The volume is high the pace is fast – the resident working “same day” at our clinic sees the urgent patients who can’t get squeezed into their primary MD’s schedule that day. Emphasis is on addressing the CC, treating what you can treat and then pointing the patient in the right direction i.e. the ER, their clinic Primary, the appropriate Consultant or back to their nice cozy home.
With an MS4 on his Primary Care Clerkship as a tag-team partner, we had battled through most of the afternoon’s patient load, a 50 year old with a URI, a 2 year old with a URI, the 2 year old’s mom with morning nausea after quitting a 10 day course of provera, a 94 year old man with a 4 week history of “bug bites”, a 3 year old Hmong girl with 3 days of vomiting and 2 deaf, non-verbal parents who had somehow lost their ASL interpreter. Got a little slowed down doing an I + D on a boil on a 2 year old boy’s chest while the Med Student charged ahead to scope out a 60 year old gentleman with increased urinary frequency and a whole body rash.
We were closing in on the end of the day, when I was interrupted in the middle of seeing a guy who came in intoxicated asking for Percocet by the MA informing me that my next add-on was a 4 year old with a fever of 102. After jotting an order for some Motrin, I moved to the next room to see a charming man in his 50’s who had GERD for years and wanted to try some stronger medicine… and by the way, food kept getting stuck when he tried to swallow and he would vomit.
Finally I got a chance to re-group with the med student and we both went in to check out the sick 4 year old. He was laid out flat on the exam table with his mom’s coat over him breathing shallowly, barely moving. Got the coat off of him STAT. He was arousable but listless. Looked sick. Trying to finesse the quick story from the mom: He had stayed at his father’s over the weekend. He was ok when she picked him up last night, but got very lethargic this morning and became less energetic throughout the day. I asked if anyone was sick at dad’s did he – “We don’t talk so I don’t know.” She replied. Had he had any symptoms? “No.”
Started to question the child and the only response was a glassy eyed stare. Starting in on the Exam: his skin was warm and damp. Heart was tachy. Lungs were tachy and clear. Belly was soft. Pupils reactive. Lifting up his limp neck, flexing his chin toward his chest – he tensed immediately, his feet kicked up in the air, he cried out and then flopped back down onto the table. I glanced across at the med student. He seemed to have seen the same thing as me. Does your head hurt? Weak nod yes. Once you think meningitis you have to rule it out.
Rechecking his vitals, his temp was now up to 105, still tachycardic, and tachypnic. With the kid this sick and no LP kit in the clinic we decided to EMS him to St. Paul kids. We threw a mask on him for transport and convinced mom that somebody else should pick up her kids from school while she got on the ambulance.
The day wrapped up with a 9year old girl who failed ketoconazole treatment for ring-worm on her leg and now had lesions cropping all over her back as well.
After a high five with the med student and the MA it was time to go home.
Posted by Dr. Will
