That's why your mom always told you...

No running with pencils!!

We had a patient come into the PICU who had a pencil stuck in her eye.  This isn't a picture of her, but it's probably what she looked like in the ER before she went to the operating room.  She apparently was running with a pencil, tripped and fell, and rammed the pencil through her eye socket.  Amazingly enough (and miraculously for her!) the pencil just missed her globe and went right next to it through her orbital canal and into the front part of her brain, missing all of her critical eye structures.  She didn't lose any vision, her muscles weren't injured, and there was no brain bleed.  In the OR they removed the pencil and cleaned out the wound, and she was brought to the PICU with a bandage over her eye.  I think she's still on the ward for antibiotics, but overall she was an extremely lucky girl!!  When I told her she was lucky, she replied, "Yeah, I know.  And I'm even luckier because I get to go to Sea World."  Uh, managing not to lose an eye vs. Sea World??  I'd rather have my eye.  Crazy kid.

Happy stories!

It's not all sadness in the PICU, thankfully!  There are some happy stories.  I'd like to share a few.

JS was a teenage boy who had just gotten a new motorcycle and went out for a joy ride.  He was wearing a helmet, but unfortunately the front piece was not attached... and JS ran into a pole.  Yikes!!  He lost consciousness, and basically his face took the majority of the trauma.  He had multiple facial fractures, including his eye socket, jaw, and skull.  He had massive bleeding in his head, mostly in the frontal lobe (the area of your brain responsible for executive function, making decisions, social inhibition, and long-term memory).  He was aggressive at the scene, requiring sedation and intubation.  He had a number of invasive surgeries and was on the vent for a week.  We weren't sure if he would wake up when we took away the sedatives, and if he did wake up we weren't sure if he'd be the same person.  Well, a week after he came in, we turned off the sedative drips.  Within hours, JS woke up and was looking at his family and squeezing his sister's hand.  Now he's making huge leaps in recovery, already up and walking.  Amazing!

DG was another teenage boy who was hanging out with his cousin, who was cleaning his gun... which was loaded, by the way.  Next thing you know, his cousin accidentally fired the gun and shot DG in the head.  He lost consciousness and had severe intracranial bleeding.  The CT of his head looked crazy - almost his entire right side was destroyed by the bullet.  He went to the OR on his first day of hospitalization to get a decompressive craniectomy.  Basically what they did was take out part of his skull to give his brain room to swell.  He was on heavy duty meds and was on the vent for a week before he was ready to extubate.  We lightened the sedation in anticipation of pulling his breathing tube, and guess what - he woke up!  He opened his eyes, gave a thumbs up, held his dad's hand... incredible!!  He is still in the PICU, but making significant progress.  Praise God!

Finally, DE was yet another teenage boy (these crazy teenagers!!) who was out at the river having fun with his friends.  Like any fun-loving high school guy, he decided it would be fun to jump off a tree branch into the river.  The problem was, as he was getting ready to jump, the branch broke... and he fell into the river at an awkward angle, landing on his neck.  He injured his spinal cord, fracturing his C5-C7 vertebrae.  He didn't lose consciousness, but on impact had loss of sensation from the waist down.  He came into the PICU and was started on a protocol for medical management of spinal injuries.  He got IV steroids and a vasoactive medicine to keep his blood pressure high (with the idea of increasing blood flow to his spinal cord).  There was nothing surgical that could be done.  He has now been in the PICU for over a week, and is starting to have a tingling sensation in his legs.  And this morning, I swear he could tell which foot I was touching.  I'm not sure how much function he'll re-gain, but I am extremely hopeful and I've been praying for him.  The happy part in his case is that he's still here!  He could've died from that injury.  He's such a sweet kid, too.  He is taking it all in stride.

So, there are a few happy stories from the PICU after all the sadness.  Yay!

The sad part about Pediatrics

I'm working in the PICU this month.  It's at a trauma center, so we see quite a few serious injuries.  Mostly from car accidents.  But almost as frequently (or so it seems) we see children come in with injuries due to child abuse.  Last week a 12-month old baby boy came in unresponsive.  The parents reported he had been "out of it" and vomiting for a day.  They couldn't recall him falling or hitting his head, and there were no signs of trauma on exam.  There was no history of toxin ingestion.  The CT of his head showed intracranial bleeds and a very swollen brain.  What was the cause?  We weren't sure but we had our suspicions.  The next day, the eye doctor did an exam and found severe retinal hemorrhages - almost pathognomonic for child abuse.  This little boy had been shaken badly by someone, so much so that it caused bleeding in his brain and severe swelling.  His intracranial pressures got so high that he had to have emergent surgery to have part of his skull taken off so his brain could expand.

Despite these extreme measures, this patient went on to develop brain death.  His brain became so swollen that the blood flow had almost ceased completely.  Once he was declared brain dead, the parents and medical team decided to take him off life support.  His heart stopped 18 minutes later.

This is the second death I've seen this year.  The first one shook me up so badly that I cried for almost a week.  This time, I didn't shed a tear.  I don't know why.  Maybe because he came in and died so quickly.  I didn't have time to get attached.  Or maybe because I didn't actually code him.  Or maybe because I'm growing calloused?  I don't know.  I tried to say a prayer for him, but my heart wasn't in it.  I think I felt more angry than sad.  I'm not sure who abused him, but I sure hope he/she ends up in jail.  I don't understand how somebody could hurt a little child.  Children are so small and vulnerable.  They are completely dependent on adults.  They are so trusting and most of them just want to be loved.  It makes me SO angry to think of all of the children out there being abused, like my poor patient who died.  He left this world far too soon.

Anyway, that's just one of the reasons I don't think the PICU is my calling.  It can be really depressing!  Also, I don't like to have to think on my feet.  And I like my sleep.  But God bless the people who do choose to go into it.  They are definitely special people, and a blessing to all the sick children they take care of.

Pediatrician AND Ghostbuster

Last week in clinic I had possibly the strangest patient encounter ever.  I looked at my computer and it said, "7 year old with sinus pain".  I thought to myself, "This will be easy.  I'll take a look at her sinuses, maybe get a CT, maybe do antibiotics, and send her on her way."  

Not the case.  This little girl walks into my office with her parents, mom looking very concerned.  I start off by saying, "So, your daughter is here for sinus pain?"  Mom replies by saying, "No, that's not why she's here.  My daughter has been seeing ghosts."

Okay, stop.  Am I a pediatrician or a ghostbuster?

After I got over my initial shock, I began my interview.  I asked the patient to tell me about the ghosts.  She said they are black, white, all different colors; some look like people.  She sees them at home, school, everywhere.  I was a little worried to ask her if she saw them there in my office... I was afraid she'd say, "Yes, in fact there's one right next to you."  Then I asked her if the ghosts talk to her.  "No.  But they scratch me sometimes."  Mom piped in and said, "Yes, I've seen the scratches."  Then mom launched into a story about how she had gotten attacked by a ghost several years ago.  That's when I started to become skeptical.  Was this mom feeding into this child's "visions"?  Was mom psychologically in the state of mind to make medical decisions for this child?  I told her as respectfully as I could, "Ma'am, I'm sorry your daughter is seeing these frightening images, and I wish there were something I could do for you, but I'm really not trained to handle this.  I am here to rule out any MEDICAL causes for her hallucinations."  Oh, that did not go over well.  The little girl's mom started getting very heated up, exclaiming "I know my daughter is seeing ghosts.  There's nothing wrong with her medically.  She is seeing ghosts, like that little boy in The Sixth Sense.  I'm afraid they're going to start hurting her.  You have to do something to help us."  I don't know what she wanted me to do - perform an exorcism???  I calmly told her, "I'm very sorry she is so upset and scared.  I will try to find someone who is trained to help you."  That's when I called the psychiatrist.  He was very helpful and agreed to see my patient the very next week (usually not that fast).  Mom was okay with that, and after 20 minutes discussing ghosts, I said goodbye to this strange family.

It was definitely an interesting appointment, and worth writing about so I can laugh about it later.  But I do hope this girl finds some help.  She was sweet.  And who knows, maybe she IS seeing ghosts.  Yikes!!