It was a busy Sunday afternoon and my weekend on call was coming to an end. With winter officially here pediatric illnesses had picked up in both the office and the hospital. There were the typical viral upper respiratory tract infections, flare-ups of asthma, ear infections and gastrointestinal infections. It is a predictably busy time of year that remains chaotic until the arrival of spring.
My pager went off and the message was about a 15-month-old female who was vomiting. I thought to myself, “Winter must be here early this year. This is the fourth call about vomiting that I have received today.” I dialed the phone number that was entered in my beeper.
Kelsey’s mom answered and thanked me for calling back so soon. When I asked what was going on with the baby she said, “She’s asleep right now. She fell asleep right after I had you paged. All morning she seemed fine. We all went to church and had donuts afterward. She seemed her cheerful self until we sat down for lunch. Then she took a few bites and looked like something really bothered her. She gagged a few times and vomited. I guess she was really nauseated because I’d never seen that look on her face prior to her vomiting.
After she threw up she seemed better and went back to playing and harassing her older brother. Later on, she and her brother got into some crackers and were sitting in front of the TV eating them. After a few bites she stopped motionless and sat there as if she was in pain. I didn’t know if she might be constipated or had stomach cramps. But she became rigid and almost pale...then gagged and started to vomit. Her brother just got over a stomach flu that had lasted five days. It started out with him vomiting everything he ate for a good two days, and then the diarrhea came, and it was awful. He is much better now.”
I asked her if Kelsey had any fever or any other symptoms to which she emphatically denied. “My main reason for bothering you on a Sunday is that I think she is coming down with the same virus her brother is getting over,” she explained. “And I’d like to be able to nip this in the bud if at all possible!”
I told her that we should find out what was really going on with Kelsey. First and foremost, I asked mom to go into the bedroom and tell me how she was breathing. “She is sound asleep,” she reported. “And she sounds clear as a bell.” I explained the difference between stridor and wheezing, and she assured me that Kelsey was breathing normally. She even held the receiver of the phone up to Kelsey’s mouth. I asked if the baby had been drooling while she slept. She assured me that this was not the case.
My concern was that she might have a foreign body such as a coin or piece of toy stuck in the esophagus. I could tell that mom didn’t think that was very likely. “Having two boys older than Kelsey, I can assure you that we have to be extra careful in this house,” she pleaded her case. She and her husband had child-proofed the entire house, including putting all the Legos in the attic. “I’d be shocked if it was something like that,” she added.
There was no doubt that mom had done an excellent job in child-proofing HER house. But what about when Kelsey is out in public? It takes but a fleeting second for her to pick up a coin she might find on the floor in a restaurant or under a pew in church. And then she could put it is her mouth. Mom agreed that this was all possible, but she wasn’t entirely convinced. I told her to watch Kelsey very closely. When she wakes up give her sips of clear liquids and see how this is tolerated. Call me as soon as this happens.
Mom called me back in 45 minutes and seemed in a very good mood. “Well, Kelsey had a good nap, and when she got up I gave her some Pedialyte which she wolfed down. As we speak, I am giving her bites of yogurt which I can’t seem to get in fast enough.” This was followed by a long pause. “She is doing it all over again,” came a concerned voice. Kelsey was not hoarse nor did she have any wheezing or stridor which indicated that her airway was not compromised. I told mom not to let her eat or drink anything more. I wanted her to go directly to the ER at the children’s hospital. I would call ahead so they could be waiting for her.
Thirty minutes later I received a call from the ER physician who was caring for Kelsey. “Good call,” he said in a hurried voice. “Kelsey has a coin, probably a dime, lodged in her distal esophagus.” I admitted Kelsey to the hospital and consulted a gastro-enterologist. We started an IV because she would not be able to eat until the coin was removed. He took her to the intensive-care-unit where she could be adequately sedated and closely monitored. The endoscope, which is a tube with a light and camera at the end, is inserted in the mouth and passed into the stomach. The gastro-enterologist was able to visualize the coin, snare it and remove it. With the scope, he inspected the entire esophagus and stomach to document that she had not sustained any injuries from the foreign body ingestion.
Kelsey did just fine, and tolerated the procedure quite well. After the sedation wore off, she was given some clear liquids, and then a regular diet. She tolerated this without any problems and was able to go home later that evening.