This morning in grand rounds the lecture was on avian flu. Which suggested the idea for a sci-fi/thriller plot, which if I can magically research and write within three months could be a bestseller during the next flu season. . . I just need a protagonist to detect the villain.

Didn’t get out of the hospital till 5, because there were lots of admissions, and I got a 1.5yrold little boy who seems to have had croup, ear infection, and viral gastroenteritis, all in the course of the last week and a half. Today he has a fever of 104, and his parents are understandably concerned and frustrated. I took a fairly meticulous history, and did a thorough physical (which at least roused the listless child into screaming at me), in hopes of coming up with some overarching explanation for all these phenomena. So far, no luck. The resident’s main plan was to observe him, with iv fluids, overnight, and see what he does. All kinds of cultures are already pending, but since he already had tons of antibiotics for the ear infection, there’s not much chance of those being positive even if, unlikely as it is, he were septic. So I have the disappointing feeling that this complicated case will be resolved by a spontaneous recovery, and no rare diagnosis.

Yesterday at midnight the ortho team at the hospital finally agreed to tap the fluid in the joint of an 8yrold boy admitted 2-3 days previously with painful hip, migratory rash (which comes and goes), migratory polyarthritis, and various other weird but not definitive symptoms and lab studies. And a low-grade fever. It’s a good thing he wasn’t my patient, because if there’s one thing I learned in rheumatology, it’s that your reflex action in any case of arthritis where there is fluid is to tap that joint!, as the professor would say. Just listening to the discussion of ortho’s evasiveness in rounds, I was upset. If he’d been my patient, I think I would have been tracking the ortho folks down with threats of grievous bodily injury if they didn’t come and do something. Especially since the fluid analysis came back, 12,200 WBCs. Which is not normal synovial fluid; which means they seriously jeopardized this young boy’s joint integrity and function by leaving that septic joint undrained and untreated for two+ days. I would throw a fit, myself; but I doubt that the intern on the case has the guts to do that, or she would have done it a couple days ago.

UPDATE: In the interests of academic honesty, I must admit that I later learned that 12,000 WBCs is not septic; you need 60,000 for that. So he does have juvenile rheumatoid arthritis. But I think the principle still holds: the orthopods didn’t know it wasn’t septic, and it alleviated his pain after they drained it. So.

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