medicine, pediatrics

Bribery

First time parents stick out in the emergency room. Not in a particularly good or bad way; it’s just that you can see, in the lines of their faces and the set of their shoulders, that they are unsure about it all, the monitors and the beeping and the rushing nurses trying to accomplish a million tasks simultaneously. As a childless pediatric intern, I resonate with first time parents because I feel unsure about it all too.

My third day in the emergency room, I met the Garcias. Isabella Garcia was an adorable 3 year old girl whose parents were extremely worried. She was coming in with a week of mild fevers, a rash on her hands and feet, and a sore throat. They had been to their pediatrician who diagnosed a viral infection known as hand, foot, and mouth disease due to the characteristic ulcers which appears on the hands, feet, and in the mouth (doctors aren’t very creative.) Isabella’s pediatrician wrote a prescription for ibuprofen and told her parents to make sure Isabella drank plenty of fluids. However, although her parents tried to help her drink, they had come to the ED because, as they said, “she won’t drink anything!” By their report, it had been 3 days since Isabella had had anything to drink. At all.

This is a pretty worrying history. Dehydration can be really serious in children, and hand, foot, and mouth disease has been known to cause a sore throat so painful that patients will drool excessively to avoid swallowing their own saliva. So as I entered the room, I was already thinking about admission for IV fluids in what I expected to be a very dehydrated kid.

The only thing was, Isabella’s vital signs were stable, and when I walked in, she was sitting up on the bed happily playing with a princess doll. Her mouth was moist, her skin was the appropriate texture, and the skin under her fingers went from white to red quickly after applying pressure to the nail, all signs of good hydration status. Although she still had some of the rash on her hands and feet, it looked like it was resolving, and there weren’t any signs of it in her throat. She looked, well, mostly okay! But still, her parents were frantic and insisted that she could not drink.

I really did not want to admit her to the hospital for IV hydration. The hospital, as many of you know, sucks intensely. But I respected her parents’ concern. They were worried in a way that only first time parents deeply in love with their child can be worried, something I actually find kind of wonderful. In fact, it’s one of the reasons I went into pediatrics – parents, even when they’re pushing back, are most often pushing because they love their children. What could be more beautiful than that?

Still. Hospitalization? Not so much.

The other reason (okay, maybe the real reason) I picked pediatrics is because there are always toys, stickers, bubbles and other fun things around. I found the sticker box, collected a few of my favorites, and returned to Isabella’s room.

I offered her a juice box, and she shook her head no. I showed her a sticker of a green cat adorned with sparkles, and she eyed it hopefully. I offered her the juice box again, with a clear intention to bargain as needed. She edged towards me, put her mouth on the straw, and took an experimental sip. I nodded encouragingly and waggled the sticker at her, at which she looked me full in the face and chugged half the juice box.

Thus began an extremely enjoyable half hour where I would proffer a juice box, Isabella would drink it, and then I would give her a choice of stickers. She would then take her sticker hoard and count it into her father’s hands; as she wandered off to the other side of the room, I would collect them back and offer them again in exchange for yet another juice box. Her parents, initially drawn with concern and ready to battle on their daughter’s behalf, relaxed more and more with each sip, until finally we were all giggling as Isabella once again carefully counted the same stickers into her father’s waiting hands.

My final note read, “Patient drinking well in ED. Parents and patient discharged home with plan in place for hydration.”

I just didn’t mention that the plan was bribery with sparkly kitty stickers.

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medical school, medicine

Mesothelioma in a 19 y/o male

AM was in every way your typical 19 year old: brash, confident, blissfully secure in the knowledge that he would live forever. Except he had bilateral, incurable cancer growing in the lining of his lungs, and would in fact probably die in the next 6 months.

He didn’t smoke, he didn’t drink (much), he didn’t inhale asbestos or eat lead – he was just incredibly unlucky. Probably had some kind of congenital genetic mutation, as of yet unknown to the medical community, leading to cancer flourishing this young, otherwise healthy adolescent.

At least, that’s what the cardiothoracic fellow, Ahmed, told me as we strode down the hall towards AM’s room, me clutching surgical supplies (scalpel, gauze, lidocaine, needle, syringe, and grasping tools of various sizes) and him carrying his stethoscope and a pair of scissors.

Ahmed had told us AM’s story in the intern room, but I stopped listening when I heard “19 year old with bilateral mesothelioma.” My brother was 19 at the time, and with those words my mind slipped away to him, off at college, playing rugby, hopefully going to class sometimes, and probably drinking more than he should. I thought about how I might feel, if I knew that my precious brother, now 6 feet tall and square-jawed, was being cut down in the flower of his youth by a fluke of genetics. But that thought was too painful, so I dragged my consciousness back to Ahmed finishing up the history, tuning back in just in time to hear that AM had been lost to follow up with a chest tube in place and was now returning to have it removed.

It turned out I was the only without a surgery to go to, which is how I ended up with an armful of surgical necessities, trotting alongside Ahmed as he sadly shared the details of the case with me. In my head, I was trying to stop myself from envisioning my brother lying in a hospital bed with a tube sticking out of his chest, dying of cancer. It wasn’t working.

We entered AM’s room, where he was sitting in bed busily texting on his phone. His mother was sitting in a chair next to him, staring sadly at his face. I thought she might even reach out and stroke his cheek, but before she could, Ahmed introduced himself, and me, and said we were there to take the chest tube out.

“Thank God!” AM said. “This thing is killing me!” His mother flinched visibly at the word “killing,” but AM didn’t seem to notice. It struck me how thin he was, way too thin. My brother probably had 30 pounds on him, maybe even 40 with his rugby weight.

I set up our supplies on the hospital table beside AM’s bed as Ahmed carefully injected lidocaine along the line of the chest tube, trimmed its dangling end, and widened the incision through which it protruded. None of this caused AM any pain.

But once Ahmed grabbed the end of the tube with a kelly and started to pull, AM screamed. Over and over he cried out in pain as Ahmed carefully wiggled the tube out of his body. From the bits of tissue and skin clinging to the tube as it emerged from the hole in AM’s chest, it was clear that the extra time it had been left in had allowed the flesh around it to become scarred, anchoring the plastic into his thin frame. No matter how much lidocaine we injected, he still sobbed like a child as his mother stroked his forehead and Ahmed resolutely wormed the tube out of his chest.

But as soon as it was removed, AM wiped the tears from his eyes and demanded that we take a photo of him, fisherman-style, proudly displaying the 4 feet of flesh-dotted tubing that had previously resided in his chest cavity, draining malignant fluid. He immediately posted it to Facebook.

Watching him, I was suddenly overwhelmed by a welter of images of my brother: playing football, watching TV with my dad, arguing with my parents, cuddling with his girlfriend on the couch, horsing around with my other brothers, making breakfast with my mom. I remembered the time he was hurt playing football; he was tackled, hard, and when he took off his helmet, blood was pouring down his face from the hole in his lip where his bottom tooth had gone through. He’d wanted to keep playing. In my memory, I could see the fear in my mother’s eyes as my brother’s face emerged from his helmet dripping with blood.

And then just as quickly I was back in the hospital room, and I saw the same look on AM’s mother’s face: the look of someone seeing their child in danger and wanting desperately to prevent it, even though their kid is completely focused on something else, something that seems so trivial to us but is absorbingly important to them, like posting to Facebook or getting to the first down. We cared about the things happening in the moment; to look further forward wasn’t necessary because we knew the future was ours and it would come to us when we called. Our mothers knew differently, and wanted to protect us from it all, to shelter us forever from pain, loss, mortality, endings. But we were too caught up in the exuberance of youth to listen to them, secure in the knowledge that tomorrow will always come for us.

Even when it won’t.

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