Stories are the way to remember…
As humans, we are hard wired to remember stories. This is how we survived for thousands of years. Lists are hard to remember, but stories are easy. In that vein, I’d like to introduce you to Billy Ache and his family. 🙂
Billy Ache was turning 10 in 2 days. His party was tomorrow but his actual birthday is on Sunday. He couldn’t decide which he was more excited for, his party or his actual birthday. This birthday was going to be special because he was getting his very first brand new bicycle. He’d been riding his brothers hand-me-down bike for the last three years, but now he was getting his very own shiny new bike.
He tried to shut his eyes and go to sleep, but that bike just kept popping into his mind. Racing down the street, flying past the older kids who always left him behind.
Tim was a great older brother, but he got everything first. It wasn’t so bad because Billy got lots of great hand-me-downs, but never anything new. This bike was going to be his.
Billy woke with a jump and was out of bed in a blink. His mother was just setting breakfast on the table. She thought tomorrow would be a busier day, so she had decided to make his favorite breakfast today.
But Billy wasn’t having it. Something was wrong. He just wasn’t hungry. His mother pressed him with a thousand questions. He couldn’t quite place it, but he wasn’t hungry at all. He chalked it up to the excitement about his party. But again, his mother wasn’t having it.
She checked his temperature 99.8.
Not enough to cancel the party, but enough to start some worrying through the Ache household. Mrs. Ache began grilling the boy. Had he slept well? What had he eaten the night before? Had he pooped yet this morning?
Billy was sure he’d be fine for the party. He just wasn’t hungry.
Oh no, his stomach was starting to hurt, right in the middle, and he felt something else. He needed to get to the bathroom quick, but how could he do that without his mother seeing him?
Dr. Andrews had just come on shift in the ER, and it was a busy morning. Well busier than usual. He had seen an ankle sprain and sent a pregnant woman upstairs to OB. There were two people waiting, but they’d have to wait a little longer. He needed coffee. The two patients weren’t in urgent need and their nurses were getting them settled anyway.
He was hoping they didn’t have abdominal issues. They were always so vague and difficult to diagnose with their non-specific symptoms and their moaning and groaning. He was hoping for some more easy ones like broken bones and women in labor.
Billy had turned on the fan and had the water in the sink running. He was hoping his mom wouldn’t be able to hear him throwing up.
Knock, knock.
“Billy? You okay kiddo?” came Mrs. Ache’s obviously concerned voice through the door.
When Billy opened the door, her decision was made. The party was canceled, and they were heading to the Emergency Room.
He was pale and still holding his stomach, and the smell of vomit was overpowering.
Mrs. Ache ushered Billy down the stairs and grabbed his coat. It was chilly out, and it was starting to drizzle. She turned to her husband. “Can you go through the list and let everyone know the party is off. I’ll call you when I know anything, and would you mind cleaning the bathroom? Thanks,” she finished with a smile. With that, she and Billy were out the door.
Billy didn’t look good. He moved very slowly to the car. He carefully climbed in.
Billy’s dad ran out from the house.
“You might want this.” He smiled. It was a small bucket and a towel.
“Thanks,” Mrs. Ache said, and they pulled out of the driveway.
“Ouch!” Billy moaned. Every time she made a sharp turn or hit bump, Billy would double over in pain. She couldn’t drive anymore carefully, but she knew she was torturing her son.
Once they go to the hospital, she eased him into the ER and then into a room.
“Ugh,” thought Dr. Andrews, a kid with abdominal pain and vomiting. Did he swallow something? Did he eat too much candy? A vague complaint coming from a kid was the worst. He flipped through the intake form.
Stomach pain, vomiting, low-grade fever. Onset was this morning.
Dr. Andrews was already beginning to form his differential diagnosis, and whiny kid was right at the top.
When he entered the room, the kid was lying in bed. He looked nervous and a little pale. As Dr. Andrews came closer, he could almost see the kid flinch. He hadn’t even tried to touch Billy, and the kid was reacting and guarding his abdomen.
His mother launched into the story about the morning they had, and Dr. Andrews decided he should get some imaging, some labs, and probably get on the phone with surgery. He’d seen this pattern enough to know what was likely going to happen next. He needed the imaging and the labs to prove it, but there was little doubt in his head where this was going.
As expected, Billy’s white count was 18,000. That didn’t clinch the diagnosis, but it definitely proved something was going on. He also had an elevated CRP at 8 mg/L. This too pointed him towards a little more than a tummy ache.
“My side hurts,” Billy complained.
Initially, Billy had been complaining about pain closer to his belly button thought Dr. Andrews. Now his pain seems to be more on the right side of his abdomen.
Dr. Andrews decided to wait on ordering the CT and call surgery.
Dr. McBurney arrived with his usual cohort of residents and students. They gathered around Billy. They read through his chart and examined all of the things Dr. Andrews and his staff had done so far.
“What important step did Dr. Andrews miss in his examination?” asked Dr. McBurney.
“There is no physical exam documented,” said one of the residents.
“Correct. Can anyone summarize this case for us.”
One of the residents, Denise, stepped forward. Denise was always trying to be the first to answer. She wasn’t obnoxious, she just knew the benefits that came from being first. “Billy is a ten-year-old male who as of this morning has had a low-grade fever, anorexia, nausea, and vomiting. He is complaining of periumbilical pain which now seems to have moved to the right lower quadrant. He has no past medical or surgical history and has no drug allergies.”
Billy moaned and held his side. He was wearing a Yankees jersey, and his skin was the same color white as the shirt.
“Can someone give me a reasonable differential?” Dr. McBurney asked.
Denise began rattling off possibilities.
“Constipation, gastroenteritis, intussusception, omental torsion, testicular torsion, cholecystitis, and appendicitis.”
Dr. McBurney turned to Jennifer, the medical student with the team, “Let’s put appendicitis at the top of our list. What physical exam findings would help us narrow our differential and push us towards or away from acute appendicitis?”
Jennifer froze. She stared blankly and didn’t answer. She stammered a little, and then stopped altogether and looked at her shoes.
Denise stepped in, not to show off but in this case to rescue the now thoroughly embarrassed student. “We’re looking for signs of peritoneal inflammation. We want to see if he has abdominal guarding, tenderness to palpation or rebound tenderness….” She trailed off
“And?” Questioned Dr. McBurney.
“And tenderness over McBurney’s point,” she finished. She always felt kind of silly saying that out loud.
Jennifer, in her short white coat, was given and rapidly took the opportunity to redeem herself. She performed an excellent physical exam eliciting tenderness over McBurney’s point. She was also able to show a positive Rovsing’s sign, pain on the right with palpation on the left. She tried for an obturator sign and an iliopsoas sign. Both were negative, but she was proud of herself for thinking of them.
There was some debate over whether or not to order a CT scan to provide further evidence to support the diagnosis of appendicitis before taking young Billy to the OR. Dr. McBurney felt that an ultrasound would be a better choice for Billy. Less radiation and probably equivalent imaging in this case.
Denise called the OR to make the arrangements for a laparoscopic appendectomy. She was thrilled because this would be her case. Jennifer was hoping to maybe get to put in a stitch or two.
The following morning Billy and his mother went home, and there waiting for him was Billy’s dad and a brand new bike.
Brian Wallace
P.S. I’m considering writing some short stories like this one to help people remember all the information. If you’re strictly a “give me the facts” kind of person, you can find them in The Final Step.