Diana Benedetti - Patient Centered Ethics: Pathography

Jan 21, 2022 at 02:09 am by pj


I think it might be time to go to the emergency room, Eddie’s been sick for almost a week and nothing has helped. He wouldn’t be this bad if his pediatrician would have evaluated him last week. Yes, I understand there is pandemic but he’s had 5 days of fever and refusing to see him and the recommended Tylenol has done nothing. Even the ointment prescribed by the urgent care only seems to make the rash worse.

We drove an hour to the closest pediatric emergency room. In the brief moments in the waiting room it became evident today was not the day to come to the hospital. The staff had their hands full, patients sitting wherever I looked, probably at full capacity. With the exception of when Eddie was born, I’ve been avoiding the hospital due COVID-19, but this is nothing like how I expected. Everyone wearing masks and using hand sanitizer everywhere I turned…and wait what are some of those people wearing? Are those gas masks? Organized chaos is the best way to describe this.

I could see the hesitation on the nurse’s face as she gathered information on Eddie. I really hope they don’t send us home again, I probably sound like a paranoid mother, of course Eddie’s fever has now subsided and he’s no longer crying. I never thought I’d want my child to be ill but at this moment I just need someone to acknowledge my worries.

A few minutes later the medical student in the ED entered the room and introduced herself. Eddie was all giggles until she started to examine his extensive rash. I had not realized its progression over the past day, but Eddie was now covered head to toe in peeling, flaky dead skin, as if he’d suffered a bad sunburn.

Four hours into my tenth shift the pediatric emergency rotation and I could tell census was slowly returning to what is was pre-pandemic. Today has been a circus, we are at full capacity, and currently have three rooms occupied with patients waiting to be transferred to the sister Children’s hospital an hour away. So, when I saw on the EMR that there was an eight month-old was in in triage with fever and rash, I sighed with relief, we needed a simple case as a diffuser. Ironically, one look at the patient I knew this would not be the case. The chief complaint at triage was rash with a medical history of eczema…but wow, I’d never seen anything like this, examining the rash made me want to cover him in moisturizing lotion. Aside some common crying while I was doing the physical exam, the rest of the exam was unremarkable. But after speaking with his mother, something didn’t sit right with me. As I presented the case to my attending I couldn’t suggest discharging the patient with a stronger emollient and topical steroid, “something just does not feel right, he has fever and progressive symptoms for a week and unresponsive to treatments. Would be justifiable to obtain a CBC?” ….she was hesitant at first “Okay let’s go in there together and see what we can do.” It was not until Dr. X examined the rashes that I noticed a parallel to when I examined him. The patient was giggling and pleasant until his left arm was moved. “Has Eddie hurt is left arm recently? Or have you noticed him not moving it as much?” I asked Eddie’s mother. “Injured? No, I don’t believe so…but now thinking about it, he has not been holding up his bottle on his own like before. But I attributed to fatigue from whatever virus he caught,” replied Eddie’s mother. As Dr. X and I walked out of Eddie’s room, she looked at me and said, “I agree, something’s off here. Let’s order a full lab panel and maybe that will give us a hint.”

What is taking so long? It’s been almost 3 hours since they drew blood and we’re still waiting for the results to come back. I’ve been pacing this room for 45 minutes, there’s so much commotion outside, I’m just praying that they don’t send us home again. Just as I was about to call for an update, Dr. X and the medical student entered the room and by the look on their faces and it was not good news. “OK the results came back unfortunately I think we’re going to have to transfer Eddie to our sister hospital, it looks like Eddie has an infection but at this point we don’t know it’s origin but his white blood cell count is elevated at 24,000 and spiked a fever within the last 30 minutes. I suggest we transfer him to a facility where he can get an accurate MRI of his shoulder, the machine here is not equipped for a patient his size,” explained the pediatrician. I sat there staring at them for 30 seconds, questions popping up every millisecond, I didn’t even know what to ask first, ‘his white cells are high? What is that? They don’t have an MRI machine? Are they doing what the other two providers did and shipping us off because they don’t believe me?’…I guess the student saw the panic in my face, “tranquilla, el va estar bien,” she said. Maybe it was my fear and need for my own mother at this moment but hearing my native language, brought me to tears but simultaneously gave me a wave of comfort. It was like I’d forgotten English, I’ve spoken English most of my life, so why when I need to communicate the most I revert to Spanish and had to ask the student to repeat everything they’d said in Spanish?

The hospital transport team arrived two hours later to take Eddie and me. The next few days are now a blur, from MRI to surgery and multiple IV access attempts, until we finally got the news we’d be discharged tomorrow.

It’s been three days since my last shift and we transferred Eddie to our sister hospital, so the first thing Dr. X and I did when arriving today check his chart to find Eddie was diagnoses with septic arthritis at his shoulder which was surgically drained, placed on antibiotics and was being discharged today. We decided to call Eddie’s mom to see how she was dealing with the diagnosis, “I cannot thank you for taking the time to listen to my concerns and not dismissing me as a paranoid mother. The pediatricians here said if you all had not pushed for the MRI, Eddie’s state could have become critical,” she said.

Now I think about this case every time I hear a patient say, “I might be overacting” or “I just have a bad feeling,” because regardless of how many times I see a similar clinical presentation, each patient is different. If Dr. X and I would have assumed Eddie’s symptoms were like the other three “skin rash” chief complaints we had seen the day we met Eddie, his condition could have worsened. As I continue to pursue my career in medicine, I am consistently reminded about the importance of detail and knowing the patient and their family and how the slightest detail can change a diagnosis and treatment.












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