Friday, September 27, 2013


Babygirl awoke with a bellyache.  The same as LAST Friday's bellyache, neither better nor worse.  No fever.  No nausea.  No bowel issues.  No urinary symptoms.  Just Babygirl, hunched over and saying she was too sick to go to school. 

Last weeks' bellyache went away with no help from anybody but God.  Each day was better than the one before, and in the end I decided it wasn't anything to worry about.

So why worry about the identical problem a week later?

Sigh.  Nothing that happens once that goes away by itself is ever really a problem.  It's when the problem comes back that we start to worry, medically speaking.  And honestly, if it weren't for the kidney transplant I'd have to say there was still nothing terribly alarming about it. 

Transplant patients can probably never truly be considered to be healthy.  Stuff that other people shake off in a minute can take a transplant patient OUT. 

So I called the transplant team.  The nephrology Fellow knows us.  I told her the story, and she said she'd track down the attending and call back with a plan - maybe an order for some blood work and an ultrasound.  That seemed like a good idea to me - and I'd be able to work that in around my half-day of work and Mom's cardiology appointment (remember the broken pacemaker wire?  Yeah, still working on that).  I don't know what I was thinking. 

By the time the Fellow called back I was hard at work on my usual Friday morning paperwork stack.  Disability forms, school physical forms, letters to insurance companies explaining why I might have a better idea what my patient needs than the gum-chewing high-school-educated pencil-pushing gateway geeks who make the decisions about formularies and medical supplies.  Stuff like that.

"Take her to the ER.  Tell them (oh, yeah, they love when I do that!) that we want a CMP, CBC, UA and kidney sono." 

I jot it all down.  Honestly, the ER doc would have to be a total moron not to want the same stuff anyway.  Except he wanted a CT scan instead of an ultrasound. 

"Dude.  You can't put CT contrast through a transplanted kidney."  Honest, it's bad for the kidney.  "Well, oral contrast only then."  "It's a lot of radiation for a kid, doc.  Why don't we do the CT if the sono doesn't tell us what we need to know."

Off to ultrasound we go.  "Does Babygirl have a full bladder?"  Likely not - she just produced a urine specimen at the request of her nurse.  "Do you need her to have a full bladder to see the kidney transplant?"  Eyebrows meet hairline.  "Let me make a call."

Once the purpose of the study was clarified and the correct orders given, we were off.  The kidney looks fine, except her right ovary appears to be adherent to the backside of it (scars happen, right?).  They can't locate her appendix, but as the radiologist who came in to assist in the search pointed out:  "No one with appendicitis would be able to tolerate this exam."  Yup.  They were pushing pretty hard.  Babygirl never peeped, but you could see her break out in sweat at one point. 

While we were in ultrasound, I passed the point of no return on getting mom out of the house and to the cardiologist.  I called to reschedule.

No wiser, we return to her cubicle.  ER doc shows me the labs:  "She has a UTI!"  She's anemic, as usual, slightly worse than usual.  Kidney's working fine, no increased white count to indicate infection (although that doesn't mean much - she can't make many white blood cells).  Urine showed some white blood cells and not much else, except some skin cells, meaning that the specimen wasn't 'clean'.  No blood.  No nitrites (bacterial breakdown products often seen in UTI's).  From my perspective, it's a pretty bland specimen.  He calls the nephrology attending, announces his finding, and then listens and grunts and 'yes, but..'s a lot while she patiently explains to him.....what, I don't know. I can only hear his end of the conversation (and I don't think he knows I can hear him).

He comes back and says CHOP wants her to have a liter of fluids and he's going to put in an IV.  Apparently I was a bit too relaxed to note her vital signs.  Her blood pressure was 80/30 on one of the readings, and the rest were pretty low as well.  They failed to get the IV on the first try and I refused a second.  The kid has mouth, you aren't considering surgery, how 'bout we just make her DRINK a liter of fluid?  (I added a bag of salty junk food while she was drinking.  Worked like a charm.)  Her pressure came up.

We were discharged with antibiotics and instructions to go to CHOP for a recheck on Monday morning.  By then they will have the results of the urine culture, and we'll go from there.

But I sincerely think that we were given the advice we were give because the ER doctor didn't want to send us out the door without an actual "diagnosis". 

We docs sincerely hate to tell patients that we have no idea at all what is going on.


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