My work life often seems to be riddled with strange coincidences, seeming patterns, and synchronicities. I do not believe that there is a supernatural etiology for these noticeables. No doubt it is the busy shifts and diverse patients, combined with a paranoid mind that tends to notice these things.
Regardless, what are the chances that I would diagnose my first case of intussusception on my first day of work at my new job, in really the first patient I saw?
So, my first day at work at my new job was yesterday. I am working as an emergency physician in a West Coast county hospital that sees around 30,000 patient visits a year. I was working the 7am to 3pm “day” shift. Eight-hour shifts are great after getting used to twelve-hour shifts at my last job in the Midwest.
My first patient was a little girl back for a recheck from a fever. She was doing great. She was afebrile now, playful, and had her appetite back. I sent her home and put cream cheese on one of the fresh bagels I had brought in as an offering to the nurses.
I had an intern yesterday for the first time since being a resident myself. That was a bit strange after working in a completely non-academic hospital last year. I forgot how much an intern (let alone a medical student) can slow down an ED (emergency department) doc. But, this guy had a good attitude, and tried his best to be helpful as I muddled through unfamiliar paperwork and administrative hoops.
Our second patient was a 6 month baby girl, and the chief complaint was “nausea, vomiting, and BRBPR”. She was slightly tachycardic, but afebrile by her triage vital signs. Almost without conscious thought I said out loud to the intern, “Maybe it is an intussusception?” I must have been channeling one of my many great attendings. I opened my mouth and the words that came out surprised me as much as they did my intern. This was his first day in the ED as well.
She was a pretty little baby with diamond earrings and a young primagravida mother who spoke only Spanish. We learned that baby had had a slight fever for a couple of days, and mother thought her anterior cervical (neck) lymph nodes were enlarged. They were. Her posterior nasopharynx was red and she had a scanty couple of drops of white exudate on the left tonsil. The rapid strep swab was negative. She looked well otherwise, except for the big slop of Bright Red Blood Per Rectum (BRBPR) in her diaper. Her belly was soft, non-tender, no mass, and had pretty normal bowel sounds. This was not the couple of strands of heme in the mucous that you see not infrequently with some infectious forms of diarrhea. Nor was it the “currant jelly” from the medical school textbook. No gross clots, but maybe 10-20 mL of frank blood.
We “lined and labed” her (IV and blood work) and I sent her for the elusive “air-contrast enema”. Her white count was mildly elevated, her hematocrit, platelets, and coagulation studies were all normal. I gave her 20 mL bolus of IV normal saline and made her NPO (nothing by mouth).
The radiologist came on the phone to say she did not have the manometer she needed for the air-contrast enema x-ray that can be both diagnostic and therapeutic for when part of the small intestine telescopes inside itself, causing pressure on the wall of the bowel that leads to the ischemia and pain and bleeding that characterize this pediatric surgical emergency. She got a plain film and brought it to show me how there was a scarcity of gas on the right side of the abdomen – a highly non-specific finding. She suggested an ultrasound, and called back a few minutes latter so say she had ultrasonographically diagnosed intussusception (one of her first, my first, and Baby’s first). Once we had a surgeon involved (to fix any iatrogenic perforation of the bowel) she attempted to undo the intussusception with a barium enema. It only worked partially, so I called pediatrician on call at the tertiary care center nearest (a world famous teaching hospital). I told him what was up – we had a 6 month old with an intussusception, at a community hospital without pediatric ICU (intensive care unit). He agreed to accept the patient and immediately called his pediatric surgeon and readied the OR (operating room). They sent their air transport team by fixed-wing aircraft and linked to us by ground transport. They had her in the OR within a couple of hours.
Baby was on her way to a definitive repair of a life threatening surgical emergency. She was an uninsured child of a Latina mom who had no documented job and did not speak English. But, by walking into her local community (county owned) hospital she received the best surgical care available in the world very short order (a few hours). Dozens of professionals will have been responsible in part for her care by now: pilots, EMTs, paramedics, doctors, nurses, social workers and many more including air traffic controllers and administrators. Pretty cool. I am very glad, and fortunate, that from my perspective, I never needed to know what her insurance status was. It truly never made any difference in Baby’s care. If Baby had been Brad Pitt’s child or a Kennedy offspring, she would have had exactly the same exams, flights, and surgery.
A very nice review of the subject of intussusception by Dr. Lonnie King is available online at: http://www.emedicine.com/EMERG/topic385.htm
I will bet my intern will never miss an intussusception, but I bet he will order a whole bunch of negative air-contrast enemas.