Why scratching at insect bites is bad

8 01 2015

During my Pediatric Infectious disease rotation, I had one of those experiences you don’t forget as a budding young medical professional: the first time you watch a patient become very, very sick, tiptoeing to the brink of death, and then rebound so hard that he or she walks out of the hospital.

That patient for me was a 7-year-old girl, I’ll call her Abigail, who came in with leg and knee pain as well as fevers. She was sent to the inpatient floor at first, and the first thing I noticed about her were her screams of pain. She was crying anyway, this look of agony on her face and tears streaming down her cheeks, but she would scream whenever any of the medical team tried to touch her legs even a little. None of her mother’s hugs and words of reassurance seemed to make any difference.

One of the most critical skills that a doctor learns in training is how to quickly tell the difference between sick and not sick. This little girl looked sick, though I didn’t quite understand how sick from looking at her at the time. What I did notice was that even though her heart rate was high–which typically happens to kids when they are screaming their heads off–her blood pressure was low. Not just low for a hysterical kid, low for a normal kid her age. When the floor attending walked into the room several seconds later, he looked at her vitals, looked at her, and walked out to call the ICU.

Abigail was transferred to the ICU and ended up getting a lot of fluids for her blood pressure as well as lots of pain medication because, to that point, she hadn’t been letting anybody near her legs. The first thing I noticed was that she had a ton of bug bites on her lower legs and ankles in various stages of excoriation (scratched open-ness), though none of them really looked infected. She also had a blister over one of her ankles that her mom hadn’t noticed before.

Spoiler alert: she had MRSA toxic shock and spent 2 weeks in the ICU. She ended up needing pressors (medicine to keep the blood pressure up, which for those of you not in medicine are a big deal and can only be given in the ICU) and she spent a week on a ventilator.

After a couple of days, when she had been on big-gun antibiotics and still wasn’t getting better, we knew that the blood culture was growing MRSA. It was strange that even with a bucket of pain medication, Abigail still grimaced and withdrew when anyone touched her legs. The blister on her ankle was a little bigger, so she was taken to the OR for wound exploration. What the surgeons found was that the bacteria had chewed through the girl’s soft tissue and had tunneled so extensively that they didn’t for sure reach the end of it before calling it quits.

An MRI the next day showed that she had nasty bone infections in both of her tibias. The ID team and the surgery team had a joint conversation with the parents about how they needed surgery to remove the infection, and how there was a good chance one or both legs might need to be amputated. I knew all of those things but wasn’t there for the conversation with the family.

When I ran into Abigail’s mother in the hallway the morning of the surgery, she burst into tears right outside of the ICU family area. All I could do at that point was sit with her while she cried. I was so afraid of saying the wrong thing, just because there really isn’t a right thing to say. They don’t make a Hallmark sympathy card for that scenario.

For a few days during that first week, I remember walking into work and worrying that she might not be there. Prior to that, I hadn’t spent much time in the ICU and all of my sick patients had been critical but stable.

But like I said, she rebounded. The surgeons did not have to amputate, and once her legs were debrided she started doing better. I left the rotation before she was extubated but continued to visit every couple of days since I was still at the same hospital. Three weeks after she came in, she was out of the ICU, and two weeks after that she did indeed walk out of the hospital.

I ran into them in the hallway the day before Abigail was discharged. Her mother was absolutely giddy when she saw me and said “This is Abigail, I wanted you to actually meet her

before we leave.” As it turned out, she was a very talkative and energetic little girl who was excited to go hunting and fishing with her dad.

Aside from still needing several weeks of IV antibiotics, she got to go back to being that kid.

Though her mother was advised to make sure Abigail wore lots of bug repellant in the future.

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