The Family Toole

I'm working in the ER these days. I've gotten to see some interesting cases. For example, yesterday evening, I palpated my first "olive" in an 8 week old who presented with vomiting and constipation.

I also had the opportunity to sow up a pretty impressive laceration of a 2 year old's left middle finger. The kid's bone was exposed and the finger nail was hanging by a thread. It was fun!

Last night, I was on with Brian McAlvin. When it got a little bit quiet early in the evening, we decided to make up an admission to call up to Jon, who was the admitting resident as a joke. We came up with something pretty good... it was decided that I would be the one to tell Jon about the admission because it would be more believable coming from me. Here's how it went:

"Hey Jon, I have an admission to tell you about. This is a 16 year old male with cerebral palsy and mental retardation secondary to congenital rubella who presents with increased oxygen requirement and fever.

Respiratory-wise, he is trach and vent dependent and is on a baseline of 21% O2 through his humidfied trach collar, and right now, he's requiring 40% of oxygen. We got a chest xray that is concerning for aspiration pneumonia given bilateral insterstitial infiltrates. The film also shows an enlarged heart.

In terms of his cardiovascular status, he is status-post AV canal repair as a baby and is on lasix and aldactone for what mom says is depressed left ventricular function. We asked about an echocardiogram. She says there was one done some years ago, but she wasn't sure what the ejection fraction was.

He is also G-tube dependent and is status-post fundoplication and has issues with severe constipation requiring daily Miralax. We spoke with GI and they recommend a clean out, but we haven't yet placed a nasogastric tube. He takes Nutren formula 1.0 strength through his G-Tube. The patient came is looking pretty dehyrated with dry mouth and lips and cool extremities and tachycardic. We gave him 2 boluses of normal saline at 20 cc/kg and held his lasix.

Of note is that he is 3 weeks status-post testicular torsion that resulted in an orchiectomy of his left testicle. The mother thinks that after this surgery is when he really when he started to get sick with difficulty breathing and high fever.

Laboratory results have revealed a leukocytosis of 29,000 with 79% neutrophils, hemoglobin of 11.9, hematocrit of 33, and what looks like a reactive thrombocytosis of 506."

Jon interrupts periodically with "uh oh," "ok." Finally at the end, he asks me a few questions. The most important being, "Do you guys think he's ok to come to the floor or does he need to go to the step-down unit?"

"Yeah, we were talking about that and he's actually pretty stable on 40% O2, but he desats to the 70's if we go below 40% oxygen."

"Has he eaten anything by mouth?"

"Well, mom gave him some food by mouth because she thought he was hungry and didn't want to see her child go hungry, but he has a history of aspiration. He's supposed to feel only through his G-tube. The family is Spanish speaking only and I'm not sure they really understand that he can't eat by mouth."

"Have you gotten a blood gas yet?"

"No, we haven't." This was a dumb answer actually, because any moron would have gotten a blood gas on this patient if he was real. I should have made something up.

"Alright. Well, I'm going to come down and look at this kid because I'm really suspicious that this kid would be ok on the floor. He sounds like step-down material to me," says Jon.

"Ok." I wanted to tell him the best part, that the patient's name was "Ima Toole."

Jon came down and started talking to the ER attending, who totally went along with the story. We told Jon that the patient was in room one, but that he couldn't go in because they were placing a Foley catheder. Jon came up to me and asked, "Are you guys making this up?"

I said no, with a straight face, I think...

Brian eventually told Jon that we made the whole thing up. Jon claims that he knew we made up the patient, and said that the fact that the family was Spanish speaking tipped him off. "Less is more," was his advice for us. We'll keep that in mind for next time :)