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.
Sunday, May 15, 2011
A few Good Books
I love reading history, and presently at my bedside is Reconstruction, America's Unfinished Revolution, by Eric Foner. We may have heard a lot about the civil war: Abraham Lincoln freed the slaves, then some stuff happened ..... But we are terribly ignorant about Reconstruction, the period after emancipation. Foner emphasizes, for one thing, that slaves were very much protagonists: as the Union Army moved through the South, slaves fled their masters and plantations well in advance, and many slaves joined the union army. People organized to demand land and services. Some abolitionists and government officials supported the slaves, others pressured them to return to their former masters as wage laborers and sharecroppers. Large amounts of confiscated land was given to the freedman, only to be taken back, as the North tried to win back some of the Southern gentry. The right to vote was not passed by the US Congress, after much resistance North and South, until 1967.
Both freedman (ex-slaves) and poor white farmers pressed to get land--land to be taken from the wealthy secessionists, the plantation masters. In one instance in Georgia, freedman and poor whites found common cause. This quote is from a petition by poor white farmers demanding land:
Appropriate out of the vast amount of the surplus lands of the wealthy, a comfortable home for the helpless and dependent black man whose arduous labor for the last two hundred years justly entitles him to such inheritance... We believe the freedman is just entitled to a home out of the lands of the secession party who tried to dissolve the Union in order to perpetuate slavery as the children of Israel were to the promised land.
While the wealthy schemed to perpetuate the plantation system by different means including convict leasing, freedman pressed for the right to be individual contractors, and have the law protect them when landlords failed to pay them. In South Carolina--which had the highest percentage of black people in a state--one freedman proposed a bill to regulate the profits of merchants and allow laborers to "meet and fix by ballot the rate of wages which their employer shall pay them." Hmmm ... sounds like an idea whose time has come.
Both freedman (ex-slaves) and poor white farmers pressed to get land--land to be taken from the wealthy secessionists, the plantation masters. In one instance in Georgia, freedman and poor whites found common cause. This quote is from a petition by poor white farmers demanding land:
Appropriate out of the vast amount of the surplus lands of the wealthy, a comfortable home for the helpless and dependent black man whose arduous labor for the last two hundred years justly entitles him to such inheritance... We believe the freedman is just entitled to a home out of the lands of the secession party who tried to dissolve the Union in order to perpetuate slavery as the children of Israel were to the promised land.
While the wealthy schemed to perpetuate the plantation system by different means including convict leasing, freedman pressed for the right to be individual contractors, and have the law protect them when landlords failed to pay them. In South Carolina--which had the highest percentage of black people in a state--one freedman proposed a bill to regulate the profits of merchants and allow laborers to "meet and fix by ballot the rate of wages which their employer shall pay them." Hmmm ... sounds like an idea whose time has come.
Tuesday, April 5, 2011
Racism Number 73
I picked up some ironing today from my former housekeeper B., a black woman who grew up in the south. She hated ironing but liked me enough to do it for me, and now that she's retired and scraping by, it's a way for us to have a visit and for her to make a little extra cash.
I've hear a lot of tales of woe from her. Just now Social Security cut her off for two months because they overpaid her some, and she's worried about paying the rent. I'll never forget the story she told about one of her wealthy clients who gave her a ride down to some poor part of town, and parked to drop B. off. The woman noticed that she was in a red zone and said she should move, but B. said to her, "It''s okay, they don't give white people tickets." B. Said I should have seen the look on the woman;'s face--we had a good chuckle over that.
Lately I've been hearing that two of her great grand children were sleeping over at her house sometimes. I had thought that it was to keep B. from being alone too much, but today the real story came out. Their mother lives about an hour east towards Sacramento, and she gets up at 3:00 AM to drive them to B.'s place, arriving around 4:30. They sleep a couple of hours and then go off to school, while the mom drives over to San Francisco to work. The town where they come from is pretty redneck, and one of the boys was being beat up by the white boys, and the schools were poor. Now they go to schools in Berkeley and the boy who was being bullied has improved his grades quite a lot.
I've hear a lot of tales of woe from her. Just now Social Security cut her off for two months because they overpaid her some, and she's worried about paying the rent. I'll never forget the story she told about one of her wealthy clients who gave her a ride down to some poor part of town, and parked to drop B. off. The woman noticed that she was in a red zone and said she should move, but B. said to her, "It''s okay, they don't give white people tickets." B. Said I should have seen the look on the woman;'s face--we had a good chuckle over that.
Lately I've been hearing that two of her great grand children were sleeping over at her house sometimes. I had thought that it was to keep B. from being alone too much, but today the real story came out. Their mother lives about an hour east towards Sacramento, and she gets up at 3:00 AM to drive them to B.'s place, arriving around 4:30. They sleep a couple of hours and then go off to school, while the mom drives over to San Francisco to work. The town where they come from is pretty redneck, and one of the boys was being beat up by the white boys, and the schools were poor. Now they go to schools in Berkeley and the boy who was being bullied has improved his grades quite a lot.
Public Transportation
Nothing like getting on public transportation to reaffirm my faith in people. That's not always easy for someone who grew up a a shy, small, lonely, and not the least bit tough little boy. For instance, today I had to take BART to San Francisco to see a specialist. I've been bed all week with bronchitis, and wasn't really sure if I could tolerate standing up for the 25 minute ride in my weakened state. With that anxiety in mind, the train I got on was fully packed and I steeled myself for a long, hard trip. The shy part of me thought, "No one will give me a seat, I'll just have to suffer." At the first stop, someone got off right in front of me and a woman and I both started to move, and I said, "Do you mind, I'm really feeling sick today," and she said sure, no problem. At the end of the ride, when we both got off in downtown San Francisco, I thanked her and she in turn said, "I hope you feel better, and I have to sit all day anyway." Of course: show people some basic respect and courtesy, and they will return it. It took me from feeling worried and alone to feeling safe and belonging. Isn't that what community is about?
About ten years ago I was in Paris in December--really cold--is there a translation for The Hawk? (when I lived in Chicago, that was what people called the cold wind that blew off of Lake Michigan.) I decided to go see the Bastille--there is a Metro stop there, so I was sure it was close by. I didn't know it had been demolished in 1789. So I'm riding along on the Metro, and I slide over to make room for a burly, taciturn man, and across from us across from us was a man with a small bundled child in a backpack carrier.
About ten years ago I was in Paris in December--really cold--is there a translation for The Hawk? (when I lived in Chicago, that was what people called the cold wind that blew off of Lake Michigan.) I decided to go see the Bastille--there is a Metro stop there, so I was sure it was close by. I didn't know it had been demolished in 1789. So I'm riding along on the Metro, and I slide over to make room for a burly, taciturn man, and across from us across from us was a man with a small bundled child in a backpack carrier.
When he got ready to get off, preparing to exit, he balanced the carrier on the back of his seat while he awkwardly pivoted around and tried to get it on his back. I was watching, thinking I would help if need be. Suddenly the backpack tottered just a little and started to slip--maybe one millimeter--and instantly the taciturn man and two other men sprang forward to help. I wish I could have thanked them in their language.
Tuesday, February 22, 2011
Exploration
I never know where curiosity will take me. For instance, last September I was up at Pyramid Lake, a large lake in the high Nevada desert, on a Paiute Indian reservation. Conditions are dry at the end of the summer, there wasn't much to see. But I found a small canyon I hadn't explored before, and started going deeper. There's a shrub called rabbit brush that for some reason blooms in the fall, a rich orange-yellow, and there was lots of it.
But mostly, the canyon was dry and barren and I walked along a long ways with nothing much to see. Then, around a bend, out of nowhere, a bush of showy penstemon, a brilliant blue as blue as the sky above the canyon walls, the first wildflower I'd seen. Spectacular, this burst of life in the midst of a parched canyon. Something inspiring wonder: THIS flower in THIS dry place.
I kept going and never saw another one. I kept going past meanders and narrows where the canyon cut through harder strata, and some dry waterfalls I scrambled over until I got to a dry waterfall 12 feet high, impossible to climb over. So I turned back to a fork in the canyon and proceeded up that, and came to the remains of a deer that had fallen into the canyon. It had been pretty well cleaned off except for tough skin, and a little ways further I found a skull--clearly carnivore--with criss-crossing fangs, mostly likely a coyote. I never did find a spring like I have in several of the canyons, but I found things I never expected. And on the way back, from time to time I could see the blue of the lake and the distant mountains. I can't wait to get back there.
Tuesday, February 8, 2011
I can walk into the exam room and tell who has older siblings.
I have a lovely picture of one of my families: a one year old boy is held by his mom with his 12 year old sister on one, side and a 10 year old sister, herself holding a six year old sister, on the other side. A little child, or a young person as I like to say, surrounded by love and attention. It's like having another set of parents, almost, except they're a lot younger and have just learned all this stuff about living not so long ago.
I've gotten to where I can walk into an exam room and tell that an infant has caring older siblings, or sometimes a father who is very involved with his children. I can tell because these infants are relaxed, curious, and much less wary of me, compared to others. I can tell with the older children because they are more articulate and mature and have ideas about their future.
There is a wonderful book called Cider with Rosie by Laurie Lee, a story of growing up in rural England in the 1920s, and the opening scene of the book captures the spirit of what I'm talking about. While moving to a new house, Laurie gets lost in a thicket of tall weeds, and he is rescued by his sisters:
From this daylight nightmare I was awakened, as from many another, by the appearance of my sisters. They came scrambling and calling up the steep rough bank, and parting the long grass found me. Faces of rose, familiar, living; huge shining faces hung up like shields between me and the sky; faces with grins and white teeth (some broken) to be conjured like genii with a howl, brushing off terror with their broad scoldings and affection. They leaned over me -one, two, three- their mouths smeared with red currants and their hands dripping with juice.
Thanks to Penguin Press 1959
I've gotten to where I can walk into an exam room and tell that an infant has caring older siblings, or sometimes a father who is very involved with his children. I can tell because these infants are relaxed, curious, and much less wary of me, compared to others. I can tell with the older children because they are more articulate and mature and have ideas about their future.
There is a wonderful book called Cider with Rosie by Laurie Lee, a story of growing up in rural England in the 1920s, and the opening scene of the book captures the spirit of what I'm talking about. While moving to a new house, Laurie gets lost in a thicket of tall weeds, and he is rescued by his sisters:
From this daylight nightmare I was awakened, as from many another, by the appearance of my sisters. They came scrambling and calling up the steep rough bank, and parting the long grass found me. Faces of rose, familiar, living; huge shining faces hung up like shields between me and the sky; faces with grins and white teeth (some broken) to be conjured like genii with a howl, brushing off terror with their broad scoldings and affection. They leaned over me -one, two, three- their mouths smeared with red currants and their hands dripping with juice.
Thanks to Penguin Press 1959
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