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Cecelia is Crying

It’s 3 AM. Only 3 hours left. It’s about time for one more cup of coffee. Suddenly the calmness of my overnight Pediatric shift is broken by the wailing of a crying baby. The family walks past me-looking exhausted, feet dragging, bewildered, holding a screaming child. They are quickly registered, and the chief complaint flashes on the computer screen before me: 4 month old female, “crying.” Ah, the crying 4 month old problem. Is there a more challenging dilemma for the emergency Room Physician? It’s 3 AM, there is a crying baby in my department, time to put on the old thinking cap, this is one of the toughies.

I entered the room to find a pleasant Hispanic couple rocking their 4 month old daughter Cecelia. They were new parents. Cecelia had been crying, and crying, and crying. Usually a very “tranquil” baby, she had turned into a monster over the past 6 hours: “she has not stopped crying,” stated the mother. “This is so unusual…” OK, Pediatric ER Rule number one…always listen to the mother. If she says something is “different”, you can guarantee something is up. The mother states she went to bed at 8PM, “and was feeling fine,” only to wake up at 1100 screaming. She thought maybe she was wet, or hungry-but was neither. She had taken her temperature (rectally…what a good mom!), no fever.

I asked the usual litany of pediatric history centered questions: did she have a normal birth, any extra hospital days, what is she eating, how often, any changes in diet, is she pooping, and peeing normally, is she vaccinated? All normal, no extra clues…the plot thickens. My usual list had been extinguished. Usually I can come up with something…”oh we changed her formula, she hasn’t had a bowel movement in days...” Now I’m going to start thinking of the rarer things….

“Any recent trauma, or falls,” I ask. The parents look at each other, “no,” they respond in unison; meanwhile Cecelia continues to wale. You always have to ask this question. One might be surprised at both the incidence of random accidental and non-accidental trauma that turns up in the ER. No red flags here.

Is she colicky? It would be really rare, she is older, and this seemed to start so suddenly. I remember back to med school, and learning the “rule of three’s,” for colicky infants: usually by three months, lasting longer than 3 hours a day, three days a week for more than three weeks…possible…”severe first time colic episode…” strange ring to it…moving on…

Is this an intussusception, or a telescoping of bowel into itself? She is in the right age range, 3-12 months, but she has no vomiting, the pain is constant, not intermittent, she has normal poops-no blood. Hmmm, I ponder, possibly, we’ll keep this one on the back burner….let’s check this kid out.

We had Cecelia undress, and laid her on the bed. She appeared healthy, just really pissed off. No rashes, no jaundice. I listen to her heart and lungs…good luck with that one; I would have had better luck hearing a mouse fart in a hurricane. I proceed to diligently examine every nook and cranny on her little body. Her head, face, eyes, nose, ears, neck, arms, legs, genitals, buttocks, legs, toes. Looking for any clues: did something get lodged in her nose or ears, does she have a “hair tourniquet,” or a piece of hair or string, stuck around and appendage? No, no, and no. I stand back and watch her pattern of crying. Between the wales, her hands move towards her face….her eyes. Strange….a few moments go by….she does it again…..her eyes.

I proceed to check her eyes. Her right eye looks red, slightly blood shot at the corner...I missed that the first time around. I ask if she has had any eye trauma….”no, I do not think so,” the mama responds. I look again at her tiny fingers….wow talk about Dracula nails. Suddenly I know the answer to the mystery. I leave the room and return with fluorescein, a gentle stain for the eye. This stuff lights up any scratch on the cornea, or the clear skin layer that overlies the colored part of the eye (iris) like a Christmas tree.

I place the stain, and look with an ultraviolet light…BEHOLD: a dazzling streak that looks like a green light saber streaks right across Cecelia’s little cornea! At some time during the night she mauled her eye with one of her Dracula nails. Talk about an owie!

The nurse gently shows the parents how to cut Cecelia’s nails, and we prescribed them an antibiotic ointment, and gave them a follow up appointment with the Pediatric Ophthalmologist. I was feeling pretty good about myself. Heck, not a bad find for 3 AM. A couple of rules I have learned to live by: In the ER you have to be sharp 24/7, and crying babies command attention to detail.
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About the Author

The Stanford Emergency Room is the center of emergency care at Stanford University.