Thursday, October 12, 2006

No Quiero Ser Pediatra

So I think we've already established that I don't handle sad things all that well. I'd like to present the following cases to prove that either I am a huge wuss, or you have to be a lot colder person to be a pediatrician than I am:

1) I had a 15 year old patient who cracked his neck in a car accident this summer. After awakening from the surgical repair of his fracture, he couldn't move the right side of his body. Neurology came to see him and, salivating, delivered a diagnosis of Brown-Sequard syndrome. Neurosurgery ran about a million diagnostic tests to try to figure out what happened. In the end, both services said "What a fascinating case" and referred the patient for PT/OT. As his only therapy. He has gone to long-term rehab to learn how to function without the right half of his body. He liked to play sports.

2) I saw a young woman about the same age as the previous patient walking around with PT, totally blank.She barely responded when the other walkers told her to "turn right here" or "slow down". Only weeks earlier, this young woman was perfectly healthy when she began having seizures of unknown origin. Now, she does not appear to even recognize her parents.

3) My service has had a total of 4 kids with liver and small bowel transplant issues (3 are awaiting; 1 has received both, and is rejecting the bowel and has ruined this new liver). A common theme to these children is that they were premature, had some injury to their guts which necessitated gut removal, leaving too little bowel to absorb nutrients. Thus, these children have had their nutrition pumped directly into their veins as TPN since birth or soon thereafter, which has caused their livers to fail. One child, toddler-age, has suffered at least 2 central line infections since he's been on the service (3 weeks); he has also suffered several strokes in his short life, and now basically lies in his crib and cries if anyone touches him. Another child, 5 years old, is the size of an infant, and can barely speak, due to spending most of her life ill and in a hospital. Another, perhaps the most poignant, is now a teenager, still awaiting transplant. She told her mother the other day that "she was thinking about escaping from the hospital" so she could go home and eat pizza, her favorite food (at least she knows how to eat). Sadly, she only has one open vein above her heart, so she's now on anticoagulation so that vein will remain patent and she can remain alive.

4) A 2 year old girl came to the ER in the middle of the night and was admitted to the floor with fever, leg pain, and limp. She'd received a diagnosis of "cat-scratch disease" at a well-known outside hospital (apparently without receiving any diagnostic tests) 2 weeks earlier and been treated with antibiotics with no resolution of her symptoms. When I saw her, I saw a beautiful little girl, very pale, who barely winced when I manipulated a very tender knee and palpated some very large lymph nodes in her groin (she was the stoic type). Upon the recommendations of infectious disease, who suspected osteomyelitis or a septic joint (as did I), an MRI was ordered, which clearly showed a large lytic lesion in her femur, HUGE lymphadenopathy in her groin and into her pelvis, retroperitoneal lymphadenopathy, and a large mass on her adrenal gland. Tissue biopsy confirmed the diagnosis of neuroblastoma, stage 4. That beautiful little girl is now a cancer patient.

5) And last night, I got called to see a 15 year old girl, who likes to play basketball and is learning to drive a car, who had had a severe headache for a week, to the point where she was throwing up. Her family history of migraines had kept her out of the ER for a week, but yesterday she went. Whether the ER doc was CT-happy or actually suspicious, I don't know, but a CT of her head was obtained, which showed a "5 cm calcified solid mass in the cerebellum, with hydrocephalus and generalized edema." Further workup shows that she might have distant metastases. She'd been told there was a mass, but I was in the room when her mother asked point blank "Is it cancer?", to which we replied "Most likely." In the span of 12 hours, she went from being a healthy kid with a headache to a cancer patient with severe disease. Her family wept last night with guilt: "I thought it was a migraine, everyone in her family gets them, I should have brought her sooner." In radiology report this morning, the radiologist looked at her MRI and said "this doesn't look good." The neurosurgeon said "ouch" when he saw her CT. She will never drive that stick shift car or play another game of pickup.

Yes, I'm a wuss. I don't know how you don't take this stuff home with you. I couldn't sleep last night for thinking about this girl, watching her cerebellar exam deteriorate. I don't know what to say in the face of such suffering. I don't know how to handle it. It hurts me, and I don't know how to make it stop without turning away and ignoring it, which isn't my goal either. I know life is short, and there are no guarantees, and it's a stupid cliche to say "life isn't fair", but it's fucking NOT.

Ophthalmology and dermatology are looking better and better.

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