I was on call on Friday and it turned out to be Fascinoma Night in the West Bronx ER. Every patient who came in between the hours of 5:00 P.M. and 8:00 P.M. had some bizarre diagnosis or some record-breaking laboratory result. The very first kid I saw was this one-month-old whose mother said he had vomited every feeding since he was discharged from the nursery. Every feeding! Now, I immediately recognized that there was some sort of problem here. I mean, I may not be Sir William Osler [a famous physician of the nineteenth century who was known for his legendary clinical acumen], but I do know it’s not normal to vomit every single feeding of your entire life. At first, I was a little skeptical about the story. It’s a little hard to believe something like that, so I asked the mother why she had waited so long to bring the kid in. She said she hadn’t waited long at all, that this was the fourth time she had been in an ER, and that no one seemed to want to do anything to find out what was wrong with the kid. Okay, so then I figured the woman had to be a fruitcake or something. I mean, any doctor seeing a baby who had vomited every single feeding of his entire life would get very concerned and do something definitive, wouldn’t he?
I guess not, because when I saw the baby, it became pretty clear the mother had to be right. I couldn’t believe it. He looked like a baby concentration-camp survivor. He looked worse than Hanson did on Infants’, which is pretty damn bad! This kid was a pound and a half below his birth weight, for God’s sake! I did an exam and I didn’t find anything. Then I sat and fed him for a few minutes. He seemed to do fine right away, but about ten minutes into the feeding he started to cry, and the next thing I knew there was baby vomit all over my sneakers. Great! So I ran over and got the attending and showed him my shoes and told him I thought the kid had pyloric stenosis. [This is a condition caused by enlargement of the muscles at the junction between the stomach and the first part of the intestine. Because of the muscle enlargement, flow of partially digested food is obstructed, and once the stomach fills, the feeding is vomited. Pyloric stenosis is surgically repaired.] He refused to help me clean off my sneakers, but he did come see the kid and we felt the abdomen, and sure enough, the kid had an olive [a mass in the abdomen overlying the site of the stomach].
But the pyloric stenosis isn’t what made the kid so interesting. What made this kid a fascinoma was the fact that because he was so sick, I sent off a blood gas to see how alkalotic he was. [Because the infant with pyloric stenosis is vomiting stomach contents that contain hydrochloric acid, these children frequently manifest alkalosis, or lack of a proper amount of acid in their blood.] It turned out he had a pH of 7.76, the highest recorded pH in the history of the pediatric chemistry lab at West Bronx. I think as a result of having my name on the lab slip as the doctor of record, I’m supposed to get a commemorative plaque or something. As a result of having the record-breaking pH, the kid is getting a no-expenses-paid trip to the ward at West Bronx for fluid and electrolyte therapy before the surgeons take him to the OR tomorrow to fix his stomach.
And that kid was just the beginning. A little later we got a call from one of the orthopedic attendings who told us that a patient of his was coming in. He told us, matter-of-factly, that the kid had been bitten by a horse. A horse! Where the hell is a kid from the Bronx going to find a horse to bite him in the middle of March? I mean, we’re talking about the South Bronx here; this isn’t the Kentucky Derby! So the story seemed a little peculiar to begin with. And then the kid showed up, and it got even stranger.
I didn’t actually see the kid right away. I heard her first. The sound she made was very much like the sea lion tank at the Bronx Zoo around feeding time. And that was just her breathing! I walked over to see what was going on and the mother said, “Don’t intubate her, she’s got a problem with her trachea, she always sounds like this.” It was at that point that I started to get a little suspicious. It turned out, this was the orthopod’s patient. She was this five-year-old with some horrible disease called metachromatic leukodystrophy, a really rare metabolic disorder. She was followed by one of the neurologists. So I’m sure this is the only case in the history of recorded medicine of a kid with metachromatic leukodystrophy having been bitten by a horse. At least having been bitten by a horse in the South Bronx during the month of March.
I have to admit, the story kind of piqued my interest, so I asked the mother how the kid got bitten. She told me the girl was involved in this therapeutic horseback riding program and she had been out for a ride that afternoon. At the end of the ride, the girl usually feeds the horse a carrot. She did it this time but she forgot to pull her hand away after the carrot was gone, and the horse, not understanding the difference between carrot and hand, continued to nibble. So she got bitten. Right; that made all the sense in the world. I’m glad she cleared that up for me!