While other moms call their pediatrician to ask about runny noses...

On my most recent night shift, the first chart I picked up said "Sore throat, fever, headache." I glanced at his vitals and his pulse was racing (100+) and he had a temperature of 103. "Strep?" I wondered. I headed back to his exam room to see.

You usually can tell which patients are the most sick by just looking at everyone as they come into the ER. As I laid eyes on this muscular young soldier, I knew he had seen better days. His bald head was completely coated in beads of sweat and his skin had a sickly pallor to it. He was laying listless on the stretcher, like a wilted plant in need of some serious watering. I knew there would at least be IV fluids in his future.

He told me he had been fine the preceding day, then just woke up that morning with a sore throat and headache and maybe a little cough. His neck also hurt, in the front… NOT in the back (which would have meant a spinal tap to rule out meningitis). On exam he had some swollen nodes under his jaw and maybe a mildly red throat. Last time he felt this way it was strep throat. "Good," I thought. "I can give him a shot of Bicillin for strep and he’ll go home and get better." I ordered IV hydration, pain meds, antipyretics and then sent the strep test and some basic labs, plus a mono test and chest x-ray, just in case.

I didn’t hear anything more from him as I waited for his tests to come back, and I assumed he was back in his exam room getting better with watering. His tests showed an elevated white blood cell count (the cells that fight infection) and dehydration, but there was no strep, no mono and no pneumonia or other airpace disease. Could this all just be viral with a fever of 103? I felt like I was missing something. I went to re-examine him and he still looked like crap and STILL had a temp of 103. I told the nurse to consent him and set-up for a lumbar puncture (spinal tap). Maybe there really was something more to this neck pain...

As I was getting ready to go tap him, he suddenly started screaming out with excruciating belly pain, and vomiting profusely. What the heck? I went and re-examined his belly and it was no longer soft, but firm with guarding…. If his mono had been positive I would have thought he ruptured his spleen. I wondered about appendicitis, cholecystitis, some strange hepatitis? So I sent him for a belly CT scan and added on belly labs to his blood work. Damn if all of that wasn’t normal too.

At this point it occurred to me to ask if he had been out of the country recently, since he was military. Sure enough… he just got back from Iraq 3 days ago. Hmmmmm… could it be some kind of weird travel related illness that you never expect to see in my podunk little ER? I sent a malaria smear and read up on what infections might be indigenous to Iraq… then I sent Q-fever and schistosomiasis serum tests. I decided to proceed with the LP to rule-out meningitis or some kind of funky encephalitis. Now this was getting interesting.

"Interesting" is never good from the patient’s standpoint. And it’s not good from the doctor’s standpoint when she get exposed to the patient’s bodily fluid… especially when the doctor happens to be feeding her breast milk to her baby at home. Until this damn spinal tap, I had never stuck myself or had any type of body fluid exposure in my entire medical career. But I guess I got a little overzealous with the soldier’s subcutaneous lidocaine. In an attempt to make the LP as tolerable as possible for patients, I typically go crazy with the lidocaine – I get extra lidocaine beyond what they give you in the LP kit, and I inject away… subcutaenous tissue, deep tissue, periosteal tissue. It usually works very well – I’ve had 2 patients tell me that my spinal tap was less painful than the having their IV started! On this occasion, however, the lidocaine did me wrong. I was injecting it… a LOT of it… right under his skin. The pressure under his skin got greater and greater and then WOOSH! The syringe came off the needle and pressurized lidocaine sprayed right out of the needle in his back and went EVERYWHERE, including both of my eyes. Shit.

With my eyes stinging, I quickly finished the procedure and then filled out an incident report. I wasn’t particularly concerned because it was such a low-risk exposure… mostly just lidocaine and probably slim to none of the soldier’s body fluid got in my eyes. Plus I’m vaccinated and I know he is too, since he’s military. I was feeling pretty nonchalant about the whole thing… until I thought about Graham drinking my breast milk. Then I became crazy psycho worried mommy… and off went the HIV and Hep B&C tests on the patient. I even had the nurse stick me to make sure my Hep B titer is good. Worrying about your kids adds another whole dimension of stress to what might otherwise been only mildly stressful, and suddenly I was acting like I had injected his blood right into my vein.

I’m still not sure what is wrong with the patient. His spinal tap ended up being normal. I admitted him to the hospital for fever of unknown etiology, and a lot of the test results for the more unusual infections (malaria, etc.) are still pending. I would have followed up on his hospital course based on academic interest alone, but now I have a personal interest as well, and I can’t wait to finally see what’s wrong with this guy. If he has some weird Iraqy infection, what are the chances I contracted it and might pass it to Graham via my breast milk?

Even though I figured chances were quite low, I decided to run it by my pediatrican. So, while other moms are calling and asking about little Jonny’s runny nose and cough, I call and ask (in a nut shell), "If I got splashed in the eyes with lidocaine from a needle in the subcutaneous tissue while doing a spinal tap on a febrile soldier who got back from Iraq 3 days ago, should I worry about passing something to Graham via my breastmilk?" I was not surprised the answer was no. I just needed to hear someone else say it. I WAS surprised that they kept from laughing while they listened to the whole saga. Sometimes truth really is stranger than fiction.

Only me, I tell you. Only me.