I glanced up from Amanda Wolf’s chart as the emergency department nurse, followed by the lab technician (tech), followed by the electrocardiogram (ECG) tech flowed into cubicle No. 5. John Benner, MD, pulled up a chair to review the case with me at the nursing station.
“Here’s what we’ve got. Thirteen-year-old girl with a one-week history of diffuse aches and pains, fever, chest pain, now with a rash on her lower legs. She’s short of breath; her oxygen (O2) saturation when she arrived was 90%, normalized to 96% on 2 liters/minute O2. Hey, thanks for coming down. I heard you were in-house. Your tie, it’s got an ugly spot on it.”
I looked down at an unidentifiable brown smudge and succeeded in smearing it more prominently with a wet finger. Dr. Benner silently handed me an alcohol swab. “Anyway, her breath sounds are diminished in the right lung base. No murmur, but her heart sounds are distant. It was a tough exam; she cried everywhere I touched her. Dad carried her in from the car. The rash is wrong for rheumatic fever; it’s mostly on the lower legs, with clusters of angry red lesions, but her face and chest are flushed as well. We’re going to culture her up. It could be a viral syndrome. Maybe it’s one of your diseases?” He paused.
I didn’t have enough data to comment. Around us was controlled chaos; our community hospital emergency department hummed with activity.
Labs
Amanda’s nurse flung open the ringed curtain and reached for an IV bag off a nearby supply cart. She cradled the bag against her chest and grabbed several test tubes off the cart. “Grab an extra red-topped tube for me, will you?” I yelled so that she could hear me above the din. “Are there any green topped tubes on the cart? We don’t want to draw her twice. Oh, and add a sed rate [sedimentation rate], ANA [anti-nuclear antibody], ASO [anti-streptolysin], and a C3 and C4 [complements] to the routine lab Dr. Benner ordered.”
She scowled—an “I only have two hands” look—before she tucked the extra tubes into her back pocket, and applied a tourniquet to Amanda’s right arm.
First Impressions
In the moment before the scene was obscured, I focused my attention on Amanda. Her shallow breathing was punctuated by fitful whimpering. She wore loose-fitting, pink-flowered pajamas and floppy, white slippers. Her mom—they shared the same jet-black, pageboy haircut—hovered over Amanda’s shoulder, whispering in her ear. The lab tech released a lever on the stretcher to lay Amanda flat in preparation for the blood draw.