JUST AN UPSET STOMACH
The Lauffenburgers were a young family that lived somewhere out in the county. The husband was a local boy who joined the Army after high school. When he returned home from overseas, he married his high school sweetheart. They had three little kids. The youngest was three. The kids were usually healthy, although the parents didn’t routinely take them to the doctor for checkups and immunizations. They didn’t have health insurance and were usually short on cash.
In the middle of the week, their three-year-old came down with diarrhea. She didn’t appear to be very ill. She was eating and drinking. They thought it must just be an upset stomach.
But by Friday, she didn’t seem as playful as usual. And she still had diarrhea. Late Friday afternoon, they considered taking her to their family doctor. But they thought she probably just had a virus and guessed she would be better overnight. They decided to wait until morning and call the family doctor if the girl was still sick.
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It was Saturday morning. My oldest daughter, Darlin’, wanted to shadow me again on my morning rounds at the hospital. We had already been in the building early where I was called to administer the anesthesia for a surgical case. It was an emergency C-section with Dr. Wambo, one of my favorite OBs. Dr. Paul Kreider was the pediatrician who was in the OR to care for the newborn when Wambo and his assistant cut open the abdomen and uterus and wrestled out the slippery baby.
When we had delivered the OB patient to the recovery room and made sure she was stable, we went up to the med-surg ward to make rounds on my inpatients. While we were finishing up rounds, I got a page from the answering service. They connected me to Dr. Kreider who had been called to the emergency room. He said he had a case that he needed help with.
Darlin’ and I wasted no time walking down the steps to the ER on the ground floor. When we walked in through the big swinging doors, the ER was quiet. Dr. Kreider was standing in one of the bays with one of the RNs alongside a young man and woman with two little boys. As we approached, I saw that there was a third, smaller, child lying on the gurney in front of them. She was a cute, little, blond, girl. She was breathing but lay completely still with her eyes shut.
Dr. Kreider briefly introduced me to the parents and excused us as we walked to the nurse’s station. He gave me a quick history of what was happening to the girl on the gurney.
He said, “These people live out in the country down south of here. This girl is three years old. They say she came down with diarrhea about three days ago. They thought it was just a common viral illness. But over the three days, she didn’t get better and started to get lethargic. Then she wouldn’t eat anything. The diarrhea persisted. They never saw any blood. When they tried to wake her this morning, she wouldn’t wake up. They got scared, jumped in their pickup truck, and brought her up here. The girl is comatose. She is in shock. She is breathing but her blood pressure is low. I am going to admit her to the ICU. Can you help me manage her?”
We did not have hospitalists or intensivists at that time. We had to manage.
I told him, “Sure. Have you had time to check any labs?”
“No. We can draw some stat labs now and look at them when we get to the ICU.”
“OK. Why don’t you let me draw some blood gases and other labs at the same time. When we get upstairs, I’ll start an IV. We should put an O2 mask on her now.”
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In just a short while, the girl was admitted to the ICU. Dr. Kreider was there. He had asked the family to wait in the adjacent waiting room with other families who had people in the ICU. When I saw the results of the arterial blood gases, I told him that the patient needed to be on a ventilator and needed an arterial line. I asked the RN to help me, and she brought a respiratory care tech and the crash cart. The child was unresponsive when I started an IV, intubated her, and put her on a ventilator. I put some ointment in her eyes and taped them shut. Then I put in an arterial line to monitor her blood gases.
The labs were consistent with a working diagnosis of hypovolemic shock. With some IV fluids and oxygen, she seemed to stabilize but remained comatose.
Dr. Kreider and I had both had ICU training in our residencies at different university hospitals. He was still in his twenties and new to the hospital staff. Like most community pediatricians, he did mostly outpatient, office practice, with only a few hospital admissions. Neither he nor I were pediatric intensivists. After we got a look at all the lab reports, he decided not to manage the case overnight. While Darlin’ and I were still there, he got on the phone and was busy arranging an emergency transfer of the girl by ambulance to the University hospital where she could get specialized care.
After he had made that call, he went to the waiting room and spoke with the parents. They were crying when he told them, “Your daughter is very sick. She is in shock from losing so much fluid from her body. We have stabilized her for now, but she needs to be in the University Hospital where she can get specialized care.”
The mother, sobbing, asked, “But is she going to be all right?”
“She is very sick. She is stable for the moment, but I’m sorry to say, you could lose her. That’s why the ambulance is on the way here right now to take her to the University Hospital.”
I went to the girl’s bedside and checked her vital signs one more time. Dr. Kreider thanked me for the help. Darlin’ and I left the ICU.
*******
The transfer went off as planned. The family followed the ambulance to the city to be with their daughter in the University pediatric ICU.
I saw Dr. Kreider while making rounds the next day with Darlin’. He told me he had called, and the girl was stable but still comatose and on the ventilator.
We saw Dr. Kreider again a couple of days later. He told us the girl had died during the night with her parents by her side.
There was indescribable sadness about the case. When I told Darlin’, she cried.