“Baby won’t stop crying,” was the chief complaint. How many times have I seen that in the last 25 years? I never know what to expect. It could be a baby with simple nasal congestion who can only breathe well through her mouth…when she is wailing. It could be an infant with a life-threatening intussiception. A lot of things swirl through my mind as I traverse the ten yards from the ‘Doctor to See’ rack to the room.
Oh she was crying all right. The nurse who had placed the mother and child in the room had closed the door in an unsuccessful attempt to dampen the sound. When I opened the door it was like I had stepped onto a noisy factory floor where everyone has to shout at each other over the high pitched whine of a hundred machines. This little girl was making herself known.
“Whoa, wow!” I said instinctively as the blast hit my ears. “What’s the problem, sweetheart?” I cooed to the baby, attempting to assume a soothing voice while reaching out to the mother. The heavy set young mother was clearly at her wits end. She nearly shoved the baby into my arms.
“She’s been screaming like this for hours,” she shouted over the racket. But then it was like someone pulled the plug on all the machines at once. Her mouth slammed shut and the room went silent. She immediately began attempting to touch my moustache with her tiny finger. The mother sat dumbfounded. “Really,” she said apologetically. “She really has been screaming like that for hours. What did you do?”
“Uh, I dunno,” I said shrugging my shoulders. “Are you sick, sweetheart?” I was looking into her piercing blue eyes as she busied herself exploring my face. She had chubby pink cheeks that perfectly matched her pink knit Nike cap. “Or are you just trying to drive your mamma crazy?”
Sick or not sick. That is the question. Oh, it sounds so easy. And sometimes it is. But every time you get comfortable and think, “ah, this is an easy one,” beware.
As I gently bounced around the room carrying the baby, two conversations were going on simultaneously. One, on the outside, was my time worn litany of questions, repeated thousands of times over the years, they seemed to roll off without conscious thought. “How long has this been going on? When was her last wet diaper? Has she been around any sick children? And so on.
On the inside was a cacophony of voices, some urging me to get on with the nights ‘more important cases’, some warning me to look for the tell-tale signs of impending disaster, some just telling me to enjoy the break from the drunks and drug seekers. One of the voices, coming from the remote past, offered a bittersweet warning.
“He’ll be fine,” I had told my wife after hearing her worry about our own four month old who was coming down with croup. I had just finished a long shift at the local pediatric ER and was too exhausted to consider the possibility of another sick kid. “Put him in here by me. I’ll watch him,” I had said absentmindedly as I plopped down on the couch to watch some post-season playoff football. “You can take a nap. I know you’re tired.” It sounded considerate, but really I just wanted to watch football.
“I think he’s sick,” my wife said raising her voice while stepping between me and the TV. She shoved our little chubby boy towards my face. He had just the slightest gray cast and the weak retractions and soft stridor of early respiratory fatigue. It caught my breath.
“I think we need to go back to the hospital,” I said slowly to my wife, trying to appear calm. It was as if I was speaking to someone who had just stepped on a land mine, but had not triggered it yet. “I’ll get the car. Don’t worry about what you’re wearing.” The drive into the hospital was quiet except for our babies soft crowing. As to be expected, he had improved some by the time we arrived, after being exposed to the cool night air. My partner was still on duty. We were apologetic. “I’m telling you,” I said to my skeptical partner. “He looked pretty sick.”
“Gray, huh?” he said with a paternal shrug. “I guess we have to get an ABG.”
“Do we have to?” It was the first time I had experienced the consequences of my words. I wanted to bypass the workup and get right to the therapy.
“Would you order a gas on some other kid if their parent said they had turned gray?” It was the first time I had faced the possibility that being too close could really be detrimental to good care.
“Let’s go for a walk,” I told my wife as I pulled her out of the room. “Let’s let them do their work.” My wife still swears that she could hear his cries from the other end of the hospital.
“He was acidotic,” Tom said when we got back. “We got cultures and did an LP just in case he was septic. He’ll need to go to the PICU. We might need to tube him for safety.”
“Try not to if you can,” I began to plead. But before he could return a reasoned response I stopped him. “Just do what you have to do.”
I spent my 30th birthday working in the Peds ER by day and sleeping in the PICU waiting room at night. The heliox mixture that they placed him on to decrease the airway resistance made his crying sound more like a duck than a baby. His tiny chest would collapse almost to his spine as he attempted to breathe on his own. But then he would smile…and quack.
“Do you have children?” the mother asked, pulling me back into the present.
“Yes,” I smiled, suppressing the urge to pull out pictures of children and grandchildren. I finished the exam looking for petechiae between the toes, checking for nuchal rigidity several times, and any other potential catastrophe that I could think of. I covered every base twice before handing her back to her mother. She immediately started to fuss again.
“That’s frustrating,” I said. “I thought we had her. Let’s try feeding her a little and see how she does. I don’t hear you telling me anything that raises red flags. The vital signs are fine and the physical exam doesn’t show me anything. Let me see how she does and then we’ll decide whether we need to do a workup.” As I exited the room the debate was still raging in my head, but the “not sick” votes seemed to be winning.
Several times I popped back into the room to observe the baby. I had done nothing except dance around the room with the baby and talk to the mom. The baby was a little calmer, fussing and grumping, but now only having brief periods of screaming. Was she sick or not sick? Sometimes I really wished I’d gone into orthopedic surgery. Finally it was time to fish or cut bait. The baby was back to screaming and the mother was looking exasperated. I walked back into the room and picked up the baby again. This time her screaming continued unabated. The voices lobbying for ‘sick’ were also getting louder in my head. “I guess we’ll need to check some things on the baby,” I shouted over roar as I danced about the room wildly patting her diapered bottom. Suddenly there was this explosive sound that came from her back side that sounded like I’d jumped on twenty ketchup packets. “Whoa, did that come out of you?” I said to the Beany Baby in my arms. She stopped screaming, looked up at me with a look of dreamy satisfaction, and fell sound asleep.
Not sick, I thought to myself with a sigh of satisfaction. I asked the nurse to grab a big pile of wet wipes as I quickly made for the door. “I don’t think you need any labs or X-rays, sweetheart. You just need a clean diaper.”
Mark Plaster, MD is the founder/editor-in-chief of Emergency Physicians Monthly
Pictured with his boys (Christmas '82)