have a hard time getting those. That makes two 310's filed in a month. I didn't see him, but I hear his family threw a shit-fit when they found out he was going to foster care. Apparently his auntie was throwing herself across the bed, sobbing about how he should be going home with her, and an uncle was cussing up a storm, and his mother was miffed that she couldn't meet the foster parents.
Then there were the twin baby girls. The UVC was afraid they had GBS bacteremia and wanted them admitted, but didn't think they needed an LP (part of the sepsis workup). JL felt they looked like they had a viral illness, sounded like they had a viral illness, and had a history consistent with it. "Why," she asks at morning rounds, "do we have these kids in?" We decided to keep them for another day, since we had pending blood cultures.
The adorable little boy baby with asthma, whose grandmother had put braids in his hair. Nobody warned the resident, who called him 'she' and offended Grandma. Whoops.
And the kid with viral meningitis who, despite me caring for him for two days, never said a word. He was cooperative and nodded or shook his head, but silent. His parents say he takes a while to warm up to people.
JK on the phone to the ER: "Seizing?" Pause. "Sodium of what?" Pause. "Feeding him free water?" Pause. "They're pushing what?" Pause. "I'll be right down there."
Baby with a sodium of 119, too low, and having seizures because of it. Apparently, it's a case of WIC syndrome. WIC syndrome, O Best Beloved, is what happens with dirt-poor mothers on the WIC (Women, Infants, and Children) program when they run out of foodstamps or formula coupons. In the interim before they can get more, they attempt to stretch the formula by watering it down progressively more and more. Never mind that the calories and electrolytes are so vital...
So baby's mother has been feeding him tap water for a few days. That's all the intake he's gotten. No wonder he's swimming. And the ER doesn't know how to handle a hyponatremic infant. That was interesting.
One look at the "possible intubation" on his notes means that he went to R for monitoring. We don't take intubated kids. We aren't an ICU floor.
Final reviews by JK and Dr. M: nothing but complimentary. Dr. M: You'll make a good doctor. I'm confident of that. JK: I've had a lot of medical students under me. You're one of the best I've ever seen at your level. If I can only keep going, motivate myself to work all the way through, I have hope.
And today - after RP and playing Cranium until late into the night, I went forth to get new tires for Michel-Ange and to pick up our copy of Gokudo. We bought the box set of Boogiepop Phantom on the recommendation of someone who compared it favourably to Lain and Perfect Blue. And this time we opened Gokudo at the counter. The reason they ordered it in was that the copy we purchased was missing a DVD. Well, missing all six DVD's. The box was completely empty. "If you were anyone else," he says as we bring the box in and show him the empty case, "I'd say 'Yeah, right'...but you're regulars." This seems to be a common theme at Suncoast. As he was ringing up all $75 in gift certificates, and having to do it by hand because the scanner didn't work, and then having to redo it because he did it wrong, the kid next to him says "Be glad they're regulars." It was a riot.
Went to the chinese food place in the mall. The girl who's always there when we come through stopped. "You cut your hair!" I laughed and nodded. "It looks very cute!" I was a little startled; we don't eat there that often... KS, the resident I worked with on the UVC rotation, noticed too. People know me and recognise me. That always startles me.
Called Dad to chat on Thursday or Friday. "I just got done the other night reading most of your Livejournal". I never expected he'd get around to it. Dad's so busy, and it's hard for him to read things - he reads slowly, and usually gets his literature in audio form. So maybe he's still around, reading. In which case, hello :)
And that's enough spam for now, O Best Beloved. I'll try to update more frequently and at less length in the future.