Sunday, July 31, 2011

An 8 Year Old with Abdominal Pain

I was working in a rural health clinic seeing all sorts of patients, from 2 week old newborns to 90 year olds with congestive heart failure.  It was always something new, a different scenario with each patient, so I was always on my toes. 
            I walked into the next exam room to find a mom with her 8 year old daughter waiting for me.  Only her daughter wasn’t exactly waiting, she was definitely in pain and was trying to stay as still as she could on the exam table.  Her face told the story, tears silently cascading down her cheeks, biting of her lower lip, and her pleading eyes. 
            I introduced myself as the physician assistant in the clinic and asked the mom what was going on with her daughter.
            “She went to bed early last night because she said her tummy hurt.  She didn’t want to eat anything last night except a small bowl of soup.  Then she woke up this morning and said that her tummy still hurt, and she didn’t want to eat anything for breakfast.  She also didn’t want to go to school, which is unusual for her, she loves school.  Then as I was taking care of her younger brother, getting him ready for school, she went back into her bedroom and fell asleep again.  That’s when I had to call into work and tell them that I wouldn’t be coming in because I had a sick child at home.  She finally woke up shortly before lunch and ran into the bathroom where she started throwing up everything and anything that was in her system.  That’s when I noticed she was running a fever of about 100-101 degrees.  Now she says that it hurts down low whereas before she told me that it kind of hurt all over.”
            Turning to her 8 year old I asked her, “okay, punkin tell me where does it hurt now?  Point to one specific spot the hurts the worst.”
            The mom’s daughter, Kelly, put her finger very gingerly on her right lower abdomen.  “Here.”
            I immediately started thinking she could have an acute appy (appendicitis).  So I quickly took the child’s medical history and did a physical exam on her.  When I got to the abdominal exam, Kelly not only had pain over the right lower abdomen but she also had rebound tenderness, which told me that she most likely had peritonitis going on. I had the lab technician run a urinalysis on her to make sure she didn’t have a urinary tract infection, it was as expected, negative.  And Kelly was still running a low grade fever of 100.8.    
            As I walked back into the exam room and advised Kelly and her mom that I thought she had appendicitis, Kelly was again lying very quietly, without any obvious muscular movement on the exam table. 
“Appendicitis is an inflammation of her appendix, which is a small piece of tissue which hangs off the end of the terminal ileum.  It is common in young kids and older adults.”  Looking at Kelly’s mom I said, “she will need to have surgery to remove the appendix.” 
With that, I heard a few muffled cries from Kelly.  I turned to Kelly and told her, “Kelly, you have something inside your tummy which is causing you to have some major pain right now.  The surgeon needs to get that out.  While he does his work, you won’t feel anything, because you’ll be asleep, then after you wake up you’ll start to feel better because that nasty appendix will be gone.  Do you understand?”
Kelly nodded yes. 
I turned back to Kelly’s mom and told her I’d be back in after a few minutes.  I went to go call the general surgeon. 
I picked up the hallway phone and put in a page for the surgeon.  A few minutes later my clinic phone rang and it was an operating nurse answering for the surgeon. 
“Hi, did someone page Dr. Morgan?”
“Yes, I did.  I have a patient for him.  I believe she has acute appendicitis.  She is an 8year old who has been having pain since last night, started having nausea and vomiting at noon today and now has a 100.8 fever with tenderness over the right lower quadrant, she also has rebound tenderness.  I’m going to send her next door to the county hospital ER with orders to do a complete blood count and start an IV on her.  Can you please let him know she’ll be waiting for him in the ER?  Her name is Kelly Miller.”
“I’ll let him know.  He should be done here in about 45 minutes, so he should be down there shortly after that.”
“Thanks for your help.”
I walked back into the exam room and advised the mom to take her daughter across the street to the emergency room of the county hospital.  I told her, “Dr. Morgan will be meeting you over there in about an hour or so, he’s in the operating room right now with another patient.”
 As Kelly’s mom was walking out of the clinic, I handed her the orders for Kelly to get a complete blood count and be started on intravenous fluids for hydration.  I watched Kelly walk very slowly and gingerly towards the hospital. 
About two hours later the clinic phone rang.  The medical assistant gave me the receiver and told me it was Dr. Morgan.
“Hello, Dr. Morgan, this is Sharon.”
“Hi, I’m in the emergency room right now with Kelly, the patient you sent over for me to see.  Her mom has signed the consent forms, they’re getting Kelly ready to go to the operating room.  I just wanted to tell you her exam, and the CT of her pelvis I ordered both showed classic appendicitis.  So she should be on her way to feeling better by tomorrow.  Thanks for the referral.”
“I’m glad she’s in good hands.  Thanks for the follow-up.”
About six months later I walked into one of the clinic exam rooms to find Kelly sitting on the exam table.  Her mom was with her and told me that she had an ear infection and needed some antibiotics.  I was glad to see her.
Playfully I said, “Kelly, I’m glad you came back to see me.  How’s long is your scar from having your appendix out?  Can I see it?”
She grinned, and lifted up her shirt to show me a very short scar over her right lower abdomen. 
“So how long did you get to stay in the hospital and eat ice cream?” I asked.
Kelly gave me this quizzical look like ‘what kind of a question’ was that.  “Ice cream, I didn’t get any ice cream,” she adamantly replied.
Kelly’s mom told me, “she was in the hospital for 2 days, the day she went into the emergency room, all the following day and then was discharged the next morning.  Thanks for taking care of her then.  I really wasn’t sure of what was going on with her, but once that appendix was out she sure recovered quickly.”
“Kids usually do that, they have an amazing ability to get better and quickly.  Now let me see this ear infection, okay, punkin?”



Saturday, July 30, 2011

Enhancing Patient Communications

            I was working in the bone marrow transplant clinic of an internationally known cancer center.  I was learning so much from working there, all of the various complications from having a bone marrow transplant to the long-term problems that can exist in a survivor.  I also saw the hope in patient’s faces as they were being worked up for a possible transplant. 
            I was asked to go in and see a new patient who had been referred over from the leukemia clinic.  She had acute myelogenous leukemia and had relapsed after her remission.  Her sister had been found to be an eligible donor and the patient was being seen just prior to her being admitted for the transplant.  We were going to go over the transplant process and what she could expect. 
            Gretchen came in with her mom for the appointment.  As usual with patients who have gone through chemotherapy, Gretchen wore a bonnet on her head to cover her hairless scalp.  She was 19 years old.  She was tall, youthful looking and had a twinkle in her eye.  Yet, I was to find out, she rarely spoke.
            I introduced myself and explained to Gretchen that this appointment was for us to answer any and all questions she would have regarding her upcoming bone marrow transplant.  After I answered the questions, then I informed her that the attending physician, Dr. Marcus would come in and go over the consent forms with her. 
            “So what questions do you have Gretchen?”
            Gretchen who was sitting next to me at the clinic exam room table, looked over at me, then looked at her mom, then her eyes traveled down to her mom’s purse and stayed there for a few seconds, then she turned her head back to me.  Yet she never said a word. 
            “What questions do you have, Gretchen?”
            Again, Gretchen did the same thing, she looked at me, then at her mom, then at her mom’s purse, then back at me.  Again she didn’t say anything, nor did her mom. 
            I asked a third time, “What are your questions?”
            Gretchen just continued to look at me and then every so often look at her mother’s purse.
            “Hmm, I thought to myself, she has to have some questions, I certainly would if I was looking at being admitted for a bone marrow transplant.”  So once more I asked Gretchen whether she had any questions, but this time I looked her straight in the eyes and changed my phasing to, “Gretchen I’m not going anywhere, I’m not going to leave this exam room until all of your questions have been answered.  So let’s start with your first one, what is it?”
            Gretchen looked at her mother, down at her mom’s purse and pointed to the purse.  Her mom lifted her purse, pulled out 2 sheets of paper and handed them to Gretchen.
Gretchen took the sheets, handed them to me and said, ‘here’s my questions.”
            I opened the folded sheets, somewhat tattered and worn, and realized answering all of her questions was going to take a long while, . . . a long, long while.  She had at least 30 questions written down on the two sheets of paper.
            I looked over her list of questions and immediately realized that she had been carrying this list of questions around with her since she was first diagnosed with leukemia more than 18 months ago.  She had just been adding questions to her list ever since, because she wasn’t comfortable with asking anyone.  No one, including her physicians, nurses on the floor when she was hospitalized, no one had taken the time or even asked her whether she had any questions.  What a shame. 
         She had gone through a whole treatment program, gone into remission, and had now come out of it, was in need of a bone marrow transplant now to go back into remission from her leukemia and no one, absolutely no one had answered any of her questions.  And yet she was willing to trust me with treasured, worn list of questions.  I was honored by her willingness to open up to me about her fears over the unknown.
            “Okay, Gretchen, we have a lot to go over.  Let me go out and tell Dr. Marcus that I’m going to be with you for a while, so that he won’t think we’re lost in the system somewhere, and then I’ll be right back.  After that I’ll go over each and every one of these questions, give you all of the answers you need, is that okay?”
            Gretchen nodded her consent.
            I came back into the exam room a few minutes later after letting Dr. Marcus know of the delay.  I sat down on the rolling exam stool and started in with her first question. 
            As Gretchen and I went through each and every one of her questions and I answered them, she began to quietly cry.  I handed her the Kleenex box nearby to dab her eyes.  An hour and half later we were finally finished with her list of questions.  By this time Gretchen and her mom were holding hands. 
            “Is that all of your questions, Gretchen?”
            Gretchen nodded yes. 
            “Okay, well I’m going to go get Dr. Marcus so that he can go over your consent form and admission orders for tomorrow.  He should be in here in a few minutes.  I wish you the best.”
            “Thank you,” she said.

As I thought back over the afternoon episode with Gretchen I realized something very important.  Gretchen was probably like a lot of patients we see in medicine.  We as providers get so busy and cram our clinic schedule so full that we don’t have the time, nor take the time, when it is needed to answer our patient’s questions.  In so doing, we have done them a definite disservice.  Patients are not comfortable enough to stop us and ask their questions.  We as providers don’t give them permission to ask their questions because we don’t portray the body language necessary for the patients to know they are important, questions and all. 

            We as providers need to learn to communicate better, take the time to answer our patients questions, put our patients as ease, and help the patients to empower themselves to acquire better health for themselves and their family members. 

            We all need to work together.    

            I later learned that Gretchen came through her bone marrow transplant and went back into remission after receiving her sister’s bone marrow. 


Saturday, July 23, 2011

A Common Complication of Diabetes

A 40ish year old male patient came into the urgent care clinic to be seen.  I had seen him before on two other occasions, and we had quickly formed a friendly relationship with each other.  He was with his two daughters, as usual.  I had seen him once previously for cellulitis around his insulin pump injection site, and the second time he had come in with both of his daughters for ear infections.
“Well, hello again, Ed, which daughter is it this time who’s sick, Kate or Melanie?”
“Neither, it’s me.  My right ankle is sore and I’ve got this drainage coming from my previous surgical site.  I don’t know what it is.  Yesterday I noticed that I had a small blister at the site which I popped and yellow to tan fluid came out of it.  It quickly stopped and I put a band-aid on it.  Then again this morning some more tannish fluid came out of it.  I put a clean band-aid on it, but I don’t know what’s going on.  The drainage site is right over where a screw is, it was inserted when I had a car accident two years ago, and broke this leg in 3 places.  I have a rod in my leg as well as several other screws.”
Ed removed the band-aid and I could tell that there was a small amount of fluid that had drained from his leg.  I felt his right ankle and it was somewhat warmer than I expected.

Trauma to a extremity which leads to implantation of surgical hardware is one of the major risk factors for a bone infection, i.e. osteomyelitis.  Another risk factor is diabetes. 
Osteomyelitis can be divided into acute vs. chronic.  This is typically decided on the amount of time the patient has had the infection.  Acute is considered to be less than 6 weeks, chronic is considered to be longer than six weeks.  Another way of determining chronic osteomyelitis is based on the presence of a sinus tract.  If the patient has one, they invaribly have chronic osteomyelitis. 
Bones can becomes infected via the blood stream,or  contiguously (i.e. local spread from the surrounding muscle).

“Ed, I used to work in infectious diseases for two years.  I took care of all sorts of patients who had osteomyelitis.  One of the major risk factors for bone infections is hardware.  They are very conducive for bacteria to grow on. And small sinus tracts like the one you have on your ankle is a tell-tale sign that you have chronic osteomyelitis going on in the bone.  The tannish drainage tells me that the infection is due to one of the skin bugs called staphylococcal aureus.  It’s a common bacteria found in patients who have bone infections.  I need you to call your wife, advise her to meet you over at the hospital in the medical center.  I’m going to write down on a piece of paper, exactly what the nurse who will assess you, needs to know so that you get the attention you need from the emergency room physicians.  Okay?”
“Okay, how far up do you think my bone is infected?”
“The orthopedic surgeons will have to take out all of the hardware, you probably have an infection all the way up the rod as well as all of the screws are infected.  I don’t know what they will be able to leave you with so that you can walk, but they’ll have to decide on that.  Right now, you need to be in the hospital and quickly.  Let me know what happens, okay?”
“Sure thing.”
 I sent him to the closest academic medical center hospital that I knew had a very good infectious disease teaching service as well as a solid teaching residency program for orthopedics.
On the piece of paper I handed to Ed I had written:  This patient has chronic osteomyelitis of his lower right tibia, most likely caused by staphylococcal aureaus.  He has a draining sinus tract on the medial aspect of his ankle where a screw can be felt.   He has type 1 diabetes and is on an insulin pump.  He needs to be seen by orthopedics and infectious diseases services right away.  I then signed my name.  With that, I knew the nurse would not be able to discount what I had written down, whereas she would probably discount the patient telling her this same info, seeing that the sinus tract didn’t look that remarkable having only a mere band-aid over it. 
Ed was on his cell phone with his wife, as I handed him the note to give to the ER nurse.  He quickly left the clinic with his two daughters in tow.

Treatment of bone infections usually last for at least six weeks.  Patients are generally started on intravenous antibiotics and then if possible they are switched over to oral antibiotics, based on their bacterial cultures. 
Cultures of their sinus tracts is a poor corrollary to what is actually in the bone causing the infection.  The gold standard for osteomyelitis is to do a bone biopsy.  Plain films of the involved area are also usually done and are quite helpful.  They can show evidence of the bone infection via the separation of the outer bone lining (called the periosteum) from the bone itself.  Other forms of xraying that helps is to do a MRI or a CT Scan.  If the patient has hardware then you are unable to do a MRI or a CT scan, in this case you can do a bone scan, which is a nuclear imaging study. 
Initial antibiotics for this infection are used based on the usual bacteria that infects bones, i.e. skin bacteria (staphylococcal aureus, staphylococcal epidermis).  Additional antibiotics are then added in based on the results of the patient’s cultures.  They can also have gram negative bacilli or anaerboic (bacteria that live in the absence of oxygen) infections. 

I didn’t hear back from him for a while.  Two weeks later Ed, using crutches came into the clinic to talk to me.  
 “Well, if it isn’t Ed, you’re a happy sight for sore eyes.  Tell me what happened, I’m all ears.”
“First off, thanks for writing that short note for the ER nurse.  She read it, and immediately walked out of the exam room and came back in with one of the emergency room docs.  He took one look at my leg, felt it with his hand, and went over to the phone and paged the infectious disease service.  The infectious disease service resident or fellow, I don’t know which, was there within 30 minutes assessing my leg.  The next thing I knew they were working on my admission papers.  Within 24 hours of my admission, I had been started on IV antibiotics for the bacteria you mentioned, and the cultures came back positive for them, by the way.  They did several cultures of the sinus tract and a bone scan which came back all lit up from my ankle up to my knee where the rod ends.”
“Orthopedics saw me in the emergency room and they told me what you said, all of the hardware would have to come out.  I was on the IV antibiotics for almost a week at which time the orthopedic service finally decided it was safe for them to remove everything.  They told me that they wanted the infection under control before they went in.  The surgeon told me after the surgery, that when they removed the rod, that it was just oozing with fluid dripping off of it, which he said would come back positive for the staph bug, which it did.” 
“They also removed all of the screws.  Then they put this plastic inflatable tube inside my bone from which the antibiotics are slowly seeping out from.  I was told that the tube will continue to treat the inside of my bone with the needed antibiotics for six weeks.  After that the orthopedic service is going to go back in, and remove the plastic tube.  I have to stay on these crutches until after the plastic tube is removed.  I’m also on oral antibiotics, . . . Cipro I think is what it’s called, I take it twice a day.  Then I have to go back and see the infectious disease and orthopedic services every two weeks, until all of this clears up.”
“The infectious disease service told me that I was lucky to have come into the emergency room when I did.  The infection was already beginning to spread into my blood stream seeing that the first night in the hospital I spiked a fever and a blood culture they did became positive for the staph bug. “
“Look at where the orthopedic guys cut me open, see here at my knee and then also on my ankle.  I’m going to have all kinds of scars.  Oh well, I wanted that rod out of my leg anyway,  I just didn’t think it would end up being this way.”
“Oh, I also wanted to say thank you.  Had you not talked me into going to the emergency room that night, and had you not known which hospital I needed to go to, I know I would not have received the care I needed, for this nasty infection I ended up with.  I don’t think too many physicians would have known that a simple little blister, which was draining such a small amount of fluid would be a harbinger of something much worse.  So I just wanted to make sure that you know how grateful I am.” 
“Well I’m just glad that it all worked out and you’re doing much better.  Thanks for coming in and letting me know what happened.”
“By the way, how did you know that I would be infected with that skin bug, staph you call it?”
“The color of the drainage from your sinus tract gave it away.  Tan is always a sign of staph infections.”
Over the next few weeks, Ed fully recovered, got his ‘plastic tube’ removed and returned to work full-time.

This patient will have to be alert to any signs that his osteomyelitis has returned.  Any patient who an episode of chronic osteomyelitis (bone infection) is at a higher risk of having it return.  Pediatric (kids) generally do better overall with this type of an infection because their bone infections are generally spread from the blood and they are easier to clear up.  Pediatric patients also have a better blood supply to the bones and therefore are able to clear out their bone infections easier. 
Diabetic patients are the ones who end up with osteomyelitis of the foot bones, this is partially due to their having other medical conditions such as a lack of blood supply to the area, lack of sensation in their feet which then allows the infection to continue to spread because the patient doesn’t feel anything is wrong.  So if you are a diabetic, please keep an eye on your feet, and make sure to inspect them every night before you go to bed.