Monday, April 27, 2009

Mother of the patient, part II

Since our last visit to the ER less than a month ago, we have been to the doctor's for my son several times. First it was the acute visit follow-up, then his routine well-child visit along with associated vaccines, and then this week, another acute visit for allergies.

I had been noticing him rubbing his eyes a lot, often with the appearance of allergic shiners, rubbing his nose, and the occasional rapid-fire sneeze sequence. My poor boy, one day, was itching his eye so much that it became swollen and red and I feared he would gouge out a layer of his cornea with his thumb. He couldn't sleep due to the itching, crying while standing at the crib rail, itching his eye. Even after I came in and rocked him to sleep, holding him, he continued to rub his eyes in between soft snores.

Of course it was the weekend. Everything only happens during the weekend.

So early this week, I took him in for a visit at the Pediatric Clinic.

We saw a resident. This time, I did not say anything about being a physician, but it must have been in the chart because he knew. I got the sense that he did not have much experience with toddlers with allergies. I sat patiently while he read Up to Date and consulted his Harriet Lane. He presented the options of just treating symptomatically with Zyrtec, skin testing via an Allergy consult, and performing a RAST screen on a blood sample. I was leaning towards some kind of testing; it seemed more logical to me to identify potential triggers and to try to eliminate them as much as possible rather than blindly treating with medications indefinitely.

But, I also wanted to know what his attending's experience was with this and trusted his/her guidance on this. Plus, I wasn't too familiar with the different sensitivities, specificities of the various tests. He went to go discuss our case.

I have to say I was a bit disappointed that the attending never came in to introduce herself or talk to us. Instead the resident just came back and said she thought we should just treat with zyrtec and that skin testing, in the absence of planned immunotherapy, was pointless. She thought allergy testing was way too aggressive, at least that's what I heard second-hand.

I left feeling kind of dissatisfied with the whole experience. With not seeing an actual attending. With a management course I wasn't 100% on board with.

But, after talking it over with my husband and doctor friends, I decided to push for the allergy testing, at least the RAST as a primary screen. I didn't want to commit my son to medication long-term without knowing the causes.

I called and left a message for the resident who did not call me back until I left a second message. (Was I just a pain in the butt physician parent that had to be avoided?) I think I nicely stated my concerns about not knowing my son's triggers and he ordered the RAST right then.

Today, I took my son to get his blood drawn. So, he's never had blood drawn outside of routine newborn tests and it's been a long while since my peds rotation...I failed to remember how traumatic getting blood from a 15 month old can be.

There were 2 adults holding him down while another poked him with a butterfly needle in his right antecubital. Oh, how he cried and struggled and looked at me as if I betrayed him. I kept kissing his forehead and wiping the beads of sweat on the bridge of his nose and his face. They could only get a few cc's from the right and had to switch to the left. At one point, I was ready to call the whole thing off. No more. But I also didn't want to have to do this again.

I suddenly appreciated how this might be the aggressive approach.

Just a few hours later, I was holding him while at the store. He kept raising his shirt and itching. Detergent? I set him down and lifted up his shirt. Red patches, scattered, maybe where he was itching. Yes, definitely a rash. I showed my husband. It was looking more urticarial by the second, yes, definitely the beginning of hives. He looked otherwise well. No trouble breathing. Not feeling ill but itching.

My heart started to race. I had benadryl in the diaper bag, just in case (ever since Tempeh's post actually). Our plans for the afternoon took an immediate detour back home, keeping a close eye on him during the 15 minute car ride for any clinical changes.

Husband: He's itching his leg.

Me: His right leg?

Husband: Yes.

Me: He always itches his right leg. That's where his worst eczema patch is.

At home, I stripped him down to his diaper. I gasped.

Huge urticarial welts covered his back. HUGE. Just the sight of them on his soft baby skin made me cringe. What did he eat? We grabbed packages to read the ingredients. Got on the internet and did rapid searching. I thought back to earlier this week when our nanny gave him some green beans in a peanut sauce that made me hyperventilate when I discovered it, despite our instructions not to give him nuts or shellfish.

The hives melted away within 15 minutes of taking the benadryl. I, however, am on perma-edge. I still don't know what he ate that did it - nothing new. Cheese and Ritz crackers right before.

Suddenly, I'm glad we got the blood test. Maybe it was the right decision after all.

8 comments:

  1. Wow. Glad he responded so fast.

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  2. Glad you guys pushed for the test. It is a trauma to see your 15 month old get a needle stick be sure (and that "how could you, Mama?" face is heartbreaking and unforgettable, but watching your child suddenly unable to breathe or unable to open his eyes from angioedema is far worse. And watching them scratch to the point of bleeding is no fun either. Hope the RAST comes back negative, but if it doesn't, we'll have one more issue to bond over, just in case being a doctor-mother and military spouse weren't enough! Glad you had Benadryl on hand. (We carry the Fast Melt tabs so as not to have to drag the liquid bottle around).

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  3. Latex allergy from the tourniquet and/or gloves from holding him?

    Just a thought...

    Poor little man.

    I believe disclosing your profession is a two-edged sword. At times, I don't, if nothing but to see what happens. Mostly I do, as I find it easier to converse in medicalese. My non-physician husband will sometimes reveal, but its oftentimes when we get the run around.

    I agree that the attending not showing face is ridiculous; just proper manners and professional courtesy, if nothing else.

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  4. My son developed rashes from the fabric dryer sheets (Bounce) and then from the scented laundry detergent. Once I took those out the rashes cleared up. So many things to worry about!!

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  5. I can completely sympathize with you and it's amazing how the sight of those welts can vanish all reason...especially when it's your own child. Despite my training, I brought my twenty-month-old to the Children's Hospital E.R. for what turned out to be a viral exanthema (I had no clue that that could last up to 2 weeks!). Perhaps it's not allergies, but rather a URI and the hives are a viral exanthema? Here's hoping for you and your little guy.

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  6. Despite the fact that we choose to go to academic teaching hospitals (let alone WORKING there) I can certainly see how it is still disappointing that you didn't get to see/meet/discuss with the attending as well. Glad the hives faded away with the dihphenhyramine, hope you can identify a meaningful trigger that isn't a false positive scaring you away from other exposures unnecessarily. And hope it stays a skin and/or mucous membrane annoyance only (that is, no airway compromise). This April has been a rough allergy season (from the outdoor pollen/trees/grasses standpoint) indeed. Lots of eye & skin involvement.

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  7. Oh, poor little guy. I hope the blood tests give you some idea of what's going on.

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  8. poor baby.. rashes are sooo uncomfortable. I hope you find out what it is soon! Allergies are so tricky.

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