Today I saw an eight-year-old girl for her first visit to our clinic. She was a bright, healthy girl, and her mother seemed very nicely attuned attuned to her. The girl was a good student. I asked her mother if the family ever got to eat together--amongst Pediatricians, this is felt to be a good thing for families: drugs and other risky behaviors occur a lot less when families are able to have dinner and other kinds of quality time together. I assumed that this must be the case because the girl seemed so together.
I learned that in fact, dad spends a lot of time in Mexico helping his family, and this mother cares for her three children AND works two jobs--one from 8:30 to 4:00 and the 5:00 to 10:30PM. She kind of joked that her chldren are raising themselves--but clearly she is doing a great job because this girl just shined--and wanted to be a teacher when she grew up--but there has to be some cost.
Mom had four siblings, and felt she was so short because they had been malnourished. Like many immigrant parents, she had left school and gone to work at an early age, eleven, in her case, taking care of other children. I can only picture her own mother being a skilled manager of scarce resources, and who taught this mother well.
I would give anything for her to have a chance to finish high school someday and have a chance to go back to school and enjoy learning, run a day care or become a teacher--to have a chance to do something for herself. It's unfair that it is so hard for working people, that immigrants are scapegoated. And I know a many more immigrant parents as worthy as she is. We need a better world for that to happen.
Wednesday, June 8, 2011
Diagnosis
Diagnosis is an essential and challenging part of medicine. I feel satisfied when I get it right--unless I've confirmed a new case of leukemia or something else with a possibly bad outcome.
When I fail to make a diagnosis, I feel bad. Twenty five years ago I was working a Saturday drop in clinic and a boy of around 18 months was brought in. He was in and out of being alert and the rest of the time moaning and falling asleep. I immediately thought that he ingested some one's medicine or something toxic--that he was poisoned. He reminded me of a boy with an ingestion from my internship--that boy was in and out of consciousness like this one and who got an invasive test for possible brain tumour. It turned out he had taken a relative's medicine. I barely examined this boy I was so convinced and asked a lot of questions and had the family search their house for an empty container. Nothing was found. I knew something was up, maybe that I hadn't thought of, and asked a colleague to look at him. He did something I hadn't--felt the boy's abdomen--and determined that he had an intussception, when the small bowel gets telescoped into the colon, a kind of surgical emergency. Some babies have cyclical vomiting and obvious pain, and others get lethargic with their pain, like this one. I had begun to narrow my thinking too soon. Learning to keep one's mind open is essential
Sometimes a missed diagnosis occurs because an illness just had not revealed itself yet. A lot depends on when a disease is ready to 'declare itself': to have developed to the point that a specific diagnosis can be made. Once I saw a 3 year old boy with vomiting who otherwise seemed well, I figured he had mild gastroenteritis. The next day I found out that he had gone to the ER with seizures, and when they scanned his brain, he had a tumor. I felt terrible, but several colleagues with similar experiences said that this is typical of brain tumors, that they are are often well advanced by the time they cause enough symptoms to be diagnosed. Another time I saw an infant as a well baby check and his mother mentioned something about decreased appetite. There was nothing at all obvious, but something didn't seem right, so I had her come back earlier rather than later. Two or three days later the baby was diagnosed in the ER with leukemia.
Years ago I saw a girl of six with fever and purple spots on her skin. She had been seen by several colleagues for other visits during the previous month for fever and vague complaints. By the time I saw her, her leukemia had 'declared itself.' What I'll always remember is her mother's reaction to hearing the diagnosis. I told her that there was bad and good news: the bad that she had leukemia and the good that nowadays we had excellent treatment with very high hope for her survival. Rather than being shattered like almost all parents, she expressed some relief: She had already figured out that her daughter had leukemia and expected the worst, so the possibility of cure gave her hope.
Appendicitis in small children is notoriously difficult to diagnosis, and most children less than 4 or 5 progress to rupture before diagnosis. This week I saw a 4 year old with vomiting and abdominal pain for 6 hours. She looked like many children I had seen in the previous week with viral gastroenteritis. I did ask some questions relative to appendicitis, but in the end sent her home on pedialyte, always with the instruction to come back if she didn't improve. Two days later I learned that she had been admitted for appendicitis. For days after, I went over and over in my mind how she she had looked and what I should have done differently--even though I know most people would have done the same thing.
Just as one can miss a diagnosis by going down the wrong track, the opposite can happen. Quite a few years ago I was seeing patients at work when four siblings with vomiting and diarrhea came in. I was about ready to send all of them out with the same instructions for clear liquids when I began to notice something different about the oldest girl of 14. As they started to walk out, I saw that she walked a bit stooped over. A doubt began to form and I tried to put my finger on it. I asked them not to leave and reconsidered. She looked a little more in distress than the others, and she had more pain. I examined her again and she had pain in her lower right abdomen. When I put it all together, I thought it was quite likely that she had appendicitis, and I sent her off to the ER, where this was confirmed. It would have been so easy to miss this one girl out of four who had something different.
A few years ago I saw a 6 year old girl a few times and noticed that her abdomen seemed to be full of air all the time, and that her torso seemed elongated. It nagged at me and I spoke to one of the radiologists who said maybe she had a connection between her esophagus and trachea which allowed air to leak into her GI tract. Sure enough, that is what she had. She had had one or two episodes of pneumonia as children with this problem do. Her mother recalled that her abdomen had filled up with air just after birth. Sometimes subtle problems can slip by for a long time until someone gets curious.
When I fail to make a diagnosis, I feel bad. Twenty five years ago I was working a Saturday drop in clinic and a boy of around 18 months was brought in. He was in and out of being alert and the rest of the time moaning and falling asleep. I immediately thought that he ingested some one's medicine or something toxic--that he was poisoned. He reminded me of a boy with an ingestion from my internship--that boy was in and out of consciousness like this one and who got an invasive test for possible brain tumour. It turned out he had taken a relative's medicine. I barely examined this boy I was so convinced and asked a lot of questions and had the family search their house for an empty container. Nothing was found. I knew something was up, maybe that I hadn't thought of, and asked a colleague to look at him. He did something I hadn't--felt the boy's abdomen--and determined that he had an intussception, when the small bowel gets telescoped into the colon, a kind of surgical emergency. Some babies have cyclical vomiting and obvious pain, and others get lethargic with their pain, like this one. I had begun to narrow my thinking too soon. Learning to keep one's mind open is essential
Sometimes a missed diagnosis occurs because an illness just had not revealed itself yet. A lot depends on when a disease is ready to 'declare itself': to have developed to the point that a specific diagnosis can be made. Once I saw a 3 year old boy with vomiting who otherwise seemed well, I figured he had mild gastroenteritis. The next day I found out that he had gone to the ER with seizures, and when they scanned his brain, he had a tumor. I felt terrible, but several colleagues with similar experiences said that this is typical of brain tumors, that they are are often well advanced by the time they cause enough symptoms to be diagnosed. Another time I saw an infant as a well baby check and his mother mentioned something about decreased appetite. There was nothing at all obvious, but something didn't seem right, so I had her come back earlier rather than later. Two or three days later the baby was diagnosed in the ER with leukemia.
Years ago I saw a girl of six with fever and purple spots on her skin. She had been seen by several colleagues for other visits during the previous month for fever and vague complaints. By the time I saw her, her leukemia had 'declared itself.' What I'll always remember is her mother's reaction to hearing the diagnosis. I told her that there was bad and good news: the bad that she had leukemia and the good that nowadays we had excellent treatment with very high hope for her survival. Rather than being shattered like almost all parents, she expressed some relief: She had already figured out that her daughter had leukemia and expected the worst, so the possibility of cure gave her hope.
Appendicitis in small children is notoriously difficult to diagnosis, and most children less than 4 or 5 progress to rupture before diagnosis. This week I saw a 4 year old with vomiting and abdominal pain for 6 hours. She looked like many children I had seen in the previous week with viral gastroenteritis. I did ask some questions relative to appendicitis, but in the end sent her home on pedialyte, always with the instruction to come back if she didn't improve. Two days later I learned that she had been admitted for appendicitis. For days after, I went over and over in my mind how she she had looked and what I should have done differently--even though I know most people would have done the same thing.
Just as one can miss a diagnosis by going down the wrong track, the opposite can happen. Quite a few years ago I was seeing patients at work when four siblings with vomiting and diarrhea came in. I was about ready to send all of them out with the same instructions for clear liquids when I began to notice something different about the oldest girl of 14. As they started to walk out, I saw that she walked a bit stooped over. A doubt began to form and I tried to put my finger on it. I asked them not to leave and reconsidered. She looked a little more in distress than the others, and she had more pain. I examined her again and she had pain in her lower right abdomen. When I put it all together, I thought it was quite likely that she had appendicitis, and I sent her off to the ER, where this was confirmed. It would have been so easy to miss this one girl out of four who had something different.
A few years ago I saw a 6 year old girl a few times and noticed that her abdomen seemed to be full of air all the time, and that her torso seemed elongated. It nagged at me and I spoke to one of the radiologists who said maybe she had a connection between her esophagus and trachea which allowed air to leak into her GI tract. Sure enough, that is what she had. She had had one or two episodes of pneumonia as children with this problem do. Her mother recalled that her abdomen had filled up with air just after birth. Sometimes subtle problems can slip by for a long time until someone gets curious.
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