ER Day 7: Office Politics

You know those awkard "political" moments in the workplace? I had my first experience with that today. I was spending some time in the Pediatric ER today (basically the back corner of the ER where they stuck a couple cribs). I saw a bunch of people bringing their kids in with fevers to get some free motrin, a couple ear infections, then the holy grail of the day: a rash!!!

Rashes are kind of fun to diagnose in kids. Based on the distribution of the rash, associated symptoms, and timing of onset, you can create a cool differential and narrow down the list of suspected causes. For some reason rashes are one of the things that really stuck in my head. Anyways this kid had a very classic rash presentation: he was young- only 10 months old, the rash was on his hands, feet, and in his mouth. The kid had no fever, up to date on his immunizations, and no other symptoms except the rash. My thoughts immediatly ran to coxsackie virus. Some other students at the hospital were saying they've seen a lot of cases of it recently, and the presentation was exactly like coxsackie aka "hand food and mouth disease". I told the mother my clinical suspicion, but that I had to run it by the attending.

I went up to the attending in charge for the day, and gave an oral presentation of the case and my clinical suspicion and treatment plan. My attending disagreed.

He believed it to be related to the childs history of eczema (which was a valid point, it could have been, but it really didn't look like it.... who am I to say, I'm still a newbie). The attending then goes on to explain that if it is an eczema related flare up, he had to chose between treating with steroids or antibiotics. If he gives steroids and there is a bacterial infection there, the rash will get worse. But if there is no bacterial component and gives the antibiotics, the rash will also get worse. The attending decides to call in a pediatric resident for a consult.


When the pediatrician comes down, I follow like a diligent student to learn how a pediatrician evaluates the patient (and also to play with the patient's adorable twin sister). The pediatrician does a quick exam and looks at the rash and says: "This just looks like coxsackie". The mother turns to me and says "thats what you said!".

I decided to let the pediatrician give my attending the news, and didn't mention the case again.

Things I saw today:
-A grade 4 bed sore (you could see her muscle and almost down to her bone!!)
-Pancreatic cancer patient with a likely DVT (cancer patients, especially pancreatic, tend to clot easily and are prone to them)
-Fluid overloaded renal failure/congestive heart failure patient that we intubated

Things I did today:
-Replaced a suprapubic catheter solo (the attending just handed me a kit and said "you've seen one done? go do one")

http://splicd.com/CcKmAuhpOBE/213/224 (pretty much how I felt when I was doing it)

-Did an arterial blood gas by myself
-Helped intubate our fluid overloaded patient