July 22, 2009

Waste Management

There's a protocol around here for how you attack an infant with a fever of unknown source (FUS). Basically, the justification is that since babies can't tell you they're sick, and are at risk of serious infections, every one of them gets a full sepsis workup. Blood culture, urine culture, lumbar puncture, CSF culture, and a cherry on top - and then they get parked in the hospital while those cultures cook in the lab.

While I was on my general peds inpatient stint, we averaged around 5 of these a week; almost every day we have another "rule out sepsis" touchdown in our ward. They begin to blend together - a day or so history of fever, maybe some lethargy or poor feeding, occasionally some sniffles or a change in stool. The cultures always come back negative, of course, and if the bigwigs on Washington saw my life as a 30min episode of reality TV, they would be up in arms bemoaning the "Waste of healthcare dollars! Defensive medicine! Rabble rabble rabble!"

My last FUS was a little different, however. He also had the classic history - 2-3 day history of fever hovering around 101, not feeding as well, a little fussy. But mom didn't take him to the doctor. After all, its just a little temp. Babies get sick, it happens. Until she was holding him and watched his eyes roll back in his head as he stopped breathing and turned blue. EMS got him resuscitated, and that's when I met him in the PICU, after the damage had been done. That moment little baby turned blue, his body could no longer compensate from the bacteria and cytokine storm raging in his body. Brain MRI showed diffuse bilateral watershed infarcts; he was brain dead. Blood cultures taken in the ED grew gram negative bacteria.

That's the crazy thing about all this preventative medicine, rule out sepsis, empiric treatment mumbo jumbo. It lulls you into complacency until that moment it blindsides you. One of the classic lessons of medicine is "learning diligence"; to never settle with an innocent diagnosis until you have ruled out the dangerous ones. It's often a lesson learned the hard way. Would the money spent ruling out sepsis on that one kid have been worth all the money spent on the other kids ruling out sepsis? I bet you his mom would have said so.

The worst part of all about this case is that his blood ended up growing out Haemophilus influenzae type B. A bug he SHOULD have been vaccinated against. But mom was afraid of vaccines.

As one of the residents macabrely put it: "At least he never got autism."

You go Jenny McCarthy!


Anonymous said...

I found this really moving on multiple levels--especially since I was starting to assume that no one who presents with chest pain is actually having a heart attack. (Hint: Tums, people.) I really appreciate that someone at the same point as me in medical education is chronicling
these things in written form. Thanks for writing.

(And don't get me started on the vaccine thing. Ugh. UGH.)

frylime said...

these stories should get published more often. not vaccinating could be akin to child abuse...especially in a situation like this...

sarah said...

yep, i admitted 2 last night.

how old was this kid? Hib immunity may not have been great if he had only gotten 1 dose of the vaccine (would have likely started @ 2 months) but i'm sure it would have been better than nothing!

i HAAAAAAATE jenny mccarthy.

MedZag said...

The kiddo was 4 mos and change. So just outside the knee-jerk ROS protocol, but I can bend things to make a point :) Should have gotten 2 Hib shots though...