Wednesday was Rashes No One Has Ever Seen Before Day.
A lovely pregnant patient came to see me complaining of an
insect bite. It was not an insect bite. Unless insects bite you only on your
groin and instead of creating a small pink welt they cause grouped clusters of
yellow or blood-filled vesicles crossing several dermatomes and only mildly
itchy or painful. I got out the atlas. Then I pulled in the Dinosaur. “I don’t
know what that is,” he said.
Awesome.
In the hospital on call a VBAC awaited. Her bag of waters
broke early in the morning and there was thick meconium. She had no
contractions yet. This is called PROM, only no one wears fancy dresses, least
of all me. The nurses needed me to talk to her also about why we weren’t
starting her on Pitocin to induce her. The reason is because it increases your
chances of uterine rupture from 4 in 1000 to 11 in 1000. And uterine rupture is
a bad thing, since it has at least a 10% mortality rate for baby. But the
longer we wait the longer we risk infection, which is more likely, just less
dangerous. And she could always opt for a c-section, which is less dangerous
for baby on all accounts, but riskier for mom. So, a complex discussion to be
sure. Try doing it in your second language.
Arguably more fun than regular prom, though.
After I finished the nurses asked me to stay for 2 minutes
and translate for their assessment. They have no translators today. They are
woefully understaffed.
I needed them to watch my strip for me because I just got
called to the ER.
Dr. ER Green Zone had a baby for me to opine on. “He won’t
move his arms. He’s 8 weeks old. His xray looks weird. I’m not sure what it
is.” Cool. I’m sure I’ll figure it out right away since I know so much about
orthopedics in 8 week old children. We
look at the xray right away. The distinguished radiologist has created a
differential diagnosis for the diffuse periosteal inflammation that includes
several vitamin deficiencies and a disease I have never heard of, Caffey’s. I
go in to see the patient. He’s cute, but he hates it when I touch him. His arms
seem weak. And there’s a weird rash on his arms.
I should have put on gloves, but the rash is unexpected. I
touch the soles of his feet, where the skin is peeling. A scalloped red border
extends to the sides. There are plenty of raised pink and red bumps, but in
circumscribed areas. There are some ring-shaped lesions. It looks for all the
world like nummular eczema, except the two spots that look like ringworm, and
the spot on his chin I can’t convince myself isn’t an early herpetic lesion.
Shit.
I ordered some labs and started reading. I asked Swiss to
come look at the rash, too. I called the patient’s PMD, who took care of his
mother in pregnancy. She came late to care and never did her labs. The hospital
drew a paltry few when she was in labor.
I decide it’s syphilis. Swiss, the resident, the medical
student and I go back to the ER to take another look. We keep refreshing the
computer screen waiting for the RPR to come back. I call the lab. “Oh it is
send-out. 3 to 5 day.”
I ship him to the University hospital. He deserves
specialist consultation, which we don’t so much have here. Not for derm, not
for ortho, not for 8-week-olds, anyway.
The VBAC PROM is still hanging out. I go home and take a
nap.
At 1 am a woman arrives at labor and delivery and goes from
5 cm dilated to delivering a baby on the floor in 10 minutes. The resident was
sort of in the room at the time.
And then… nothing. My hands may have syphilis. It is not
confirmed. That is all.
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