Wednesday, August 3, 2011

Kids and Their Fascination with Foreign Objects!

I was working in a rural clinic and went into see my next patient.  She was the 7 year old daughter of my medical assistant.  He had been called by his daughter’s school nurse during her lunch time due to her having suddenly started to wheeze.  He had just arrived back with her and needed me to see her urgently.
            Little Melissa was noticeably wheezing and was in acute discomfort sitting on the exam table.  I turned to my medical assistant and asked him her medical history which was not significant.  He then said, “they told me at school that she was playing around with a quarter, showing off to a friend when all of the sudden the quarter disappeared and she started having problems with her breathing.”
            “Okay, Melissa did you swallow the quarter?”
            Painfully she turned her head from side to side giving me a negative response.
            “Where does it hurt, Melissa?”
            She pointed to just below her neck area at the top of her chest. 
            “Hmm, okay, well Melissa, let me take a look at you.”  I quickly examed her throat, nose and felt her cervical lymph nodes (in the neck).  Nothing was out of the ordinary.  I then listened to her chest with my stethoscope.  She was wheezing everywhere with inspiratory stridor (a sign of a foreign object blocking the airways) heard over the upper midline. Her cardiac sounds were fast, with a pulse of 120.
            With the idea in mind that she could have potentially swallowed the quarter and it was stuck in her trachea (airway) or her esophagus (swallowing tube) I sent her across the street to the county hospital to get a plain film of her chest done.  I expected to see her back rather quickly, knowing it would only take about 30-45 minutes or so to get it done.
            When an hour and a half had gone by, as I had continued to see patients, and she hadn’t showed back up I was really beginning to wonder.  I called the county hospital radiology desk to find out that she had been seen, her x-ray had been taken and she had been sent back over to the clinic more 30 minutes ago.    
            I walked into the front reception desk area of the clinic to find the receptionist gone.  She was Melissa’s mom.  So now, the clinic didn’t have any staff but me, her father, the clinic’s medical assistant had taken her over for the x-ray, and now her mom was gone. 
            “Great, my patient has gone who knows where, and I have no staff to help me see patients.”
            Just then, one of the medical assistants from next door, which housed the family practice clinic of my two supervising physicians walked in the back door of the rural health clinic.
            “Dr. Spencer sent me over to help you out with the patients needing to be seen.”
            “Okay, thanks for the help.  But where is Melissa and her parents?”
            “They’re next door, Dr. Spencer is trying to figure out how to get the quarter out of her esophagus.  It’s sideways, about right here as she pointed to the upper midline of her chest.”
            “I see. Well can you check this next patient in, get their vital signs and I’m going to go next door and see what’s going on, seeing that she was my patient.”
            “Sure.”
            I quickly walked next door, went in the back entrance and walked towards the commotion.  Dr. Spencer was leaning over a squirming Melissa on the procedure exam table.   Her parents were unsuccessfully trying to hold her down, in an attempt to keep her motionless. 
            “Melissa,” Dr. Spencer sternly spoke, “stay still.  I’m going to try to have you swallow the end of this tube and if you can do that I might be able to wiggle the quarter back up.”
            I could hear her wheezing and trouble getting her breath.  Melissa was also crying and more than likely scared. 
            “Dr. Spencer could we try to have her swallow a small amount of olive oil?  That will make the quarter slippery and then you’ll probably be able to joggle it lose and back up if it’s oily, in other words slippery.”
            “Good idea, someone go get a small amount of olive oil out of the kitchen for her to swallow.”
            I knew by now that the patient who was checking in over at the rural clinic was most likely ready to be seen, so I left Melissa in Dr. Spencer’s hands.  I walked back to my clinic and continued seeing patients the rest of the afternoon.  About an hour later my medical assistant walked in.  His wife, the clinic’s receptionist had put Melissa in the car and was driving home. 
            “Okay, fill me in on what happened with Melissa?”
            “Well, after Melissa swallowed the oil, Dr. Spencer had her swallow the foley catheter tip and with the oil helping to get it to slide down, he then nudged it past the wedged quarter, inflated the balloon on it and started gently tugging on the catheter.  I think the oil made it a little bit slippy because it came lose quickly and with the balloon tip pushing it upwards, Dr. Spencer was finally able to get it back into her mouth, where she spit it out.  Melissa was still pretty upset, but her wheezing quit almost immediately and my wife thought it was best to take her home for the rest of the day.”
            “Okay, well thanks for telling me what happened.  Now it’s back to work for the two of us.”

            Kids will swallow or poke up their noses, or into their ears the strangest things.  I remember during my student days at a well known medical college I was doing a rotation in pediatrics when a 6 year old came into see us.  I went in to take the history and her mom told me that her daughter had a very pungent odor to her, which she couldn’t get rid of. 
            I examined the patient and noticed that she was having some sinus congestion.  The odor seemed to be coming from her mouth or nose, that was for sure.  But I couldn’t figure out exactly where or why. I went into the pediatric attending, presented the patient to her and she went into the exam room and asked this little patient, “okay, Annie, what did you do this time, did you stick something up your nose?” 
            I remember Annie looking rather coy and finally admitting she had stuck an eraser up her nose so that she could know what it felt like. 
            “How long ago did you do that, Annie?”
            “A week ago.”
            “Okay, well then the attending stated, you have a chore to do every day for the next two weeks.  You’re going to have to blow your nose several times a day and blow hard.  You’re going to have to blow out that rubber eraser you sniffed up your nose.  Understood?”
            Annie nodded ‘yes.’

            Another small tyke of 3 years came into the emergency room while I was doing my rotation there and his mom said that he had swallowed his pet baby turtle.  We asked how big the turtle was and the mom said it was about 2 inches in diameter.  The 3 year was acting fine, we did an x-ray of his abdomen and there was the turtle in his stomach.  This 3 year was sent to surgery to have the turtle removed due to the concern that the turtle could perforate the child’s stomach with his paws. 

            When you work in pediatrics you have to be prepared for many things.  You have to be inventive in retrieving foreign objects out of a child’s nose, ear canal, airway and esophagus (swallowing tube). 
            Thankfully, Dr. Spencer had the ingenuity to try using a small foley catheter with a balloon tip and it worked.  Otherwise she would have ended up being emergently sent to Houston, a hour’s drive away for a pediatric gastroenterologist (kid’s GI physician) to see her and scope her to remove the quarter. 
            Kids really will do the darn-est things!
           

           

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