Rashes

Yesterday I visited my mother at her home to find a note that she'd gone to the emergency department. While not exactly the news one would want to hear, I still found it exciting. This was an opportunity for me to partially, unofficially, shadow the role of a physician in a setting I found personally interesting and I could also support my mom, who was probably sitting there alone. I turned around and ran out the door.

My mother was falling victim to a rash that had slowly been spreading across her skin, even welding into one large red welt on her back. It wasn't necessarily painful, she said. There was a slight burning sensation, but little else, almost surely due to the inflammatory response. She'd first noticed it Thursday, but by Sunday morning, it'd crept onto her face and she needed to go to the ED. There were plans to get a port ("portacath") this morning, and if the rash was in the way, she surely needed to delay those plans.

The port is a catheter installed beneath her skin near her heart (on the chest); it serves essentially the same function as an peripheral IV (IV in the hands or forearms or other distant point from the heart). However, PIVs have two main problems that a port solves: (1) the veins on the hands and forearms are less structurally stable and unable to withstand the toxicity of many drugs, including chemotherapy drugs; (2) PIVs (and PICCs) have to be removed and reinserted after a specific period of time -- if needed, a port can be essentially permanent. The skin will just regrow over the port and when needed, my mom will go to the hospital and have the port repunctured by a Huber point needle, and the port will be useable.

At the ED, my mom and I suffered 1/3rd of the waiting people probably typically endure (we were in a small, slow ED, so waiting times were fairly short), but it was still enough that my mother kept peeking out the door and staring down the long empty hallway.

Of course the emergency physician had no idea what she had, although he was very polite, and I managed to see how little time a physician really spends with his patient -- even when it's slow. First he ran the standard blood labs, which all came back normal. He then contacted the dermatologist on-call for a consult. He came in and performed a skin biopsy, which was fascinating to watch. They brought in a sterile laceration kit, and he numbed her up with some local anesthetic. Next, he snipped away a 2 mm by 5 mm piece, and dropped it in a cup of formaldehyde, then proceeded to suture her up. His conclusion: the lab results today hopefully told more, but he suspected that it was related to her lymphoma, either directly or due to a partially compromised immune system. If not that, perhaps it was a drug reaction. His tentative diagnosis was some form of erythema, and should clear up within two weeks of initial onset. (This didn't comfort my mother later that evening when the burning pain worsened.)

Time in: 10:30 AM. Time out: 1:15 PM.

Conclusion A: Port appointment postponed until Thursday.
Conclusion B: Emergency medicine is often unfinished.

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Edit 02/05/08, 9:39 AM: The biopsy results are "nonspecific reaction." The rash is still progressing on my mom's body.