(kid with cystic fibrosis).
(Kid with cancer).
FTT: Failure to Thrive
(losing weight/not gaining weight, either from chronic disease or from neglect)
(going quickly downhill/possible to death)
Two kids I saw in the office, who were completely fine.
Baby L. Perfect newborn exam. Perfect. Slight ductus arteriosus, I think, that was closing. Breastfeeding was going well. Mom had 4 other kids at home, lots of social stressors, but her husband was involved, there was a grandmother somewhere, and maybe one of the older kids was around to help out, too. History of post-partum depression and chronic mental health issues – we talked about that – but doing well, couldn’t take meds during pregnancy but on top of her symptoms. In touch with a social worker.
Minor issue – her 20 month old son had a cold.
Well, try to keep her away from the new baby.
(easier said than done. Baby wants attention away from the new baby).
Sunday, I was in the ER, and I glanced over at the list of patients admitted the previous day. Baby L was on there. And Baby L was in the Pediatric ICU (PICU).
I had seen Baby L in the office on Thursday, I think, and the attending had seen her as well. Doing beautifully, as they say, with the requisite “congratulations!” and “what a cute baby!” “what a perfect baby!” Baby L was doing fine.
…and then Baby L caught RSV* from big brother. And Baby L started having apneic episodes, when she stopped breathing. And Baby L came in by ambulance and was in the ICU hooked up to monitors, now.
*respiratory syncytial virus. In adults, it’s almost asymptomatic. In a number of toddlers, too. But some of the ones who get sick, and some of the babies…get sick fast. There’s no treatment.
Then there was Little E – I won’t call him Baby, because he’s 13 months old (not quite walking yet, though). Little E wasn’t even in the office to see the doctor; his mom had brought in his big sister (age 4) for an earache. The ear was a little red, not bad, and the attending on that day was one of the ones more liberal with antibiotics (most wouldn’t have treated at all). Then the attending noticed how fast Little E was breathing. He looked sick, ish. His mom asked, offhand, “oh, could you listen to him, actually?”
His lungs were crackles everywhere, little tissue paper-popping sounds. Bronchiolitis – also usually caused by RSV. In the office, though, he was RSV negative. He was breathing okay, just a little fast, and the oxygen saturation (fingertip probe thing) was fine. We sent him home with, as they say, “strict precautions.” We phone followed up the next day – doing about the same. On Friday – doing a little better, but temperatures of 100F (still low). Seemed to be on the upswing, no one was worried, have a good weekend, have a good weekend, and that’s that.
And the next day Little E was also having trouble breathing, also came into the ER, and got admitted (he went to the regular floor, at least, and not to the ICU). And when I went to see Little E, he was on oxygen and still too low in oxygen. RSV, now, was positive.
Kids aren’t little adults. They can go down fast. Fast. From something that seems minor by all other measures.
Two other kids in the office, last week, developed symptoms while they were there – good thing, because, when they first came in, they weren’t diagnosable with anything significant.
That’s another thing about pediatrics, though – a lot of the time, you have no diagnosis, and, ohwell, most of the time kids will get better and you still won’t know exactly what it was. A kid with roaring sinusitis won’t have a headache. A kid with a terrible kidney infection will have no pain with urination and no back pain. A kid with an earache will come in for vomiting, not for ear pain. You could call everything “atypical,” just as we call “atypical” symptoms of heart attacks those that occur more often in women and diabetics and African Americans…
|Is there a giraffe in your ear?|
The art of medicine here is the art of distraction.
My new “standards”:
…depending on chronological and developmental age. And how much sarcasm they have developed (also part of development, I think. One father thought I was fabulously funny; his 8 year old sarcastic son seemed to have the same idea).
Where’s your heart? Where should I listen? (good for little ones)
(and, yes, sometimes you start out by listening to a hand or a shoe or a forehead or a doll. Then they’ll let you listen to them…)
…goes on to…
Well, how am I supposed to know if you don’t?
For the little ones (haven’t used this in awhile, actually).
What am I going to find in your ear? Is it an elephant? Is there a dinosaur?
There’s the basic school ones, sports, commenting on princess shoes and racecar shirts and spiderman jackets. I was relieved to learn from one mom that kids are still watching Sesame Street. And she was reading Berenstein Bears books to her daughter!
I have no idea what the new things are.
Even with high schoolers….
I had to convince a 15-year-old to let me get a nasal and a pharyngeal swab. Flu and strep throat. “Come on, please…. I did this with a three year old this morning…” (yes, I told him that). I showed him the materials. I had him practice before I actually got the swabs.
I did what I always do, too – honesty – told him:
“I can’t imagine this would be fun, either. But if I needed this, I would let you do it to me.”
Shining light directly in the eyes and they wince – “I know, I don’t like this part either.” (True).
Tip the kid backwards over parent’s lap to get them to open their mouth wide enough to see.
Restrain the kid for an ear exam – you put their legs between the parent’s legs. Clamped. “Now give him a big hug…” puling both arms and side of head into the parent’s chest. Tight.
And now I brace one hand on the head and the other hand between the otoscope and the head, to make sure the instrument moves with the head that still might jerk a little, so I don’t accidentally puncture the tympanic membrane (ear drum).
Those heal right up, anyway. In kids.
|Nlobo river, near Zoebefam|
I didn’t get how this worked. Learning to feel bodies, to know what’s “within range of normal” (wnl. Better/more PC/more accurate than saying “normal” or “nl.” The note is covered with “wnl.”)
I have no idea how many patients I’ve examined at this point. Not countable; a thousand is a very low estimate. More like 1500, maybe? 2000? I don’t know*. But the point is that the other day I felt a spleen that was just very slightly enlarged, and I was confident enough that I knew it. I’ve done that with livers now. With murmurs, I’m starting to know how to grade the intensity – I,II,III,IV,V,VI - it’s another of those gestalt things. They can’t/don’t teach exactly how loud merits a II, III, etc. We were told that medical students couldn’t hear anything less than III, so I had been grading most murmurs III/VI. Then I realized that was wrong. There have been some I-IIs and a lot of IIs.
*A little incredible to think about. This has varied a lot by rotation, and when I’m following patients in the hospital, I examine the same people several times. On a rotation like this, though, over 15 days I’ve seen about 6 -10 kids per day. Medium estimate, 8x15 is 120 examined. In three weeks.
An attending taught me the liver exam on an infant, and how to run your fingertips lightly over the abdomen until you feel the change in consistency. It’s subtle, but it’s there. In newborns, the liver normally juts out very slightly from under the ribs. Later in life, the liver shouldn’t be that far out. For adults, we press in under the ribs. Hard.
“Take a deep breath….” (patient inspires) “and let it out…”
The liver might slip against my fingers. Might now appreciate the edge, and might not. Even with this, you can use multiple senses to find it. The “scratch test” helps localize the border of the liver – part of a full exam is measuring it. With stethoscope in ears and on the abdomen, you lightly brush a fingertip up, up, up the patient’s abdomen, vertically, until you hear the change in sound. Without the stethoscope (and with perhaps more talent/practice), you do this just by percussion. Tap one finger onto another finger on the patient’s skin. (abdomen, lungs/back, sinuses). Everything that is hollow makes a sound.
Twice, now, I’ve accurately appreciated hepatosplenomegaly*. It was one of the first times I had felt a spleen that was neither grossly enlarged nor had already been signaled to me as an interesting physical exam finding. Feeling the spleen tip, I had no idea what it was, exactly, but knowing it wasn’t quite what I had felt before. Range of normal. WNL. And for the patients who aren’t, yes, a group of people might parade through to look or feel. They’re asked, first.
* In medicine, we say “appreciate” when we mean “feel.”
We also run liver and spleen together into one word, as if they were inseparable and not physically placed on opposite sides of the abdomen.
Generally. It’s explained that they would be contributing to education (true). I’m not sure I’ve ever heard anyone say no – interest in doing it, versus hesitancy of contradicting anyone in a white coat. These days, kids with chickenpox get treated to seeing every resident, student, and possibly attending in the clinic. The not-so-old practice of taking kids to be exposed on purpose is replaced with vaccination and freaking out over symptoms/placing in isolation those who aren’t immunized.
The entire cultural context is changing.
|Nurses walking through the rainforest to deliver measles vaccines. Cultural context: disease never thought about/only recently re-seen in the US with "fads"/"campaigns" to not vaccinate...|
Neurologically, working with children proves the circuitousness of health and experiences. The normal reflexes of the newborn are pathologic if they occur later in life – reflexes that means an infant is healthy and neurologically “intact” means an adult has had a stroke, has ALS, has MS…something pathologic.
A few weeks ago, I was doing a newborn exam in front of parents. Scanning through my methodical checklist, I tested the Moro reflex. Moro is the startle reflex – the infant is lying on his back and you pull him up by his hands. Just a little bit. And then you let him drop. Yes, the head hangs back a little while you do this. And yes, you are…dropping the baby (from a slightly raised torso to back onto the table). The arms shoot up straight into the air and the tightly fisted palms spring open.
“DON’T DO THAT IN FRONT OF PARENTS!” the attending admonished me.
“Or… at least, not so high.” (I was doing exactly what we do out of view).
You get more cavalier, this way. Things we can do. Things that are indestructible.