Beware The Silence

Know what it sounds like when a kid drowns?

Silence….

That’s what I was taught in my lifeguarding class. Our teacher, a guard for 20+ years admonished us in a stern voice, “Beware the silent pool.” Rarely is there thrashing and splashing and gurgling out a diminuitive “hel..gh..lp!”. Typically, the affair is alarmingly un-dramatic. It happens this way with adults sometimes too, but especially with kids. They just slip quickly beneath the water’s surface and unless they’re seen within about 60-120 seconds, the result is terrible.

This little rule correlates well with much of medicine, too. Last night, for example, I saw two cases, one “loud” and one “quiet”.

The loud case was a boy who came in by ambulance – siren, lights, DRAMA – because the mother is certain there’s something wrong with him. She says he has unexplained fevers, and doesn’t eat sometimes. Once in awhile, it doesn’t seem like he urinates normally. She noticed that he gets short of breath, too. She wants a full work-up and if we aren’t willing to do it (or not capable), she wants transport to the Very Excellent Children’s Hospital up the road. For her, there is certainly some sort of major metabolic problem and serious intervention is needed.

The “quiet” case is an older man who “just has a cough, man.” His friends made him come in because he keeps coughing and recently isn’t interested in eating…or drinking. Once in the ER, it is found that he has been smoking lots of cigarettes for lots of years; the patient says he’s had this smoker’s cough for a long time. “‘Course,” He adds in apparently sudden introspection, “…I guess the blood is new.” Over the past week or so, each cough is not just tinged with blood, but volumes of red, mucousy blood that is painful to produce. Labs show that his kidneys are virtually destroyed and after multiple liters of fluid he still can’t pee (one liter and you’d be running for the bathroom every 10 minutes…assuming you don’t have this guy’s kidneys). We also noticed that he has no platelets – the blood elements that cause clotting.

So, I’m sure you can see which case is medically alarming and which one isn’t. This is not to say that the kid really has a problem, he might. Odds are, however, that his mom is the one with the problem and will improve dramatically with some close doctor contact and lots of reassurance. It could also be that the old guy is also relatively ok. Maybe it’s just a pneumonia and severe dehydration or something simple like that. But there’s a good chance, he’s headed toward multiple organ failure and his time in this realm is short. Here’s a couple of the major flashing red lights in this case, if you haven’t seen them for yourself: Not eating for a short time really isn’t very interesting from a medical perspective. Lots of people have fluctuations in their eating habits, especially if they get basic, non-dangerous viral infections, etc. Not drinking is a BIG DEAL. In the brain, the drive to drink far superscedes eating. It trounces heat-seeking, comfort-seeking, sleep, procreation and even safety. Probably the only drive more dominant than drinking is breathing. Losing your drive to drink means something very basic in the base of your brain stem is awry. Also, some blood-tinged sputum after frequent coughing is nearly normal. It has to be looked at by a doc, but it can happen easily with even a common cold. Volumes of bright red blood is a problem. There’s a few things that cause it, all of which are life-threatening, most not treatable. Add to this the no platelet thing…and we have a serious problem in the guy who says he just has a little cough.

The contrast between these two patients – in terms of their severity – in interesting mostly because it reminds me that sometimes, the bigger problem lies quietly in the patient adamantly assuring everyone around them that things are fine, there’s nothing to worry about…and please, take care of that poor sick kid with the frightened mom.

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