I had been congratulating myself, at the children’s hospital, on not having to deal with much in the way of bad news. Sure, we were consulted a lot to help with cancer patients; but usually by the time we turned up, the parents had gotten the news from another service. Many parents also seemed to receive the news of appendicitis as though it were bad, too. I guess the idea of your child needing surgery at all has to be a bit of a shock. To us, though, the fact that it wasn’t lifethreatening, wasn’t cancer, and had been diagnosed appropriately seemed so good that it was sometimes hard to stay on the same page as the parents. Nevertheless, though not quite as routine for the family as it was for us, appendicitis is a widely known and accepted fact of life.
The last night, though, was not so simple. The young parents had brought in their six-month-old daughter after she’d been fussy for three days, not eating properly, and then over the last 12 hours seemed especially fussy about her belly. When she started passing bloody stools in the ER, the diagnosis was obvious, and was quickly confirmed with ultrasound: she had an intussusception. (Which is where one segment of the intestine telescopes inside the next segment, producing swelling and eventual ischemia, if not corrected.)
The classic treatment is an air or barium enema, which both provides a definitive diagnosis, and is usually successful in reducing the intussusception. This time it wasn’t. The radiologists tried all their tricks, and were unable to undo the intussusception.
I was around watching, because the usual procedure is for surgery to admit the child for observation after radiology fixes the problem, as it recurs 15% of the time. When the radiologists announced that it wouldn’t be safe for them to try anything else, I started making calls. It was great timing, from our perspective, because the OR was just finishing up with another case. So the staff were on hand, and with 20 or 30 minutes of turn-around time, they would be all ready to go.
Which meant I had five minutes to explain to the parents that a relatively simple problem with a minimally invasive solution had just become a lot more serious, and now needed a very invasive treatment. Because we didn’t know how much of the intestine would have been damaged, the OR consent had to include possible bowel resection and even stoma formation. That’s a lot for young parents to deal with in a few minutes.
They seemed very close, and mostly held on to each other and their daughter while we set things up. I went back a couple times to ask if they had any questions, but I think they were too shocked to say much (or perhaps my first explanation had been so lucid that it left nothing else to be desired!).
The night had a happy conclusion, because the attending and fellow were able to release the intussusception pretty easily, and nothing else had to be done. We were all pleasantly relieved, as the length of the child’s symptoms had been worrisome. (Most children with this problem are sick enough to come to the hospital within 8-12 hours of it developing.)
Cut On The Dotted Line 
February 1, 2009 at 12:24 am
We had a NICU patient recently who had to be shipped to one of the larger area hospitals with an intussusception the radiologists hadn’t been able to fix. Must be the season.
It is a shock to parents when you tell them that their baby needs surgery. Especially if it’s emergent. I always managed to put on a good show, but even relatively minor surgeries are probably more traumatic for parents than for the children.
I think the realization that there are things in the world from which you simply cannot shield your children is very hard to accept. For me, that came the first time my oldest child’s eardrum ruptured. By the time he was having his 5th ear surgery, it was fairly routine. For all of us.