Case 27: House Rules

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My seven-year old studies the poster in his older brother’s room. Baseball Rules. Always step into your throw. Don’t bunt on two strikes. There’s no crying in baseball. If my colleagues and I were to make a list of rules, based on what we’ve learned over years in the ER, it would take up all four walls and the ceiling as well. Some would be obvious: Don’t bike without a helmet. Around a pool, keep kids within arm’s reach. Wear your seat belt.  Others would be less obvious: Slice grapes and cherry tomatoes in half.  Don’t keep household cleaners in Evian bottles. Always maintain your grip on a vibrator.

My son followed the baseball rules as best he could, and, on a scorching Sunday in June, his Minor Rookie team won their first tournament on a dusty field on the east side of Toronto. That evening, my brother hosted us for the celebratory dinner. As I sipped a French red with a fancy label, I spotted my twin prepping the grill as he unwrapped marbled steaks from the overpriced butcher two blocks down. A wine glass in one hand, he was committing a crime with the other – smiling all the while – his head swaying unevenly to Duran Duran’s ‘Hungry like the Wolf.’

My brother is not medical. He often calls me, in search of advice. “My son has a sore throat, can you call in a prescription?” You’re out of the country. My license doesn’t work there. And I don’t speak the language. “A friend of mine has prostatitis and has a few questions. Can you chat with him?” Sigh.

I approach him. “I think those are banned. And if they aren’t they should be.”

He holds the tool in front of me and smiles. “What? This?” He gives me the look he’s been giving me since we were five. You’re an idiot.

“No, seriously,” I say. “They’re dangerous. At the very least there’s an advisory about them.” He ignores me and continues. I take two steps through his back door and grab a cloth from his kitchen sink. I return to the deck where he’s swatting away a wasp. “Just let me know when you’re done.”

***

Three weeks later, I pick up a chart and scan the triage note. I hope that there’s nothing wrong with this patient – that she just thinks something’s wrong. Many patients with this complaint are like this – they feel that something is there, but there isn’t. We call this Globus. Short for Globus Pharyngitis, or Globus Hystericus. I step into the room, and I see her – a tiny third-grader in the large dentist-office chair. Her vital signs are normal. She isn’t drooling, she isn’t wheezing, and her color is good. Her face, however, is cringed. It’s the face of distress – of fear, of discomfort – eyes scrunched, smile upside down – like she might start crying at any moment. An hour earlier, she was eating a cheeseburger at her grandfather’s house, and then she felt it – something stuck in her throat.

Her mom already knows the first question I’m going to ask – she’s a medical professional, and she’s familiar with this. She answers before I finish – “it was one of those wire brushes” – the same type my brother used on the grill on Victory Day back in June.

I ask her where she feels it. She points to the middle of her neck, just above her breastbone. I have a camera – a scope that I can feed into her nostril and turn downward. If there’s something stuck there, it’s too low – I can only see down to her vocal cords. Besides, her nostrils are tiny. Unlike an Ear Nose and Throat specialist, I don’t use the scope enough to navigate through her tiny passages without crashing several times. She isn’t coughing, she isn’t choking, and she isn’t drooling. Whatever it is, it didn’t go down the wrong tube. It went into her esophagus. The question is, did it just leave a scratch, or is it still there.

“Most of the time,” I tell her mother, “when people feel something in their throat, or their esophagus, it’s just that something left a scratch, and it’s gone. I write an order on the chart – soft tissue neck – and I point them toward x-ray. “It is possible, though, that there’s a wire stuck there. And if there is, it should show up on the x-ray.”

Ten minutes later, they’re in a different room. I see them in there – before I have a chance to look at the x-ray. I ask my assistant to pull it up on the screen behind me. I turn around and study it.

Chart in hand, I enter the room, hoping that something has changed since I last saw them. The little girl is smiling now, and so is her mom. “Do you still feel it there?” I ask, hoping that she’ll say no – hoping she’ll tell me that she felt it magically dislodge and swoosh down into her stomach.

“Yes,” she says, holding her neck once again.

“Exactly the same?”

She nods.

I turn to her mom. “It’s there,” I say. “Clear as day. Stuck at the top of her esophagus.”

***

When my brother is finished scraping the grill, I wipe it down with a wet cloth. I tell him to throw the away the wire brush and that I’ll buy him a new one – a wooden one that’s not going to work as well, but that’s less likely to get his kids hospitalized. I jog over to the hardware store, and to my surprise, wire brushes aren’t outlawed. You can buy them just as easily as you can by other lethal items such as grapes, cherry tomatoes, balloons, whistles, trampolines, ATVs, and Tide Pods. I shake my head and spend thirty bucks on a giant spatula that will clean his grill as well as my baseball star makes his bed.

***

Screen Shot 2018-09-06 at 3.15.25 PM

I show them the X-ray. I tell her that our gastroenterologist isn’t comfortable with 8 year old passages, and that I’ll have to make a call to the pediatric hospital and have her transferred there. “I just hope that it isn’t embedded too far into the tissues of the esophagus,” I tell her mother quietly. “There are times when they can’t get these wires out.”

Her mom is as calm as she’s been from the beginning. And because of this, my tiny patient is calm as well.  They spend the night at the pediatric hospital, and the following day, she’s put to sleep in the OR and the wire is successfully removed.

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3 comments

  1. Always love reading your case files/studies – you write so well. Didn’t know you had a twin. Wish you had stayed in Markdale.
    Keep well
    Hugh

  2. You know I am as aware of these things and the risk as anybody. My question is why has this become an issue in the last three years while those brushes have been around probably since the 50s?

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