Over the years I have written many journal entries about patients I have seen, or situations I have encountered in my travels through first ambulance work, then medical school, residency and now life as an attending staff.  Periodically I will post one on this blog.  Here is the first, from a few years back when working at a pediatric center.

Trigger warning: severe illness in a child, a teenager with violent thoughts.

 

“A hard day”

It’s late, and finally the house is quiet. My sweet girl is asleep for the last hour and a half, my hubby too. I finished watching the no-brain-involved reality TV silliness of The Bachelor, and now it’s time to dive into the day.

It was a hard day. Perhaps the hardest I’ve had yet as staff. Maybe I write that every time I sit down to the keyboard, but I can’t recall. It feels like the hardest day.  Today I saw a few semi-sick kids, many not-sick kids, but two cases really stood out.

I walked into a room to find a beautiful little girl, 6 years old, lying on the examining table. Immediately I knew something was up, because 6 year olds don’t lie still for very long, especially not on hospital beds. She sat up only when I asked her to, so I could examine her left ear that was draining pus and blood for the last week. Her mother mentioned in passing that her daughter had been looking a bit pale. On exam, besides the ear I noted multiple lymph nodes on both sides of her neck – not unusual in a child with a rip roaring otitis (ear infection). However, given the pallor and the obvious fatigue, I ordered a CBC (complete blood count) to ensure that there wasn’t more going on. My mind was steering towards a complication of otitis, such as a mastoiditis or intracranial infection (although both seemed unlikely). I managed to arrange for the ENT specialists to have a look at her and send her back down to the emerg for the CBC.

A few hours later I got the blood test back, and I had to sit down in horror because my legs felt weak. On the paper in front of me was a life sentence for the beautiful black haired angel with the sweet innocent smile: leukemia. Not a definite diagnosis without a bone marrow biopsy, but this blood test was highly suspicious for malignancy. This left me no choice but to call the hematologist to assess her, and before he could come down I wanted to tell the mother why he would be visiting the bedside. I called the mom and girl into a quiet room in our observation area, and sat down with them to explain.

In medicine, we are always taught to be direct.

Don’t beat around the bush.

Tell it like it is.

So I did.

I told the mother that the reason her daughter was so pale and so exhausted, and probably why her infection was not improving on antibiotics, was because it was very possible that she has leukemia. Immediately, it was as if I had taken a knife and stabbed it through her heart. The mother burst into tears, a look of shock and betrayal on her face. She reached out to her daughter, lying on the bed next to her, with a gesture that as a mother I understood to mean – how could this happen to my healthy, lovely child? I understood her fears without having to ask; when she asked me if her daughter was going to die I knew her terror. I tried to reassure by informing her of how eminently treatable most leukemias are in young children, and by telling her that the diagnosis was still unconfirmed.

But the minute a physician raises the spectre of cancer, all rational thought goes out the window and the emotional train wreck begins.

Thinking back on things, I do wish that I had thought to ask her to have her husband come before we had the discussion, but then again if I had said that she would have already known that something serious was wrong. And I also wonder, should I have spoken to mom separately from her daughter, who had to witness this breakdown in her mother? I examined the girl’s abdomen for an enlarged liver and spleen as her mother was wiping her tears, and I took the time to explain to the child that her mother was crying because she was worried about her being sick in the hospital. I told her that we were probably going to have to give her medicine to help make her better, and the innocent asked “what is medicine?”. My heart broke as I explained that medicine is a special thing doctors use to fix kids who are sick.

How do you explain illness, severe illness, to a child? How do you explain to her that she will have years ahead of her of IVs, toxins running through her system that will actually heal her? How do you tell a little girl with long, curly braids that she will lose all that glorious hair?

As an Emergency Physician, I don’t generally have to go into all this detail. Thank God for hematologists and oncologists, who help relieve that burden. Thank God. But even trying to just explain what “medicine” is, to a six year old whose mother is crying her heart out in anguish, that is maybe the hardest thing I have ever done in my life. Ever.

When I got home I hugged my daughter so much. I told her how glad I am that she is mine, and that she is healthy. When I got frustrated because she wouldn’t go to bed, I kicked myself for yelling. All I could think of was how that mother must feel tonight. Is she sitting by her baby’s bed, touching her hair, crying into the pillow? As a mom, I can only imagine that she is.

 

The second case that threw me today was a boy I saw immediately after breaking the cancer diagnosis. He was sent in by his school for aggression issues. At 14 he was entitled to talk to me alone, without a parent present, so when he asked his dad to wait outside the room I felt it was appropriate. However, as with any patient at the Emerg for psychiatric issues, I made sure I had the exit close by.

I asked him, “why are you here today?” and boy was I unprepared for the answer. He proceeded to tell me how the school had sent him to the ED for violent thoughts. Over the last two weeks, this boy had been ruminating on killing every person in his school, teachers and students both. He told me how he wanted to take guns and shoot them all, and he even made the hand motions at me “pow pow, pow pow”. When I asked him why, he said that he didn’t know. There were no specific triggers. He said that he doesn’t like people, that he feels he has to pretend to be friends with others, when really he doesn’t feel anything at all towards them. I asked him if he had access to firearms at home, and he said no. But he said he has knives, and then said that he wouldn’t use those. I knew I had to do some sort of physical exam on this young man, but my guard was up as I listened to his heart and lungs. As I was close to him and starting my neurological exam, he began to look at me in a creepy way that really rattled my cage. I got the heebie-jeebies, which I very very rarely get in the ED. But when I do get that feeling, I know it’s time to leave the room, and fast. So I did.

Psychiatry and social work assessed him, and felt similarly to me but with the added thought that he was possibly experiencing the prodrome of a psychiatric illness such as psychosis or schizophrenia. However I was shocked when they decided that he was dischargeable, with a close follow-up. They had discussed this with the young man and his father, and while the father seemed to be minimizing the situation, the patient said that he would feel safer if he stayed in hospital because he didn’t know what he might do otherwise.

I called psychiatry back and said that I was very uncomfortable with the idea of discharging this patient, and that I thought we should hold him overnight for observation on the psychiatric ward. I pushed, and managed to convince the psychiatrist. Later when she came down to write the orders, she thanked me because she agreed it was the right call to keep him. I told her, we hospitalize people for way less than threatening to commit mass murder and shoot up their entire school. Thankfully, the patient was admitted to the psychiatric ward.

I can only hope that by this intervention perhaps I have helped prevent the next school shooting. If not, at least I know I did the best I could and acted in the most responsible manner. This kid scared me; I have the impression he is likely sociopathic and I am not entirely sure what can be done to remedy this. I can’t help it, I felt like I was in the presence of a monster-to-be. The way he eyed me when I came close to examine him, it felt so deeply, viscerally scary. So scary. Looking into his eyes felt like looking into the eyes of a lion who is stalking you. Predatorial.

 

So that was my day. Along with those were a suicidal 11 year old and a 10 year old with a pathologic fracture through what could very well be a sarcoma of his upper arm.

Not a fun day. Such a hard day.

And yet – this is why I do what I do.

I diagnosed leukemia in a girl who presented for an ear infection, and hopefully by picking it up early she may do better in the long run.

I possibly stopped a teenager from killing people.

At least I can sleep tonight knowing that the pain I feel inside is okay, because good came of it.

But it doesn’t make it hurt any less.

Goodnight. Kiss your kids.