Monday, May 30, 2016

Two Patients

I'm always challenged by primary care pediatrics. It's partially because I'm not really the best pediatrician in the world. I try hard, and I always see a patient in front of me, which tells my ethical self that I have to try as hard as I can, but I constantly think about how much I don't know. And then I don't see so many patients anymore, so I forget what I used to know. That troubles me. I'm hoping to go out without a big bang, quitting seeing patients before I have to. But then, I also know my standards are high, so I'm always troubled more by my downside than happy with my upside.

Still, there are the little triumphs that come from helping someone. That is really the best thing about being a doctor, we get to help people. Sometimes trite is true. A couple of weeks ago I saw a ten year old girl at the 95th percentile for both height and weight – big. With a little bit of a mustache starting, just a little. Her history was a little hard to get because her mother is primarily Spanish speaking, and while I can converse in Spanish some, only some. The patient herself goes both ways linguistically, but she's only 10. Her main problem, it said on the chief complaint part of the appointment, was abdominal pain. But when I looked at what I could find about her history, I found that she had been in the hospital last month for vaginal bleeding – a 10 year old in the hospital for vaginal bleeding? And that she had had a transfusion. Then that she had been discharged on birth control pills starting at a high dose and then tapering. When I talked to the mother and daughter there were other things troubling her, including a rash that appears at times on the arms and is treated well with aloe vera, and alarmingly to them, two instances when she was lying down on the couch and then found herself unable to breathe for five seconds each time. That is, she found she couldn't breathe, stood up, and then finally was able to. She had also been tired a lot, maybe other things, too, but I don't remember them right now. (Not to be profiling, you understand, but years of experience were ringing in my ears “Hispanic teenage female!”)

I'm not great on gynecology, but it's not uncommon for girls just beginning menstruation to have irregular periods, to have some scanty bleeding, and sometimes to have very heavy bleeding. What this poor girl had had was irregular bleeding, but then a month of heavy bleeding. That's what led to the hospitalization. A transfusion? Well, that's very unusual, but it could be just impatient housestaff, or maybe the bleeding really was hemorrhagic. But then what had led her to our office? It was her first visit to us. It turned out that her mother was worried about her and thought that she had better come to someplace where she could have confidence that the care was very competent. It always makes me proud to see that we have a good reputation, but it also makes me anxious to make sure we live up to that.

While I was going through the process of making a first contact with a frightened mother and daughter, getting the history and doing the physical exam for a girl who didn't want to be seen in her sensitive areas and who had on tight jeans, I couldn't help noting how tense they were. Well, who wouldn't be after you had bled irregularly for months and months and then had menorrhagia and had to have a transfusion?! So I mentioned to the patient that I could see she was scared, and a lot of times people have something specific in mind – did she worry that she had cancer? Or what? She just kept shaking her head and wouldn't say anything.

Her mother said that she was terribly worried about the no-breathing. I told her I wasn't, that this didn't sound like anything big to me, but she was adamant. Then I put some words in her mouth and I said, were you afraid she was going to die? She looked at me as though I finally understood and told me yes, that's exactly what she was afraid of. Then I looked back to my left and our 10 year old patient on the exam table was crying.

“Ah,” I said to her, “that's what you're afraid of, too, isn't it?” She started nodding her head with some tears rolling down her cheeks. Yes, she nodded.

“You're afraid there's something really bad wrong with you? Is that it?”

More nodding.

“Good,” I said, “so that's it.” And then I reassured her. I told her that she didn't have anything very serious wrong with her. (Hoping I'm right, as always.) At Children’s they had told her that what had happened “was normal.” That's what she heard, anyway, as they were trying to reassure her. But of course getting hospitalized for heavy vaginal bleeding is not normal. What does a patient think then? That they didn't know what they were talking about? That they were lying to her, that they were withholding the truth? Especially when she is an immigrant from El Salvador and her English is only partial. They were afraid they were being lied to.

Then our patient got down and went over to her mother and put her head on her mother and they held each other. I went out of the room to do something, and when I came back there were smiles. Not that they completely trusted me yet, and the mother asked if they could see a Spanish speaking female doctor. You bet, I said. My Spanish isn't really good enough, and I bet you don't completely trust me yet. The mother smiled. That's OK, I said, let's get you a second opinion. And she'll feel more comfortable with a woman doctor.

They were talking with me more easily at this point. The patient told me she was the last of five children and I said, “Do you know what they call the youngest one?”

She shook her head and wondered. I said, “The princess! Everyone loves the baby!”

She loved it. Both of them were smiling and talking. I put her on birth control pills to regulate her periods and made an appointment with one of my colleagues for next week.

As I say, I'm not the greatest pediatrician of all time, I'm hoping just to be above average and good enough not to hurt anyone and to help some. But I felt pretty good about this one.

Then I went on to the next patient, a 9 year old with fever for three days. As I walked into the room I was confronted with a grandmother missing several teeth, a mother, the patient, and three other kids.

“What's the problem?” I asked.

Anthony, the six year old, looked at the poor little sick girl and trenchantly observed, “She has an anger problem.”

The patient had some vomiting and some diarrhea, didn't look dehydrated, the ears were clear, not much else seemed wrong, so I told them it was probably viral and they wanted some Tylenol which I was happy to prescribe. I laid the patient down on her back and flexed her neck and the grandmother said, “He's testing for meningitis.”

I told her she was pretty smart to know that, and she observed she had had a bunch of kids. I told them to come back in a couple of days if it doesn't get better, or go to the ER. “We sure will,” said the grandmother. I wish I could do more for them, but they were happy. They knew the ropes, they had confidence that if we looked at the 9 month old we would do well by them, and they knew the road map. They didn't feel abandoned or alone or vulnerable. I hoped that the patient would get better in a couple of days, poor little girl, but it was good to see how well she would be cared for.

And it was so nice to see that both these patients had Medicaid and they didn't have to worry, they had a source of good care. That was great.

I do have to wonder, however, when I will quit. I will miss doing good for people. I sure hope I don't wait too long, because as I say, I'm not the world's best pediatrician, and I can always make a mistake. Although I have to say, my circumcisions, of which I have performed a couple of thousand, I think, are only getting better and better.

Budd Shenkin

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