Too Big for Pediatrics, Too Small for Medicine
But just right to get stuck, critically ill and combative, in an ER
Dear readers: Thanks for your patience as I’ve gone quiet some this summer. I had a couple of outside research / writing projects that used up all of my bandwidth. (I may share them as they are published!) And of course, I still have my full-time job as an ER doctor. So here’s a tale from life in the emergency department.
He was a 16-year-old, followed by child protective services and staying with friends due to an unstable family situation. Someone had found him on the floor, altered, and called 911.
EMS arrived and found him confused, moaning, with a racing pulse, and a sandwich bag of white powder at his side. He was breathing ineffectively and had low oxygen levels. The paramedics gave him naloxone, the opioid reversal agent (brand name Narcan®). This woke him up — but not to coherence. Instead, he was just moaning a lot more, and louder, now with some thrashing and kicking added in.
The paramedics arrived with him on oxygen, drenched in sweat, battling restraints, making unintelligible noises. They’d barely woken him up, and already I started putting him back down, with lorazepam, haloperidol, more lorazepam (sedatives and anti-psychotics).
He was hypotensive with blood pressures of 80s/60s mm Hg, tachycardic with a pulse in the 180s, tachypneic with a respiratory rate in the 40s, with an O2 sat of 88% on 6L of oxygen via nasal cannula. He had no fever.
His stat labs showed he was having early signs of muscle breakdown and kidney and liver damage. (For the medically savvy: Lactic acid 6, white count 18, CK was 7,000-something, with a mild creatinine and transaminase bump.) A portable chest Xray showed extensive lacy infiltrate of his entire left lung. COVID-19 was negative. Urine tox was positive for fentanyl and cannabis.
My working diagnosis: Substance abuse clearly, but complicated by what else?
Seizures possibly … The left lung haziness could be from a choking / aspiration event, or it could be a viral or bacterial pneumonia, or an asymmetric pulmonary edema (fluid in the lungs, a known, rare side-effect of naloxone after an opioid overdose) … His liver and kidney function derangements could represent organ damage from the low blood pressures (a.k.a., “shock liver” / “shock kidney.”) Or perhaps he has a viral hepatitis, as a side effect of IV drug abuse? The kidneys could also be failing due to his rhabdomyolysis (muscle breakdown): muscle proteins spill into blood and can clog the kidney drain systems. … Why the muscle breakdown itself? Seizures and other forms of wild over-exertion — like battling against restraints — can cause that. So can laying on the floor obtunded and not moving for many hours. For that matter, substances like cocaine itself are notorious for having a direct effect on muscles to cause their breakdown … cocaine and its analogs also can cause head bleeds … which in turn can cause altered mental status, combative behavior, seizures … His initial presentation sounded like an opioid overdose, but when the medics woke him up with naloxone, he acted like he might also have a cocaine-like substance on board. True, the urine tox screen was negative for cocaine, but perhaps it was K-2 or another synthetic cannabinoid that ramps people up like a cocaine … or some other substance the toxicology screens just don’t catch. I wondered not only about a brain bleed but also about a hypoxic brain injury … Or maybe he was in the early stages of multi-organ failure from overwhelming sepsis, with bacteria coursing through his bloodstream from a dirty intravenous injection …
So I did all of the things an ER doctor would do, and I got him stabilized.
I sedated, fluid-resuscitated, anti-biosed, electrolyte-repleted, and ran him head to toe through the Donut of Truth (a.k.a the CT scanner). No head bleeds, nothing else on imaging other than the extensive left lung infiltrate (which I treated as a pneumonia). His blood pressure came up, his heart rate came down, his oxygenation improved. I considered a lumbar puncture (putting a needle between the vertebra to tap and sample spinal fluid), but I had such a low suspicion for meningitis that this seemed excessive, and anyway he was already covered with antibiotics. (That said, as I reviewed the case later, I’m not sure why I felt I could rule that out clinically; I think I reasoned that 1) he had no fever and, 2) it’d be bizarrely challenging to abuse IV drugs in the same afternoon that one also has fulminant meningitis. Just logically, it seemed like his major problems would have started with the overdose; that’s usually how it works, although of course not always.)
The entire time, I skated the edge of over-sedation, with a plan to calmly intubate this muscular 16-year-old and put him on a ventilator if all of my lorazepam tipped him over into not breathing again. For now he was improving, and I hated to commit him to the vent. (This is always a tough call, and I made sure to take a close look at him just prior to sending him to lie flat on his back for 10 minutes in a CT scanner.)
But none of that is what makes this case worth discussing. The real challenge, the one I recognized with a sinking feeling as soon as I met him: Who is going to take over his care once he’s stabilized?
Because he’s 16.
‘Too pregnant for Ob, too psychotic for Psych …’
I called the pediatric service: He’s too sick for regular pediatrics. Agreed.
I called the adult medical ICU: He’s too young for the MICU. The critical care attending regretfully told me, “My license only covers me for age 17 and above.”
We didn’t have a pediatric ICU at this particular hospital.
I called six other hospitals, and gave every PICU in a 100-mile radius the facts of the case.
All of them declined: “No beds.”
Some of them truly had no beds. Others just seemed unenthusiastic about taking a 5’10”, 190-lb combative adult into their peaceful kiddie oases. They’d say, somewhat guiltily: “Call us back if no one else takes him!”
Too adult for the PICU.
Too pedi for the MICU.
This kind of thing is often a point of truculent pride for us in emergency medicine: We handle the stuff no one else can or will. “Too crazy for psych, too pregnant for ob/gyn, too sick for the ICU” — that’s our mantra.
You can’t admit a florid psychiatric decompensation to psychiatry, you’ve got to get control of that!
You can’t bring a full-term woman with contractions and crowning to Labor & Delivery, that’d be a chaotic mess!
You can’t run a septic patient up to the ICU with a blood pressure of 60/40 mm Hg even if they are on triple pressors! You need to stabilize them with, uh, intensive care!
But for my sick patient — a “pediatric” male who looked ready to start as an NBA point guard — this seemed particularly mindless.
Transporting him safely across the state might force me to intubate him for airway protection, when otherwise I could just hold my course (which was working). The safest and best disposition for him would have been our adult ICU, which had beds, and frankly much more experience in managing combative substance-impaired adults. In the end, after six hours of me managing him in my busy emergency department alongside many other critical cases — a day where I saw more than three per hour and found myself wistful for a return of COVID-19, back when everyone was too afraid to come to the hospital — I made a second round of calls to regional PICUs and got him accepted. They even sent their critical care transport team to collect him, so I didn’t have to worry about intubating him (he had improved enough by then that I wasn’t really worried about this, but a critical care team could handle anything en route if he worsened).
It seems to me that the treating emergency physician should be allowed to determine whether a patient is “pediatric” or “adult”, based on our clinical gestalt. I guarantee you we’d serve the patient’s interests far better than leaving them in limbo — too old for one service, too young for the other, and abandoned by all.
An earlier version of this article appeared in Emergency Medicine News.