Tuesday 17 June 2014

Vomit and zebras

There is little in this world more disgusting than vomit.  I'm not talking about your own baby spitting up - somehow when you feel a bottle's worth of milk oozing warmly down your back, it isn't so bad.  But when a grown adult empties his stomach onto the floor - the sound, the smell . . . it makes others want to follow suit.  The big problem with vomiting (other than the smell and sound, of course) is trying to figure out why

There are approximately 2,957 causes for vomiting.  Common reasons include a stomach bug (aka viral gastroenteritis or stomach flu, which isn't actually the flu but a different virus), medication side effects, pregnancy, eating "bad food", inflammation, and the ever-present "other".  Trying to figure out why a certain patient can't keep anything down can be maddening, though tests (like blood tests, X-rays, abdominal CT scans, and stool tests) can be helpful.  In viral gastroenteritis, all these tests are typically normal, however, making it a diagnosis of exclusion.

But what happens when vomiting is due to one of those "others"?  

When you hear hoofbeats, the first thing you think of is horses.  Obviously.  But zebras have hooves too, so how can you be sure it's a not a zebra coming?  Because common things are common and because zebras don't live here, that's why.  

Oh really?

Karen (not her real name) had just such an experience with her daughter Zebra, er, Ella (not her real name).
Hi Doc Bastard,

I am writing to you about a medical story that I hope you will agree has ridiculous parts to it.
In 2011 we had one child, a 26 month old named Ella (not her real name) {Karen wrote that, not me!}.  One morning, Ella threw up right after she woke up.  No big deal, kids get the flu all the time.  I took off work and stayed home with her.  She got better throughout the day and was even eating by the end of the day, so I decided this was a 24 hour thing and didn't even take her to the doctor.  Then the next morning, again she threw up. I decided I should take her in.  My pediatrician (Dr. K) looked her over and decided she had the flu, just like I had thought.  Give her fluids and rest, she will get better.  And Ella did, for the most part.  She was fine for the next few days, went to daycare, and was gaining her appetite back.  But by the weekend she had begun throwing up again and had a new symptom: she was lethargic.  Normally I could never get her to take a nap, she would fight it and then finally she would go down.  Now she would sleep for 3-4 hours and I had trouble waking her.  Since it was the weekend, Dr. K advised us to go to the ER. 

We saw a very young-looking, very tired-looking ER doctor who wanted to do a CT of Ella's abdomen to see what was going on.  The CT only showed constipation, and the doctor said the reason Ella was vomiting was because she was constipated.  She kindly assured me that this is more common than I would think, given the diets of Americans today and that she sees about 100 cases a year.  

After some enemas, they did another CT. She was clean as a whistle.  And then Ella promptly threw up again.  I asked the doctor what was causing her to throw up now that the constipation was gone.  She told me Ella must have contracted the flu during all this, so wait a few days and it would clear up.  Okay. 

For the next several days, Ella got worse.  Throwing up all day, not eating anything, and lethargic, not playing.  I brought her back to Dr. K, who was concerned Ella was dehydrated.  She sent us back to the hospital for IV  fluids, and we went home.  The next day, Ella threw up again. This has been going on for two weeks now and Dr. K was very concerned.  She sent us for labs, but they came back NEGATIVE.  No virus, no bacteria, nothing.  So, Dr. K made us an appointment for the next day to go back to the hospital for another CT, this time it was of Ella's head to "rule anything out" {looking for zebras!}.  The following day we got the CT results, and the doctor looked shocked, perplexed and upset.  "I looked at her scan," the doctor said.  "She has a mass in her brain.  She has hydrocephalus so badly that I am afraid to give her any more fluids. You will be transported immediately to the Children's Hospital downtown".  That is what he said, but the look on his face told me "Your two year old has an inoperable tumor and she is going to die".  What happened after that is pretty much a blur. 

We waited in triage for hours, and eventually her neurosurgeon (Dr. F) showed up.  He was the calmest person in a room full of hysterical people.  His calmness helped me.  "She has a brain tumor.  We get these all the time.  I have seen this before.  We will give her steroids to bring down the swelling, and then I will do my best to remove the entire thing".  He then explained to me that tumors do not kill people, hydrocephalus kills people. 

Ella had an 8 hour surgery to remove the tumor.  She came out of the surgery slowly, with Dr. F standing over her the entire time.  She stayed in the hospital for a few days, and then we took her home.  Little by little, she got better and much happier.
You said that surgeons, since you can't see the results, are judged on their bedside manner.  That is true, but in this case, if he had left any of the tumor in, the results would likely have been fatal.  I know you say that people tell you thanks and appreciate what you do.  I don't know if this is normal, but to me the amount of gratitude and admiration I have for this man seems equivalent to love.  It's a weird feeling, loving someone you don't really know.  I don't know if other people love their surgeons, but I do.  He unequivocally saved Ella's life, and because of him, she has the best chance at survival that she can have.  She still sees him every 6 months, after her MRI.
Thanks for letting me share my story with you.
Thanks to Karen for sharing her (and Ella's) zebra story.  I'm happy to report that it's now been three years since Ella had her surgery, and she remains happy, healthy, and best of all, tumour-free.  I hope she remains that way for many decades to come.

With all the stupid, ugly, and awful stories I share, stories like this are, unlike the smell of vomit, a breath of fresh air.


  1. When my son was seven years old, he would have these spells where he would soil himself or vomit and then deny, deny, deny. He had been diagnosed with hypotonia as a preschooler so we all, including his pediatrician, thought his bladder and bowels were weak. The vomiting, we chalked up to sensitive tummy.
    I began to notice that whenever he had these episodes, he'd sleep for hours afterwards and would just be lethargic the rest of the day. I brought this up to his doctor, who assured me that my son was fine and we moved on.
    One day, my son woke up with a horrible headache and was given Tylenol. I asked him if he felt well enough for school and he said yes and went on his way.
    That night, we were out shopping and suddenly the boy just blanked out. He got a thousand yard stare and was unresponsive. My son had pretty much left the building.
    When he came to, he vomited once and didn't realize he had vomited.
    A week later, he was diagnosed with an astrocytoma in his occipital lobe. All this time, these episodes were seizures that no one saw until he had one in front of me. Over a year of these episodes and no one saw a thing, he presented normally to his doctors, had no deficits and no memory of these things happening to him. Biggest zebra in the universe and not a teacher, parent, doctor, coach, pastor or another child saw it. That was eleven years ago and he's now a smart ass eighteen year old who sells computers at Best Buy. He has an interesting scar on the back of his head and a really cool story to go along with it.

  2. Karen is not alone. :) There are two surgeons I love as well, and one of them I've only met for about 10 minutes... Children's Hospital, pediatric surgeon who saved my son's life when he was born extremely premature (6 surgeries) and pediatric cardiac surgeon who operated on his heart when my son weighted less than a kilo - open heart surgery on someone as big as a kitten... so yes, love them both and their teams, including every single nurse :)

    My son is 3 years old, happy, smart and awesome. Thanks to them. As long as I live. :)

  3. I have a whole herd of zebras and some of them don't play well on the Serengeti. It usually takes a long time and several wrong diagnoses to figure out what is really happening. The problem with zebras is that sometimes they are so rare that the doctor hasn't even heard of them. And because they are so rare, nobody has studied them enough to come up with an effective treatment. In the 90's, before House threw the term out in every other episode nobody knew what Long QT Syndrome was. Instead I would tell them I had a prolonged resting phase of the heart that could lead to polymorphic ventricular tachycardia. Usually even that got a blank stare. If you come down with anything you really want it to be the plain old garden variety that every doctor has seen. It's your best chance of getting well.

    1. I have noticed you sharing a lot of stories about having zebras. If I were you I would have a panic attack every time I got a headache. =P

    2. Headaches don't do me in, I leave that to my oncologist. My defibrillator pacing and electrolyte imbalances make me crazy...bone pain too. I have accepted that I over react.

  4. Former nurse me was looking for the description "explosive vomiting." Because had I heard that, or had the misfortune of observing it, I'd have thought "brain tumor" a whole lot quicker.

    Glad for the happy outcome, and for persistent parents. A long and happy life to Ella <3

  5. So happy things went well for babygirl. :)


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