Slow attendings and swallowed coins

The attending I worked with for the first part of my shift was very, very slow, which, of course, caused the patients to pile up. I think the average length of stay for patients this morning was over four hours. I had two patients who had been in the ER for over three hours before being seen by a physician, and that was the physician who took over at 3:00, when the first attending got off. One of them was a 17-year-old girl with abdominal pain, which the mother was positive was appendicitis (it wasn't when she was in on Monday, and still wasn't today), and the other was a 92-year-old man with congestive heart failure and a chronic cough. Both are okay and hanging out at home (I assume).

The excitement came later in the shift, when we got a 20-month-old patient with a complaint of "swallowed a penny". It wasn't the first "foreign body" complaint that I had seen (we had a few when I was doing a couple of shifts a week in the ED at Children's Hospital on my pediatrics rotation). This was the first I was handling "on my own", so I was the one ordering the initial x-rays to see where the penny was.


First of all, it looks more like a quarter than a penny to me, but that's beside the point. The point is, it's in his esophagus. Two clues: 1) in the frontal view, if you can see the face of the coin, it's in the esophagus. I don't know how they've come up with that conclusion, but it's likely based on many, many x-rays and some sort of anatomical studies of the musculature of the esophagus and trachea. 2) Also in the frontal view, you can see the airway (gray shadow that branches off, like an inverted Y), and it's not distorted by the coin. 3) In the lateral view, you can see the airway in the neck in front of the coin.

General rule is, if the kid is asymptomatic and the foreign body is in the GI tract, not the respiratory tract, you can let it pass. However, this kid was gagging and drooling, which means it has to come out. If he had been in Columbus, we would have just paged the ENTs to take it out. However, in Bellefontaine, there aren't any ENTs willing to do a foreign body removal on a 20-month-old, so this kid bought himself an hour-long trip to Columbus for a three-minute procedure at Nationwide Children's Hospital. My attending (not the slow one) wasn't happy about this. As he was saying, if he were in Alaska and there were no children's hospitals, the ER doctor would be the one taking care of it. However, since there are pediatric ENTs within a reasonable distance, it would be "irresponsible" for the ER physician to do it. Defensive medicine at its best.