“Can we pleeease feed that little girl in room two,” the nurse pleaded. “Her mother is driving me craaazy asking if she can go down to the vending machines and get something. I think she needs to smoke and needs an excuse to leave the baby with the dad. All she has is a bladder infection.”
“I haven’t seen any of her labs yet,” I responded, trying to change my focus from the chart in my hand to the one in the nurses head.
“Oops, there she goes. I’ve been telling her that she needs to wait for your decision, but I guess she got tired of waiting.” As she passed, I watched her fumble in her purse and produce a pack of Winstons. The patient was a cute, chubby little red-headed two year old who was sitting calmly on her father’s lap.
“But she’s got diarrhea and a fever,” I protested to the air, the nurse having turned away already. Oh well, I thought, now that I’m thinking about her, maybe I can sort this out before the mom comes back. I started thumbing through the chart of lab results.
The UA wasn’t negative. But it wasn’t really positive either. The dip stick was negative with two lonely white cells, five red cells, and a few epithelial cells on micro. No bacteria. And leuks and nitrites were negative, too. “I wouldn’t call that a bladder infection,” I mumbled to myself. “Ooo, what’s this?” I paused after seeing the CBC. A white count of 24 thousand. “Ninety-four percent segs. That’s certainly not good.” It surprised me given how good the patient looked.
I rolled my chair over to the PACS monitor and began scrolling for the little girl’s name. I had ordered a two view abdomen almost reflexively. I didn’t really expect a volvulus or intussusception. In fact, I hadn’t really expected anything. To be honest, I don’t really know what I was looking for. It was just an old habit. But there it was. Sort of. There was a slight suggestion of a partial ileus. Maybe some mild air fluid levels. It wasn’t dramatic, but there was too much gas in the left upper quadrant and not enough in the right lower. “What do you think?” I asked the other attending who was walking by the monitor.
“Pretty non-specific, if you ask me,” she said. But she did pause to stare at the film. “I wish there was more gas in the right lower quadrant. Could this be an appendicitis?”
“I suppose it could be. But she really doesn’t have abdominal pain,” I explained. She has a sore throat and a fever…a some diarrhea. That’s probably where her fever is coming from.” I had to admit that I’d considered appendicitis. But in a two year old? I tried to talk myself out of the diagnosis. “Do you know how rare appendicitis is in a two year old? What would be the ‘pre-test probability’ on that CT?” I said sarcastically.
“Five percent of all appendicitis occurs before the age of four is what I remember,” she said. “But it is possible.” All I could think of was the headache of getting a CT in this little girl. Our scanner was down, so the only alternative was the pediatric hospital about an hour away. “I hope I don’t get that uppity radiologist I got last time,” I muttered to myself. “He already thinks I’m ordering too many scans.”
I made the call to the peds ED and oversold the case a little. “Was the kid’s abdomen rigid?” the attending asked me before accepting the case. “Not ‘rigid’,” I said, exaggerating the term. “But she’s very, very tender.” As I spoke I stared across the ED at the child sitting calmly on her father’s lap. Ok, well maybe not very, very tender, I thought to myself, but she did stop playing to grimace when I palpated her abdomen.
“OK,” he said, finally. But I could hear the groan in his voice. Just then the mother returned reeking of smoke and carrying a coke and a bag of chips.
“I’m sorry, ma’am, but you can’t give her any food,” I almost shouted across the ED. “We’re sending her across town to the Children’s Hospital for a CT scan. She might have appendicitis.” The mother’s face grew red and I thought she blew smoke out her ears. It was clearly a case of the child’s mother getting more than she bargained for. To her credit, she knew her child was sick, but she couldn’t, or wouldn’t think beyond her own expectation of a quick fix.
The next morning, as I related the night’s events to my wife in our usual morning after briefing, she couldn’t wait to get to the bottom line.
“Well, was it appendicitis?” she blurted out without waiting for my extended story to unwind.
“Actually, it was. And it was perforated,” I said, feigning modesty. “She probably felt better because her appendix had ruptured.”
“Did the emergency physician ever call you back and apologize for giving you grief?” I love how she’s always so protective of me.
“Actually, he did, sort of. He told me that after his first exam of the patient he thought I was full of crap. And after he had to deal with the mother, he thought I was a lazy bastard of dumpmeister.”
“That’s an apology?”
“Yea – he was laughing. Because when he got the CT results, he realized it was kind of a gutsy call.”
“Did she do OK?” my wife said with her typical motherly concern.
“Oh, yea, the kid will do fine. But she wouldn’t have if she’d been sent home with diagnosis of sore throat.”
“So how did you know? How can you be so sure all the time.”
“You don’t,” I said with a sly smile. “And I’m not sure all the time. But you can’t let anyone else know. ‘Don’t let ‘em see you sweat,’ I always say. I told that guy at Children’s that this was a slam dunk appendicitis.”
“You always were pretty sure of yourself. Even when you were dead wrong,” she smiled shaking her head. “I can’t believe how many times you’ve talked me out of the right answer.”
“Hey, baby, if you don’t have a touch of ‘I know I’m right’ you don’t belong in this business. But the truth of the matter is that I’m not right all time. That CT could just as easily been negative. I’d look like idiot and the mother would have been ready to string me up for irradiating her little girl. And now the government and insurance is getting into it and they are trying to deny payment for “unnecessary testing”. But that’s how you find the zebras.”
“But now there is more of a down side to hunting for zebras,” I continued. “You have to be right all the time. And that’s pretty hard to do. You want to know what I feel bad about, though,” I said as if suddenly feeling the need to confess. “I really wanted that little girl to have appendicitis, so I wouldn’t look like a fool. I feel like I caused her to have appendicitis.”
“That’s silly,” she said with a scowl. “You didn’t cause her to have appendicitis.”
“I know. But in the past I’d do a test and hope that it was negative. Now it’s just the opposite. It’s strange. I don’t like it.”
She paused, seeing that I was really struggling with this.
“They say that To err is human,’ but the tolerance for error is getting so narrow.”
“I know you may not want hear this,” she said cautiously, “but that’s progress.”
Mark Plaster, MD
Founder and Executive Editor of Emergency Physicians Monthly