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Warning: medically intense post ahead!  The last few months have involved a lot of one on one patient care and I wanted to take some time to share the stories of some of my patients and I’m hoping it will be somewhat cathartic for me while at the same time allowing those that follow our blog some insight into the lives and issues raised by the people that I care for.  To protect my patients’ privacy I’ve changed some of their identifying details.

I’ll begin with some stories from my time at Children’s ER.  My second month at Children’s seemed to be filled with examples of kids who decided to be sexually active far earlier than they ever needed to be.  The first was a 14 year old Hispanic teenager that had just started high school a few months back.  She came in because she had been having abdominal pain for several weeks.   She stated that she last had a period about three weeks ago so it wasn’t time for her to have another period.  She last had intercourse several months ago but adamantly denied “messing around” recently.  As is typical for any woman that I see who is of childbearing age, I checked a urine pregnancy test along with the other abdominal labs.  It came back positive.  I talked with her first about the results and to say the least she was shocked.  How could she be pregnant?  What would this mean for her schooling?  Who would take care of this new life?  Her mom, a first generation Hispanic lady, quite graceful and obviously very concerned about her daughter’s abdominal pain was also there with her.  She didn’t speak any English.  I talked with the daughter first and she asked if I could be there as she talked with her mom about the results.  I had a Spanish translator come in to help me talk with this young teenager and her mother.  We broke the news and clearly the mom was visibly distraught.  For a while she just kept shaking her head not knowing what to say.  Then tears started to flow…her daughter could not make eye contact with her.  In her broken English she kept saying to me “I told her don’t mess up…I told her don’t mess up.”  After talking with them a while more to help them figure out how to get in touch with an OB to supervise her pregnancy, I grabbed our ultrasound and took a look at her uterus.  There was a little 8 week old baby in there.  Moving his/her hands and feet.  The mom still looked overwhelmed but she seemed to resolve herself to be a parent once more – now to her grandbaby.

The second was a 13 year old Caucasian girl who came in for her first OB visit when I was in the OB-GYN urgent care.  When I initially walked into the room I was a little confused because I saw this tall lanky girl sitting on the examining table and I started looking around for the patient.  I quickly realized that this girl, who looked much more like she should be in a schoolyard playing than sitting in a GYN urgent care, was my patient.  She was in 6th grade and she decided to have sex just one time when she was 12.  She was very fertile because that one time was enough to make her pregnant.  She looked so totally lost as I asked her the usual questions about sexual history, menstrual periods and symptoms since becoming pregnant.  She had found out she was pregnant two weeks ago when she saw another doctor for increased frequency of urination who also decided to do a pregnancy test.  Her mom and she had obviously done a lot of talking since then because they both seemed to be on the same page when they came for her first visit.  She seemed so frightened when I first got to the room because she initially had wanted to talk with a doctor first without her mom there.  When it came time for me to do the GYN exam I asked one of my female nurses to step into the room both to help this girl get through her first GYN exam and for me to have a chaperone.  I first described the exam to her and explained how I needed to examine her cervix and do a bimanual exam to feel the size of her uterus.  From the look on her face it was clear that she did not even understand the term cervix much less what was going to happen to her body over the next nine months.  I’m not sure who was in more distress when I did the exam – I was so scared about hurting her because she looked so fragile and she was scared because she obviously did not understand what would happen if she got pregnant.  Finally the mom asked to come in after the exam and by looking at her it was clear that this young girl did not make a choice that was much different that her mother because her mother was maybe in her mid twenties.  It was such a heartbreaking encounter to see such a little girl have to take on such grown up responsibilities all because of a poor choice she made.

The month at Children’s also brought along some kids who were extremely sick.  The first was middle school African American girl who was brought in by her father and mother because they thought she had asthma.  From the first time I saw her, I knew something was terribly wrong.  This 14 year old was not having difficulty breathing because of asthma, she was having difficulty breathing because she was Kusmauling.  Kussmaul breathing is something we see in patients with severe metabolic acidosis usually as a result of diabetic ketoacidosis.  She was not answering any of my questions and so we moved her back to the critical care area and got an initial venous blood gas.  Her pH was 6.85 (normal is around 7.4).  It was one of the lowest values I had seen in a patient who was still alive.  Since she was so obtunded we intubated her and started pouring fluids into her veins hoping to reverse some of the damage that had been done from a condition that had probably gone unrecognized for several weeks.  Her initial glucose came back at greater than 2300!  Most of the diabetic ketoacidosis patients I have seen before have sugars in the 300-500 range but never this high.  We started her on an insulin drip and within about an hour her pH had already started to improve and she was admitted to the ICU.  The parents looked overwhelmed, looked guilty that they hadn’t realized something was horribly wrong with their daughter earlier.  It wasn’t their fault, they didn’t know that what looked like just her acting more tired and having difficulty breathing was not just worsening of her asthma it was that her pancreas had stopped working.

Next is the story of a teenage girl who woke up with really bad back pain.  She was a star athlete in her school.  She clearly came from a well off family as evidenced by the clothing her parents wore.  It was a Saturday morning and she had gone out with some friends the night before.  She went to bed feeling fine.  She woke up around 7 AM and her lower back hurt terribly.  She thought maybe she had worked out too hard the last few days when she was at soccer practice and decided to just stay in bed.  When her parents noticed that she had not gotten out of bed by nine they checked up on her and she complained of bad back pain.  Her dad had problems with his back as well in the past and he had some muscle relaxers left over from a previous back pain episode and so he gave his daughter some pain pills.  That seemed to make her feel better and she slept for most of the morning into early afternoon.  When she woke up she noticed that her back pain was still there but now also noticed that her legs both started feel numb, almost like they had fallen asleep.  That definitely got her parents concerned and so they went to their neighborhood ER where an ER doctor noticed on his exam that not only did she complain of paresthesias but on his exam he noticed that she was visibly weaker in her right leg than in her left.  Thinking there might be some sort of herniated disk that was causing sciatica and nerve compression he ordered an MRI.  The MRI showed a herniated disk at L2 with some slight compression of the L1 nerve root and because there was no neurosurgeon available at his hospital he transferred this patient to Children’s.  I picked up her chart around 2 AM but even before I had gotten to the room the nurse had come to me several times to ask me to write for some more pain medication because this girl just could not get comfortable unless she got morphine about every two hours.  I talked with her and her family and got the same story.  I examined her and found that she was weak in both her right and left leg with the right one more affected than the left.  She had the hardest time with knee and hip flexion which seemed weird to me because it did not fit a typical spinal nerve root distribution.  I reviewed the films and she definitely had a herniated disc at L2 but it didn’t explain the clinical findings because her deficits were consistent with deficits in the L1 and S1 distribution.  I asked my colleagues in neurosurgery to evaluate her and they agreed with my findings, her deficits were not explained by her disc herniation.  I admitted her to the hospital and ordered a repeat MRI of her spine.  Her repeat MRI confirmed our worst fears, her diagnosis was not disc herniation it was transverse myelitis.  Transverse myelitis is a rare neurological disorder which in cause by an acute inflammatory process in the spinal cord that can often cause permanent neurological damage with few who ever recover fully.  It occurs in about 1-5 people in a million.  What a devastating diagnosis for such a young woman to endure.  What would this mean for her long term?  Would she ever be able to fully participate in the activities that once made up her life?  Would I see her again and again in the ER over the next few decades as she suffers from chronic pain secondary to her condition?  It is amazing how just a night can turn someone’s world upside down.

Perhaps the worst part of working in the children’s ER is having to care for children who have been abused.  So far this year I have dealt with three cases of child abuse.   The first couple kids were identified before the kids were injured too badly so further injury was prevented.  The first was a 6 month old who came in with multiple rib fractures and a spiral fracture of tibia – all classically associated with child abuse from the leg of a baby being twisted.  The second was a much harder one for me to pick up on.  It was a concerned mom and dad who brought their young infant in because they were worried that their day care provider might have been abusing the baby.  I performed  x-rays of the affected joint but neither I nor the radiologist saw a fracture.  They returned a few days later and this time repeat x-rays showed a developing callus forming from a corner fracture on the distal femur.  I’m so glad they came back because who knows what would have happened if they had not followed their intuition.  The worst case of child abuse that I’ve had to deal with this year really shook me to the core.  It was a 4 month old baby girl who was found seizing by her grandmother when she returned home after entrusting this baby to a relative for a couple of hour.  She brought the baby immediately to the ER and we knew quickly something was wrong when the baby required multiple doses of Ativan to get the seizures to stop.  The baby was quite lethargic and thus we decided to intubate the baby to protect her airway.  When we examined her head, the back of her skull just didn’t feel right.  A CT scan confirmed our physical findings – multiple skull fractures on the back of her head and a subdural hematoma.  Based on the exam it appeared that whoever wanted to hurt this baby literally took the baby’s head and slammed the back of her head against a hard object multiple times until the baby stopped crying.  I pulled up her chart to check on how she was doing a month later.  Her inpatient opthalmology exam showed multiple retinal hemorrhages.   She was put into foster care and when her foster mom brought her in for a checkup she was deaf, blind and now could barely hold her head up.  How could someone be so angry that they did something so horrible to a little baby who could only cry for help?  I went home and kissed my kids several times that night.

I think I’ll stop with the stories for now and hold off on my experiences back in the main ER until I get some more time to write.  I think the experiences I’ve had in the emergency room confirm to me yet again what a fallen world we live in.  A world that without Christ has no hope and no meaning.

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