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Life's Horrors
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Felgraf



Joined: 10 Jul 2012
Posts: 716

PostPosted: Fri Feb 28, 2014 12:21 pm    Post subject: Reply with quote

Dogen wrote:
So, this story involves a kid. Read on at your own risk.

This girl came in for appendicitis recently, had an appendectomy. Then she came back with peritonitis (infection inside the abdomen; you know, where the appendix is) and her mom said she wouldn't take her antibiotics. Turns out she freaks out when you try to give her anything orally, or do a physical exam.

She'd been in hospital for two days by this point, freaking out constantly, because they had to get her infection under control and manage her pain, and all the residents had ordered were oral medications. Every day at 9am they'd have to force her to take pills, then she'd spend two or three hours crying inconsolably until she fell asleep, only to do it again around 12-2pm. She wouldn't eat, wouldn't get out of bed, and cringed whenever you would talk to her.

Me: "So... has anyone assessed her for sexual abuse?"
Dead silence.

No one had ever thought of that. Four hours later we find, yes, she was assaulted as a very young child, the mom is doing everything right for her and - here's the shocker - we switch her to IV everything so we don't have to continually traumatize her by forcing her to swallow pills. And it totally works. Anyone could have done it at any point over the last two days and saved this girl so, so much emotional pain.

Fuck sakes. No one thought of it. It took a first year grad student to point out something they should have assessed for the first day.

I don't have many occasions like this, but that girl... man, she's stuck in my head tonight.


First Reaction: Dogen, you are an amazing person, both to quickly think of that, and to have to deal with such things.

Second Reaction: (╯ー□ー)╯︵ ┻━┻
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Yinello



Joined: 10 May 2012
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PostPosted: Fri Feb 28, 2014 2:36 pm    Post subject: Reply with quote

Dogen, I don't know if anyone's said it but I'm glad you're there. The world needs more like you.
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Darqcyde



Joined: 11 Jul 2006
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Location: A false vacuum abiding in ignorance.

PostPosted: Fri Feb 28, 2014 5:46 pm    Post subject: Reply with quote

Dogen wrote:
So, this story involves a kid. Read on at your own risk.

This girl came in for appendicitis recently, had an appendectomy. Then she came back with peritonitis (infection inside the abdomen; you know, where the appendix is) and her mom said she wouldn't take her antibiotics. Turns out she freaks out when you try to give her anything orally, or do a physical exam.

She'd been in hospital for two days by this point, freaking out constantly, because they had to get her infection under control and manage her pain, and all the residents had ordered were oral medications. Every day at 9am they'd have to force her to take pills, then she'd spend two or three hours crying inconsolably until she fell asleep, only to do it again around 12-2pm. She wouldn't eat, wouldn't get out of bed, and cringed whenever you would talk to her.

Me: "So... has anyone assessed her for sexual abuse?"
Dead silence.

No one had ever thought of that. Four hours later we find, yes, she was assaulted as a very young child, the mom is doing everything right for her and - here's the shocker - we switch her to IV everything so we don't have to continually traumatize her by forcing her to swallow pills. And it totally works. Anyone could have done it at any point over the last two days and saved this girl so, so much emotional pain.

Fuck sakes. No one thought of it. It took a first year grad student to point out something they should have assessed for the first day.

I don't have many occasions like this, but that girl... man, she's stuck in my head tonight.


This is the degradation of our education system at it's finest.
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Dogen



Joined: 10 Jul 2006
Posts: 10707
Location: Bellingham, WA

PostPosted: Fri Feb 28, 2014 8:02 pm    Post subject: Reply with quote

Felgraf wrote:
First Reaction: Dogen, you are an amazing person, both to quickly think of that, and to have to deal with such things.

Second Reaction: (╯ー□ー)╯︵ ┻━┻

See, that's the thing. Everyone should have thought of it. Any time you have a kid who hates to be touched, is afraid of having things in their mouth, and/or is terrified of strangers you should suspect sexual abuse. All of these people are trained health care professionals and should know the signs. And they're good people, who are good at their jobs normally, which is why it was so frustrating.
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Dogen



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PostPosted: Fri Feb 28, 2014 8:03 pm    Post subject: Reply with quote

Darqcyde wrote:
This is the degradation of our education system at it's finest.

... what?
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mouse



Joined: 10 Jul 2006
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Location: under the bed

PostPosted: Fri Feb 28, 2014 9:40 pm    Post subject: Reply with quote

Dogen wrote:
See, that's the thing. Everyone should have thought of it. Any time you have a kid who hates to be touched, is afraid of having things in their mouth, and/or is terrified of strangers you should suspect sexual abuse. All of these people are trained health care professionals and should know the signs. And they're good people, who are good at their jobs normally, which is why it was so frustrating.


but as sherlock holmes would say, it's not enough just to see, you must observe. they were focused on the medical issue (the infection), and probably not seeing her reaction beyond how difficult it was making their job (although i'm really surprised they didn't almost immediately switch to an iv when they were having problems giving things orally - jeez, you would do that with a cat). about how old was she, if i can ask? young enough that they may have just put it down to "child having tantrum because she feels rotten"? a lot of young children are not too wild about going to the doctor, especially if it involves anything that might be painful - but most of them haven't been abused.

in short (or in long, as it is turning out) if they haven't been aware that they have dealt with some patients who had histories of sexual abuse (either because the patient was able to control their reactions, or the reactions just didn't cause enough of an issue that it needed to be dealt with), then they may have "history of sexual abuse" categorized as a zebra - something you push to the back of your considerations. you, on the other hand, as a shiny new graduate student are immersed in all of this stuff, and it's all about equally new. it gives you more flexibility to look at the situation with fresh eyes, not through the filter of all the other patients.

which is not to say that what you did wasn't great. you did a really good thing for the girl, and you did a good thing in educating your coworkers. i'm sure none of them will forget this patient, and they will be more alert to the signs in future. and more willing to take action on them.

i'd offer you a churro, but i don't want to sound flippant. also, i'm going to be seriously broke as soon as i pick up my car. so you have to buy your own churro anyway.
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Darqcyde



Joined: 11 Jul 2006
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Location: A false vacuum abiding in ignorance.

PostPosted: Fri Feb 28, 2014 10:07 pm    Post subject: Reply with quote

Dogen wrote:
Darqcyde wrote:
This is the degradation of our education system at it's finest.

... what?

Not you, I mean the other people demonstrating a lack of what seem to be basic medical skills. It reminds me of various articles I've read by older doctors, specifically those who teach, who are advocates of current healthcare providers needing better training at the more routine fundamentals of patient check ups.
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mouse



Joined: 10 Jul 2006
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PostPosted: Fri Feb 28, 2014 11:07 pm    Post subject: Reply with quote

i think it may be a little harsh though to ascribe it to that. people tend to fall into grooves, of thinking and behavior. if they don't see much of something, or think they don't see much of something (whether it be signs of sexual abuse in a child or, i don't know, lesser bushtits), they tend to think that thing is not there, and they stop looking for it.

sometimes they need someone to say "there - you hear that whistle? that's a lesser bushtit!", and then they remember to look for them.


(i chose "bushtit" because i knew then everyone would read this. it's actually a type of bird.
(although oddly, it appears there are no lesser bushtits. there are lesser bushbabies - and where do they think those come from ?)
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Jinx



Joined: 09 Jul 2006
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Location: America, fuck yeah!

PostPosted: Mon Mar 03, 2014 1:50 pm    Post subject: Reply with quote

Dogen wrote:
Felgraf wrote:
First Reaction: Dogen, you are an amazing person, both to quickly think of that, and to have to deal with such things.

Second Reaction: (╯ー□ー)╯︵ ┻━┻

See, that's the thing. Everyone should have thought of it. Any time you have a kid who hates to be touched, is afraid of having things in their mouth, and/or is terrified of strangers you should suspect sexual abuse. All of these people are trained health care professionals and should know the signs. And they're good people, who are good at their jobs normally, which is why it was so frustrating.


Dogen, I'm glad you were able to help that girl out. I expect that bring the kind of satisfaction that has driven you to your vocation.

I have to say, I don't even know if this is a medical training thing. The first thing I thought of was that she might have been abused. That may be because of the set up. (Dogen's telling a story, with a disclaimer, etc.)

OTOH, the engineer in me was also wondering why the medication had to be oral, regardless of WHY the girl didn't want things forced down her throat. If she doesn't like pills, and there's an alternative, why not go that way?

Good on ya', dude.
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Snorri



Joined: 09 Jul 2006
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PostPosted: Mon Mar 03, 2014 10:32 pm    Post subject: Reply with quote

Jinx wrote:
Dogen wrote:
Felgraf wrote:
First Reaction: Dogen, you are an amazing person, both to quickly think of that, and to have to deal with such things.

Second Reaction: (╯ー□ー)╯︵ ┻━┻

See, that's the thing. Everyone should have thought of it. Any time you have a kid who hates to be touched, is afraid of having things in their mouth, and/or is terrified of strangers you should suspect sexual abuse. All of these people are trained health care professionals and should know the signs. And they're good people, who are good at their jobs normally, which is why it was so frustrating.


Dogen, I'm glad you were able to help that girl out. I expect that bring the kind of satisfaction that has driven you to your vocation.

I have to say, I don't even know if this is a medical training thing. The first thing I thought of was that she might have been abused. That may be because of the set up. (Dogen's telling a story, with a disclaimer, etc.)

OTOH, the engineer in me was also wondering why the medication had to be oral, regardless of WHY the girl didn't want things forced down her throat. If she doesn't like pills, and there's an alternative, why not go that way?

Good on ya', dude.


I think abuse is just this thing that people don't really even want to think of. Unless you have experience with it you tend to assume it just happens somewhere else. It's not the kind of thing you want to see.
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Darqcyde



Joined: 11 Jul 2006
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PostPosted: Tue Mar 04, 2014 3:03 am    Post subject: Reply with quote

mouse wrote:
i think it may be a little harsh though to ascribe it to that. people tend to fall into grooves, of thinking and behavior. if they don't see much of something, or think they don't see much of something (whether it be signs of sexual abuse in a child or, i don't know, lesser bushtits), they tend to think that thing is not there, and they stop looking for it.

sometimes they need someone to say "there - you hear that whistle? that's a lesser bushtit!", and then they remember to look for them.


(i chose "bushtit" because i knew then everyone would read this. it's actually a type of bird.
(although oddly, it appears there are no lesser bushtits. there are lesser bushbabies - and where do they think those come from ?)

When I mean by basic medical skills, I'm talking about the routines that doctors or other attending medical help are supposed to go through. Part of the issue, from what I recall reading, is that the tendency has become to eschew these "old fashioned" practices, especially the literately more hands one stuff, especially in environments like hospitals where things are the most micromanaged and things have been expedited over the years through advances, especially with improved tests and the adaption of more devices and electronics.

Don't get me wrong though, I understand the part about routine, but depending what's at stake, it could be scary
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Dogen



Joined: 10 Jul 2006
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Location: Bellingham, WA

PostPosted: Tue Mar 04, 2014 7:56 am    Post subject: Reply with quote

mouse wrote:
in short (or in long, as it is turning out) if they haven't been aware that they have dealt with some patients who had histories of sexual abuse (either because the patient was able to control their reactions, or the reactions just didn't cause enough of an issue that it needed to be dealt with), then they may have "history of sexual abuse" categorized as a zebra - something you push to the back of your considerations. you, on the other hand, as a shiny new graduate student are immersed in all of this stuff, and it's all about equally new. it gives you more flexibility to look at the situation with fresh eyes, not through the filter of all the other patients.

I think this is essentially exactly what happened, and almost certainly was by the time she got admitted (because once you're admitted people have this annoying tendency to try and fit everything into the box of your existing diagnosis to the exclusion of other diagnoses - you'd be amazed what can be chalked up to peritonitis when a child doesn't have trauma documented in their chart).

Jinx wrote:
OTOH, the engineer in me was also wondering why the medication had to be oral, regardless of WHY the girl didn't want things forced down her throat. If she doesn't like pills, and there's an alternative, why not go that way?

Well, there's no good answer, but there is an answer. IV is never the preferred route, because it opens a pretty big hole in their immune system (literally), can damage vasculature, is generally less comfortable for patients, and is more expensive. So, while we do them all the time, we try to avoid them if they're not necessary. I guess we all have different ideas about what constitutes necessity.

Snorri wrote:
I think abuse is just this thing that people don't really even want to think of. Unless you have experience with it you tend to assume it just happens somewhere else. It's not the kind of thing you want to see.

I'd be more apt to buy this from the nurses and doctors on the unit where she was admitted, but the ER staff should absolutely, unequivocally, always be on the lookout for abuse. In theory they should be trained in the signs, and in practice the ER is where many abused people eventually end up. I imagine if she'd been in intense pain in the ER (before they began treatment) they may have chalked it up to fear and stress.

So, the people who should have seen it may have had a good reason to believe it was something else, and the people who weren't trained to see it never noticed it as different from other "difficult patients." It could easily have just been an awful, terrifying coincidence.
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mouse



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PostPosted: Tue Mar 04, 2014 8:26 pm    Post subject: Reply with quote

Dogen wrote:

Jinx wrote:
OTOH, the engineer in me was also wondering why the medication had to be oral, regardless of WHY the girl didn't want things forced down her throat. If she doesn't like pills, and there's an alternative, why not go that way?

Well, there's no good answer, but there is an answer. IV is never the preferred route, because it opens a pretty big hole in their immune system (literally), can damage vasculature, is generally less comfortable for patients, and is more expensive. So, while we do them all the time, we try to avoid them if they're not necessary. I guess we all have different ideas about what constitutes necessity.


is this something that varies by hospital? seems like any time i'm actually on a bed in a hospital (even just for tests) they stick an IV in me. on the other hand, i'm an adult and expected to lie quietly and not mess with ivs and things.
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Dogen



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PostPosted: Tue Mar 04, 2014 9:44 pm    Post subject: Reply with quote

mouse wrote:
Dogen wrote:

Jinx wrote:
OTOH, the engineer in me was also wondering why the medication had to be oral, regardless of WHY the girl didn't want things forced down her throat. If she doesn't like pills, and there's an alternative, why not go that way?

Well, there's no good answer, but there is an answer. IV is never the preferred route, because it opens a pretty big hole in their immune system (literally), can damage vasculature, is generally less comfortable for patients, and is more expensive. So, while we do them all the time, we try to avoid them if they're not necessary. I guess we all have different ideas about what constitutes necessity.


is this something that varies by hospital? seems like any time i'm actually on a bed in a hospital (even just for tests) they stick an IV in me. on the other hand, i'm an adult and expected to lie quietly and not mess with ivs and things.

No, there's just frequently a good reason to do it. If you need fluid - and the vast majority of people need fluid - then you can double up therapies. IV dosing is also more exact and works more quickly than oral meds. Also, if you're in an ER they'll pop one in pretty early in case you're worse than you look or head south, for the above reasons (or if you may need imaging with contrast). But, since we don't normally send people home with IVs (because they're expensive and you have to train people how to use them and get a new IV inserted... Except they're only good for 72 hours, so if they need meds for longer then they have to have a special IV put in...), so we transition them ASAP so we can do patient teaching and manage expectations.
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Dogen



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PostPosted: Wed Mar 05, 2014 1:58 am    Post subject: Reply with quote

I'm not really sure that made sense. There are a lot of good reasons to put an IV in someone, but because of the risk of infection we don't leave them in very long (72 hours, your definition of "not very long" may vary) and discontinuing them is usually a priority for both provider and patient once they've become stable. Most people hate them. It's also considered a "best practice" to remove an IV when it's no longer necessary for treatment, because of the risk of infection. The question is how it's decided that the IV isn't necessary.

You can read the CDC guidelines to see all the fun things that happen because of IVs, and why hospitals have switched to "IV teams" made up of specialized providers who insert, replace, and track IVs on every patient in the hospital.
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