The Three Year Old
It’s 12:00. I was just ushering my last morning patient to checkout at our clinic. The patient was an 18 month old boy who screamed every time he saw me even if I ran into him and his mother on the street. I completed all of my morning charting and headed over to the hospital to check on my inpatients and get some lunch from the hospital kitchen, hoping it wasn’t cow’s liver day. They always bread-loafed the liver exactly like the pathologists did to human livers; it looked exactly the same. Not very appetizing and I don’t like liver anyway.
I had to pass by the one bed emergency room to get to the nurses station. Just as I was passing the door to the ER, the Locum Tenens surgeon was walking out. I saw a child who looked like a 4 year old, at least, sitting at the foot of the ER exam table. He was slightly hunched over and had somewhat shallow breathing.
I asked the surgeon what was up? He said, “The kid has a really bad sore throat. I’m going to the nurse’s station to order a shot of penicillin.” I said, “Gee, if that kid was three years old or younger, I’d strongly suspect epiglottitis.” The surgeon said, “The kid is only three years old!” I asked if he minded if I saw the kid and he said, “Go ahead.”
Back in the 1980’s there were illnesses caused by a nasty little bacteria called Haemophilus influenza. You don’t hear much about this bacteria anymore because there is a vaccine for it that children get as part of their early childhood vaccine series. So now, the incidence of it causing infections is low. It doesn’t cause “the flu”, that’s caused by the influenza virus. This bacteria usually causes mild to moderate illnesses like sore throats, earaches, etc. However, it can cause two life-threatening illnesses: Meningitis and epiglottitis. The epiglottis is the little “trap door” at the top of your larynx that shuts tight when you are swallowing so you don’t aspirate food, drink or saliva down into your lungs. When H. influenza infects the epiglottis it swells so much that it blocks the throat and the larynx itself. It can completely block the larynx and cause respiratory arrest. It usually occurred in children less than four years old.
Treatment of H. influenza epiglottitis was ampicillin and intubation until the swelling goes down. The thing is, you can’t intubate a child with epiglottitis unless they are anesthetized because the gag reflect causes the epiglottis to spasm shut and you have to do a laryngotomy to get an open airway.
I walked into the ER and saw this child, sitting there with his head down, breathing with shallow breaths and drooling. These were classic symptoms of epiglottitis. The child had a fever of 102 degrees. I listened to his lungs but was afraid to look in his mouth or touch his throat until I got the key test to rule in/out epiglottitis, a lateral X-ray of the neck.
The X-ray tech wheeled the child into the X-ray room and took the picture. I was waiting in the reading room. She brought the X-ray in to me and it showed a hugely swollen epiglottitis that looked like a thumb. This was the classic “thumb sign”.
I told the X-ray tech to run to the nurse’s station and have them call the two nurse anesthetists who lived just outside of town. I ran into the ER and started an IV. I got a dose of ampicillin started and a dose of steroids (to try to reduce the swelling). The X-ray tech ran in and said the two anesthetists were up in Duluth working. I asked her to activate the volunteer ambulance crew, we had to get this kid to Duluth before he had a respiratory arrest.
The ambulance crew arrived quickly. We gently ushered the child into the ambulance and told the mother to follow in her car, but not at the speed we would be driving. I had the boy sit on the ambulance stretcher facing me. I was sitting on the bench facing him with an endotracheal tube in one hand and a laryngoscope in the other. It was 76 miles to Duluth.
The ambulance took off and when we got to the interstate, it was pedal to the medal, 90 miles per hour. It would still be at least an hour to the hospital in Duluth. I sat there staring at the boy praying we would make it there before he had a respiratory arrest. I had a headset on so I could talk to the ER staff at the hospital in Duluth. The two EMT’s were in their seats in the front of the ambulance.
About half way to Duluth, the boy sat up straight and grasped his throat. He had arrested! I couldn’t do anything until he passed out and then I had about three minutes to successfully intubate him or he would be either dead or brain dead. He started flailing, writhing. I just tried to have him not injure himself until he passed out. Finally, after about a minute, he went limp. I quickly positioned him for intubation. It was 50/50 that I was going to be able to slide the ET tube past his swollen epiglottis in good conditions. Here I was in an ambulance going 90 mph up the interstate! The vehicle was rocking and rolling with the bumps in the road. I wasn’t going to get more than one chance!
I could see the big red epiglottis through the laryngoscope. I slid the ET tube down this throat, my heart racing. When the tube passed the epiglottis there as a slight puff of air. I put the bag on the tube, put my stethoscope against his chest and gave the bag a squeeze. Yes! Breath sounds! Hallelujah!
I started bagging the boy and he pinked up but didn’t regain consciousness, which was actually a good thing since I was sure he would buck the tube if he woke up. Then, something totally unexpected happened. Pink frothy fluid started filling the ET tube. I’m an Internist, not a Pediatrician, so, I’d seen a lot of pink frothy fluid….it looked exactly like pulmonary edema.
Pulmonary edema most commonly occurs when someone’s heart is not pumping well. Actually it is usually pumping very poorly. This causes blood to back up in the lungs. The pressure builds up in the lung blood vessels and they exude fluid into the air sacs in the lungs.
Well, this was a three year old without a history of heart problems. I had to keep popping off the bag to suction the pink frothy fluid out of the ET tube to keep the airway open. I hailed the Pediatric ER in Duluth to give them the update that the child had a respiratory arrest, I had successfully intubated him and now it looked like he had pulmonary edema. The pediatrician on the other end of the line said, “ Nice job Dr Angellis, but, children don’t get pulmonary edema.” I said, “Well, OK, but I’ve seen a lot of pulmonary edema and this certainly looks like it!” He said, “It’s probably secretions from the H. influenza infection that may be in his lungs.” I thought, OK, he’s the specialist.
The ambulance screamed into the receiving bay at the hospital. The EMT’s opened the back door and there was a bunch of ER staff there waiting to receive the patient. They rushed him into an ER room and started working on him. I gave a quick summary of what I had seen and done. The X-ray tech came in and did a cross table lateral of the neck and a chest X-ray.
We usually didn’t stick around long, since we were now bystanders and we had to get back to our town. Just as we were saying our good-bye’s, the radiologist ran in waving the chest X-ray and yelling, “This kid is in pulmonary edema!” He put the X-ray up on a glow box and everyone stared at it. The lead pediatrician said to me, “Well! Unbelievable! I’ve never seen this! Good call Dr. Angellis!
We left the ER and headed back to our town. Four days later, we had to transport another patient emergently to Duluth (that was not an uncommon occurrence!). I checked with the Information Desk and found out the boy was still in the hospital, but was going to be discharged the next morning. I went up to the Peds ward wondering if the child had any brain damage from his anoxic episode. To my happy surprise, he was running around the room playing, his mother sitting in a chair watching him. I knocked and said “Hi” to his mom and asked her how he was doing. She said he was just fine and the neurologist said he had zero brain damage, all the doctors gave him a “clean bill of health.” I said I was so relieved!! She gave me a big hug and thanked me for saving her child’s life.
That’s the ultimate reward for being a doctor.
About a month later, I got a letter from one of the Pediatricians in the Duluth ER. Along with the letter was an article from the journal Clinical Pediatrics (Nussbaum E. Adult type respiratory distress syndrome in children. Clin Pediatr 1983; 22: 401–406).The article described pulmonary edema in children who had experienced increased pressure in the lungs! Exactly what had happened to my patient! It was the first published description of this condition!