I was about five years out of residency, working the pediatric ED. I walked into a room with a chart that said, "Vomiting, can't keep anything down," to find a pair of 3-year-old African American boys wrestling playfully on the stretcher. It wasn't obvious which one was sick, so after introducing myself, I playfully asked the boys: "Which one of you is throwing up?" Both hands shot up. Both giggled.
"Help me out, Mom, which one is here to see me? Can you hold him in your lap for me?"
His brother peeked out from behind their mom while we talked. Twin premies born at about 30 weeks, and my patient had a history of esophageal atresia that had required early dilation by surgery. They had done well, and were average-sized. But my patient had vomited multiple times soon after eating over the past eight hours. No diarrhea or fever. He tolerated liquids. His exam was normal: no stridor or drooling, and he looked great. She said there was no history of a foreign body ingestion, but my first thought was that he had swallowed a quarter.
I ordered a chest x-ray, and went to the next case.
The x-ray was normal. Still concerned about a nonradiopaque foreign body, I went back and asked again. No, she said he had not choked on anything. He also said he had not swallowed anything he wasn't supposed to. The pediatric surgeon on call that day was difficult to work with, and I knew he would resist seeing the child based on my suspicion alone.
They had been there an hour, he was still playful, and he hadn't vomited. I decided on a PO trial with two ounces of water. He grabbed it, quaffed it, and lifted the cup, pleading for more. Obviously thirsty. I waited for a couple of minutes, and gave him a bit more. No problem. I asked the mother about trying some graham crackers, and she approved. I gave him a couple of graham crackers and returned to the charting area, which was immediately adjacent to his room.
Ten minutes later, she burst from the room screaming, his unconscious form limp in her arms: My baby's choking! Help him, he's choking!
I jumped up, grabbed him, and sprinted to the crash room across the hall while yelling for help. "Code Blue STAT! I need suction and the crash cart!" He was apneic, limp, pale. I proned him over my left forearm in a football hold and gave two sharp back blows. He retched up graham cracker slurry. His chest heaved with inspirational effort, and he began to move air.
We laid him on his side and suctioned more slurry. Then he started to hyperventilate, retracting, honking like a goose. We gave him oxygen, and his color and oxygen saturation were normal within a minute, but he was still unconscious. He was rapidly improving, but I still didn't know what was going on, so I elected not to intubate. I had no difficulty convincing surgery to take him to the OR.
A couple of hours later, the pediatric surgeon, often critical of others, swung by to tell me he had extracted a 2 cm chunk of turkey hot dog from the boy's esophagus. He was uncharacteristically gracious, probably the nicest I ever saw him. "I spoke to mom afterward," he said. "And when pressed, she admitted she had fed him the turkey hot dog. She lied because she was afraid she'd get in trouble with child protective services."
Apparently, the meat was impacted distally at the EG junction. The graham crackers caused him to vomit, causing the meat to move proximally, resulting in extrinsic compression and obstruction of the distal trachea. This wouldn't happen in an adult because of the calcification of the tracheal rings that occurs with age.
People of color face a different world. At first, I was angry with the mom for withholding information that almost cost him his life. Later, I realized that fear of child protective services was a reality in her world that I had never had to face.
Nonmetallic esophageal foreign body is one example of the most difficult diagnostic challenges we face—when decision-making is based on suspicion from the history alone, without objective clinical or ancillary findings
I dodged a bullet. This was the closest I had ever come to causing the death of a patient. After this case, I never hesitated to request endoscopy to rule out a foreign body in nonverbal patients, and I ended up being right more often than not.