by Barbara Ebel
The paramedic asked him more questions about his health history and made a big deal whether he was allergic to any medications. Soon the ambulance stopped and the two men wheeled him out and into more bright lights. Faces peered down at him as the stretcher stopped in a curtained cubicle.
The drapes flung open and Anne Owens burst in. She ripped her glasses off, rubbed tears away, and then stuck her glasses back on. “Oh my God!” she exclaimed. Toby’s father, Jack Owens, ended up at the end of the stretcher while personnel hooked Toby up to monitors.
Toby’s heart pounded in his chest with all the commotion. He heard the paramedics tell the doctors what happened and then his mother echoed his health history all over again. Someone stuck a needle into the IV port, and a few seconds later, the pain in his leg eased away like a calm after a storm. Next thing he knew, he was in a different, dark room, where an X-ray tech manipulated him on a table to snap the leg images that a doctor ordered.
Toby dozed off and woke in another quiet room near a large machine. “Toby, go back to sleep,” a young woman said. “We’re going to give you a ride into the CT scanner.”
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An orderly wheeled Toby back into his cubicle and Mr. and Mrs. Owens jumped out of their seats. A middle-aged man wearing a surgical hat and white coat followed close behind. “In all the commotion before, I’m not sure if I properly introduced myself. I’m Dr. Castle, the orthopedic surgeon on call tonight.”
With enthusiasm for his job, he pushed the X-ray he carried up on the view box. “With Toby’s accident, and pain, tenderness, and bruising in that right leg,” he said, “you both have probably assumed correctly that your son has suffered a broken leg.” He pointed to the film. “His fibula, which is the outer, smaller bone of the lower leg, has a shaft fracture - a break right in the middle of the leg.”
As her pupils dilated, Anne Owens rushed her hand up to her mouth. Toby vaguely listened but grasped the important points and formulated questions. No more basketball and would he be able to walk? What about school?
“Your son is very lucky that the larger bone next to it, the tibia, is not broken and that he does not have an open fracture.” He glanced at both adults.
Jack Owens grimaced at the film. “Can you fix his break?”
“Yes, with a closed reduction. I can set the bone without surgery so that it will grow back together. However, the procedure is painful and I don’t want to expose him to that, especially at his age. Better for all concerned if we take him to the OR for IV sedation or a general anesthetic. The anesthesiologists are experts at taking care of airways and sedation while I do my job.”
Anne and Jack glanced at each other and nodded. “Whatever’s best for our son,” Anne said.
“Then I’ll put him on the OR schedule. After a bone breaks, it is best to realign the ends as soon as possible, which will also lower the risk of infection in the bone.” He nodded with encouragement. “We’re admitting him to a room. It may be a few hours, so you all may be more comfortable waiting upstairs. After surgery, he’ll go back to the same room until I decide about discharging him.”
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Thursday morning, Bob Palmer strolled into his pediatric hospital team’s office in fine spirits. After a day of rest after call, more studying under his belt, and time with Oliver, he was energized for a new day.
Linnell and his chief resident, Rick Mares, were slipping into their white jackets. Rick was an effective team leader and teacher and overly zealous about tackling his last year in residency. He had a pinched nose and a small chin and his long strides in the pediatric hallways were difficult to keep up with. He put his index finger on a piece of paper on the table and glanced at both students.
“We’ve been asked to do a consult this morning. Why don’t one of you get started with it and report back to me while I start rounds with the other students?”
Bob guessed Nell would deliberately pretend to be thinking about it; she was skilled at deflecting work when she wanted.
“I’ll do it,” he said.
Rick handed him the piece of paper. “Patient’s name is Toby Owens and he’s eleven years old. Consult says he was in a car accident last evening and suffered a broken fibula. Dr. Castle did a closed reduction under anesthesia in the middle of the night and the kid just got back to his room an hour or two ago.”
“So why does the ortho team want pediatrics involved?”
“Apparently, the kid already had a fever in the OR. Dr. Castle is being cautious and not sending him home today. There’s always a chance for infection in a bone break and he would rather have us overseeing any medical concerns.”
Bob stuck the paper in his pocket. “I’ll go see him and talk to the family if they’re there.”
“The basics, Bob. An H&P and anything pertinent.”
Bob slipped through the office door while Nell pretended to be studying the team’s list of patients on the board. He left the pediatric floor and headed to the orthopedic wing, where there were no cartoon character pictures hanging in the hallways and no rooms designated for play therapy.
At the nurses’ station, he stood aside and went through Toby’s chart, which was up-to-date with his admission information and the surgeon’s operative procedure note. He strolled into Room 532 where the youth was semi-inclined in the bed and focused on the drip, drip, drip of the IV fluids hanging from the nearby pole.
“Hi, Toby, I’m Dr. Palmer, a medical student in training. Sorry to see you laid up like this, but I’m glad you are not more injured from the car accident. Hopefully, Dr. Castle will have you back on your feet in no time.”
Toby curled his lips with displeasure. “I don’t ever want to be in an accident again. Totally scary. Anyway, a physical therapist is supposed to come by later today to show me how to walk with a cast and crutches.”
“You’ll do fine, especially since you’re at the age when you’re playing sports and are fit and growing. Are your parents around?”
“They went to eat. They stayed all night long.”
“Can I ask you some questions? The orthopedic doctor asked my team to look over your medical care during your short stay in the hospital and I’ll report back to my chief resident. We cover pediatric patients in the hospital.”
Toby nodded and looked back up at the IV bag.
“I suspect they’ll shut that off soon,” Bob said. “Especially since you’re probably famished and will be eating soon. Breakfast should be on the way.”
“The nurse and I talked about that. I don’t really want to eat because I feel nauseous.”
“Maybe that’s because of the anesthesia you had and it’s still wearing off. They can give you a medication to alleviate that sensation.”
“She did. Anyway, they don’t want to ditch the fluids until my stomach settles down and I eat something.”
“Maybe by lunch time, then. So, looking at your chart, it appears like you’ve been healthy growing up. Do you have a regular pediatrician?”
“Yeah. Dr. Gillespie’s my doctor. I just saw him this week for my school physical. Do you know him?”
“No. But my medical school friend is with him in his office for two weeks and I will be soon. I guess you’re up to date with all your shots.”
“Besides Dr. Gillespie, my mom makes sure of it.”
“Super.” Bob pulled his stethoscope off from around his neck and stepped up to the bed. “Mind if I examine you?”
“You don’t need to stick your finger up my butt, do you?”
A woman’s and man’s voice approached the door, and Anne and Jack Owens entered. “Another doctor?” Anne asked.
Bob finished raising his eyebrows at Toby’s remark and turned around. “I’m one of the medical students on the pediatric service. We’re going to offer assistance to the orthopedic service in taking care of Toby.”
“Good,” Anne said. “Obviously, we’re his parents.”
“Toby was just telling me of his nausea after his surgery.”
“But I was already queasy yesterday before the doctor set my leg and I had anesthesia.”
“What are you talking about? You mean after the accident, don’t you?”
Toby avoided her eyes. “Kind of before.”
“When before?”
“Like when we went shoe shopping.”
Mrs. Owens right arm showed no restraint and she clunked him on the head. “Why didn’t you tell me?”
“Anne,” Jack said, “leave him alone. He’s at that age where he can’t tell his mother everything.”
Bob stayed out of the family squabble and pressed on with his short but diligent physical exam.
CHAPTER 11
Bob raced downstairs to catch up with rounds and found Rick Mares at the head of the team hurrying down the hallway. “We’re finished, slow poke,” Dr. Mares said. “We’re going to the office to talk about all our patients and you can tell me about our consult.”
Rick nodded for the last medical student in to close the door.
Nell squeezed into the couch, making a contiguous line of medical students as Rick pulled up a chair. “If I didn’t know any better, you four look like green first-day medical students.”
Bob wiggled in the upholstery. Nell was so close, their thighs and hips bumped alongside each other.
“We are still green to pediatrics,” Nell offered. “We need your supervision and leadership.” Her dark almond-shaped eyes darted to Bob as if she was buttering up their chief resident for all of them.
“Take your pediatrics rotation very seriously,” Rick said. “Think of pediatricians as the gatekeepers to springing kids into healthy lifestyles for the rest of their adult lives. There is no other specialty that can impact the future of patients like peds. During their formative years, children are open to the suggestions of their doctor. Often the parents are the ones who steer kids the wrong way by setting bad examples. Also, a friendly, skilled, and nonjudgmental doctor is important, as is the way he or she performs a physical exam. Children are developing self-worth and are coming to grips with wanting privacy over their own bodies. The physical exam must be executed with sincerity and respect.”
Rick wiped his brow and leaned forward. “So, Dr. Palmer, we’ll start with you. I want you to follow Dr. Castle’s patient now that you’ve seen him. Fill us in, please.”
Wishing Nell would afford him more space, Bob wiggled his hand into his pocket and took out the index card on his new patient. “Toby Owens is an eleven-year-old male, status post an MVA late yesterday. He suffered a fractured fibula and Dr. Castle did a closed reduction in the OR early this morning. He has no allergies to medicines and no prior medical or surgical history. To the surprise of his mother in the room, he mentioned a bout of nausea and vomiting yesterday before the accident.
“On physical exam, he is a well-nourished young male who was a bit groggy from his night of events and anesthesia, and is wearing a cast on his right leg. His vital signs were normal except for a temperature that has been creeping up. A tech just took one while I was leaving and it was 101.2. His lungs and chest sounded fine and abdomen felt normal, as well as his ears and nose.”
He checked the index card to make sure he had Toby’s temperature correct and flipped it over.
“Dr. Crystal confirmed that he set the bone in the right position with an X-ray after the procedure. The little lab work ordered on his admission was normal.”
“Thank you,” Dr. Castle said. “Nice job and I’ll jump in here. Obviously, the cast was put on to keep the bone in the correct position and to protect it while it heals. So, I want to say a word about post-operative fevers in children. A surprising fact is that they are a common occurrence after surgery. Testing for infectious sources of fever is not usually required, it can be costly, and most of the time not diagnostic.
“In addition, according to a recent large study, patients undergoing orthopedic surgeries have one of the highest incidences of postoperative fevers, but they were no more likely to have an infection. Even children who stayed in the intensive care unit or who suffered high fevers were more likely to undergo testing. And lo and behold, they were no more likely to have an identified infection. The vast majority of kids with an infectious source of fever had an identifiable risk factor, such as a urinary catheter or central venous catheter in place.
“All of this has told us that a post-op fever may be part of the body’s expected inflammatory response after surgery. It is rarely due to an infection!”
Bob scrunched his eyebrows. “But my patient didn’t undergo a real surgery.”
“Exactly. Yet he had a bone break, which is still an insult to his body; there is always a risk of an infection in the bone. So it’s confusing, and a good doctor must weigh the clinical picture. Toby’s fever may be from an infectious etiology or a normal response. To compound the issue, he didn’t feel well yesterday. But heck, he may have been swimming in a pool all morning and became dehydrated and nauseous.”
Dr. Mares rose and wrote Toby’s name to the team’s list of patients on the wall board as Bob slightly moved his upper body to stick the index card back in his white jacket. Nell plucked it from his hand and slid her hand into his pocket and left the card. Her gesture surprised him, but he kept his expression neutral.
Rick turned around. “For sure, Dr. Castle is aware of literature surrounding post-orthopedic surgical fevers, yet he knows that we are the bible when it comes to children’s medical care and the most recent information such as the study I just cited. He is being diligent in asking us to oversee Toby’s hospitalization. I’ll write a note on the chart to recommend a ‘watch and wait’ plan.”
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Annabel woke before her alarm clock startled her out of bed. She decided to get up, get ready, and use the time to study. It was Friday and she was headed into an entire weekend off when attending a county fair would be like stepping back in time and enjoying the sights and sounds she’d experienced as a kid. Tomorrow’s excursion, she thought, may prove to be the best ever. Bringing Oliver and showing him off in a ring was going to be an absolute adventure. Whenever she took him on walks, everyone commented about how gorgeous he was. Would those remarks be substantiated by the judges of a dog show? Highly unlikely, but it was going to be fun anyway.
Since Bob was back on call for the night, she also had to retrieve Oliver later from his apartment so he could be walked. They were fortunate they didn’t live on opposite ends of Cincinnati. She finished in the bathroom, opened the blinds to the front street, and poured a one-cup French vanilla brew. Before she sat down to read, she schemed about her travel arrangements for the day. She needed to use her own car; later, she would be transporting a dog and, other than service dogs, car transport services probably didn’t allow them. She blocked out all extraneous thoughts other than Type 1 Diabetes for almost two hours and then scurried out the door with one more cup of coffee.
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The techs and nursing staff were still preliminarily checking in patients and putting them in exam rooms. Dr. Clark cluttered up the kitchen doorway, so Annabel stopped and waited there for Dr. Gillespie’s arrival.
“Don’t be shy to tell me what you really think,” Heather said. “How do you like pediatrics?”
“It’s fine,” Annabel answered truthfully. “Too early to tell if I will consider it as my specialty. At least Stuart and I are with seasoned pediatricians good at their jobs. Dr. Gillespie seems thorough with his history and physicals, succinct with shorter exams for patients with specific chief complaints.”
Heather brought her hands up to her mouth. Her fingers were extended in thought. More like a prayer-like hand gesture, Annabel thought.
Dr. Clark turned, stepped inside, and poured a cup of coff
ee. “Would you like one?”
“No thank you. I had two at home. I woke early and studied. It was marvelous.” Anabel leaned against the counter. “What percentage of your patients are Type 1 diabetics?”
“You bring up a good question. Not as many as you would think. Yes, Type 1 is the juvenile diabetes that develops in childhood, but the peak age of diagnosis is more often made around fourteen years of age.”
“Hmm. I didn’t realize that.”
“It’s a terrible disease, one that I consider to take over a patient’s lifestyle … both Type 1 and Type 2. Of course, the prevalence of Type 2 is way higher at around nine percent of the adult population. The obesity epidemic in America doesn’t help.”
“Too many of the patients I helped take care of on internal medicine had diabetes. I ended up considering it a disease process, because it rarely presents in a patient just by itself.”
“Yes. Hypertension, heart disease, eye problems, cognitive dysfunction,” Dr. Clark added. “Ha, that’s one reason I stayed out of internal medicine. Trying to take care of those diagnoses wore me down. There is something about children that makes my heart bleed a lot more, so I reach down into my gut to try and help them over and above what I would do for the adult population.”
“Makes sense.”
Stuart walked in, followed by Dr. Gillespie.
“I’m finishing the coffee before you two get here,” Heather said. “They’re still putting my patients in the back rooms, so I’ll be happy to put on another pot.”
Stuart stayed quiet and Dr. Gillespie was in his own world and not listening.
