Playing with zebras

There's a saying in medicine: "If you hear hoofbeats behind you, don't turn around and expect to see a zebra." Thus, the term "zebra" in the context of medicine refers to a very rare and unlikely diagnosis.

It just so happens that I am spending the last couple weeks of my pediatrics rotation working at a private practice that specializes in zebras. My preceptor is a pediatrician who provides health maintenance for children with "special needs." In the short time that I have been working at this private practice, I have seen a wide range of diagnoses; no child has been "normal":

• Non-accidental trauma, child abuse, and in utero exposure to alcohol and drugs. These are children with nauseating histories who otherwise would have been lost in this world if they had not been taken in by incredible adoptive parents who love these kids as their own.
• Attention deficit hyperactivity disorder, learning disorders, and developmental delay
• Autism spectrum disorder. These patients take the prize for most exasperated parents.
• Down syndrome. At various ages and levels of severity.
• Fragile X syndrome. I was struck by the variability of presentation. Aggressive behavior was the biggest concern.
• Williams syndrome. Truly a cocktail party personality.
• Prader-Willi syndrome
• Cri du chat syndrome. The child I saw was too old to have the characteristic cry.
• VACTERL syndrome

I can't overstate how helpful, in terms of my medical education, it has been to see in the flesh these patients with rare genetic disorders: to take in the gestalt of their presentation, to interact and play with them, to listen to their parents' experiences raising these children with special needs.

More personally, I am amazed, inspired, and humbled by the depth of love lavished on these children. Regular parenting is a full-time job, but caring for and raising special-needs children demands an enormous amount of fortitude that I cannot fully comprehend.

Sick

It was bound to happen on my pediatrics rotation: I'm sick. What else would I expect from exposure to coughing and sneezing and drooling and runny noses for 12 hours per day over the last 3 weeks? Kids are germ-machines.

I wore a mask when seeing almost all of my patients, always with the sick ones, and I washed my hands like someone with obsessive-compulsive disorder. This past week while on inpatient service, I also wore a gown and latex gloves while seeing all of my patients - required precautions. Apparently, all of that wasn't enough.

Abdominal pain in a child

Of all kids coming to the emergency department complaining of abdominal pain, plain old constipation is to blame 70% of the time. Just such a kid came into the ED, but it turned out to be much more interesting than constipation.

Talking to Mom, I found out that the girl had been having stomach pains intermittently for over a year, that she could be fine one minute but doubled up in pain the next. These episodes came in clusters, were not associated with school, and were separated by months with the last episode happening several weeks ago. She was indeed previously worked up extensively for her abdominal pain ruling out things like appendicitis, pancreatitis, and celiac disease. In fact, an abdominal x-ray a few weeks ago even ruled out constipation.


The little girl last had a bowel movement earlier in the day, and Mom noted it to be soft without excessive straining required to defecate. She also had two bowel movements the previous day. None of this was pointing toward constipation as the cause of this girl's abdominal pain.

My patient was difficult to talk to. She would hardly look at me. Even when I asked her simple questions like "What's your favorite color?" she would look over to Mom, who professed that her daughter was normally very talkative. Mom was also difficult to talk to: she couldn't get words out of her mouth fast enough, she went off on tangents before eventually answering my questions, and she spent a lot of time unloading all her worries about what might be causing her daughter's abdominal pain.

Within a few minutes of entering the room, and without even touching my patient on exam, I was already pretty confident about my diagnosis. This could be delicate and require some tact.

"Are there any significant psychiatric problems in the family?"

Jackpot. Mom described symptoms in herself highly suggestive of no less than three psychiatric diagnoses, all of them undiagnosed and untreated. She also said that the kid's father is on medications for two psychiatric disorders. Further delving into the social history revealed significant turmoil at home, including an absent father and other significant stressors.

After a thorough exam, I explained to Mom that I ruled out the scary stuff that could be causing her kid's tummy pain. I said that the clinical picture doesn't really fit a physical cause and that I thought it was more likely that her daughter's stress or anxiety might be behind her symptoms.

Brace for impact....

But to my surprise, Mom accepted what I had to say: "You know, that makes so much sense. No one has ever suggested that before!" Encouraged, I then explained to her that it is very common for children to convert emotional or psychological stress into physical symptoms and that this is called conversion disorder.

In hindsight, this child in fact didn't have conversion disorder because the diagnostic criteria for conversion disorder require another non-pain neurologic symptom, which this girl did not have. She probably met diagnostic criteria for chronic pain disorder with psychological factors, the treatment of which is psychotherapy and antidepressants.

I explained to Mom that it is really important that her daughter receive prompt treatment for this problem to decrease the chances of her developing other psychiatric problems such as an anxiety disorder. For what it's worth, she said she would follow up with her daughter's primary care physician for a referral to a child psychiatrist. I really hope that actually happens.

Pediatric emergency medicine

For the past two weeks, I've been doing shift work in the Children's emergency department at St. Joe's. I only had to do seven 12-hour shifts over these two weeks, and the rest of the time I had off. While I definitely very much appreciate all the free time it has given me, I have also learned that I like more regularity in my schedule. What's worse is that these shifts are 11a-11p, which has shifted my internal clock back several hours. Returning to a normal routine will be a bit painful.

Most of the patients presented with fever, ear aches, runny nose, cough, vomiting, diarrhea, or a combination of the above. It is flu season, after all. This got to be routine, boring. I also saw a few kids with minor broken bones. There were a few other truly interesting cases, which I'll write about later.

But all in all, I have come to the conclusion that I definitively do not like general pediatrics. Good to know. How does this affect my level of interest in pediatric neurology, a course of training that requires two years of general pediatrics? I still have to figure that out.

Endless ear exams

My least favorite part of the physical exam is looking in ears. It's especially difficult in kids because their ear canals are small and crooked, and of course kids tend to squirm and scream when you try to stick something in their ear. Go figure. But a good ear exam is absolutely essential in pediatrics. That's why I made a point to hammer away at the ear exam until I got the hang of it.


Tough going, at first. Too often I would look in a kid's ears and just see a ball of wax, or the sides of the ear canals but no tympanic membrane. When ear pain wasn't a chief complaint and I wasn't concerned about an ear infection, I just nodded my head reassuringly and continued with my exam. This falls under the category of "Fake it until you make it" - first to avoid alarming parents that they are entrusting the care of their child to such an amateur, and second to protect my own ego. But I would return to my attending, tail between my legs, and sheepishly report "Tympanic membrane not visualized" in the physical exam section of my oral presentation.

The attendings are for the most part understanding that a third year medical student isn't going to do a first-rate ear exam. In fact, they seem to expect it. One attending said, "I don't even expect pediatric interns to give a good ear exam. You have to look at thousands of ears to get good at it." Fair enough. Being that we're in the middle of flu season, I've gotten a good jump-start on those thousands.

I think I'm already getting better. I'm probably visualizing about two-thirds of all the ears I look in, at this point, up from around 0-5%. If there's wax, I remove it and try again. If the kid is squirming, I coach the parent on how to hold the kid down. If the kid is screaming, I ignore it. I'm such a meanie.

But being a heartless sadist has paid off. Today a kid came in tugging at her right ear. I looked in the left ear first, then the right, and thought I saw infection in both. The left ear actually looked much worse with erythema in the canal, no light reflex, and yellowish fluid behind the tympanic membrane obscuring the bony landmarks. I described these details to my attending, aware that they were at odds with the patient's history. After doing her own exam, she said five words that every medical student loves to hear from their attending: "I agree with your findings."

Suturing on children

I feel pretty comfortable at this point suturing a superficial laceration. I've even sutured some lacerations in sensitive areas such as the face and hands. But, man, it's a completely different beast suturing on a screaming squirming child! I didn't try this, thankfully, but I saw several of them during my first week on pediatrics. With one kid, even a hit of Versed wasn't enough to calm him down!

One attending's advice: Immobilization. If you keep them completely immobile, they'll eventually stop trying to move; but if you let them move just a little bit, they'll squirm throughout the entire procedure. Just holding down their arms isn't enough. We used blankets to wrap these kids into burritos to immobilize their arms, legs, and torso all at once.

Another attending's advice: Patience. Make any sensitive movements while the kid is actually crying since they tend to be more still during exhalation. One attending spent what felt like 5 minutes trying to take out a single suture, his hand braced against the child's face steadying the scissors to be ready to snip the suture during the briefest window of calm.

To do a good job suturing on children takes a level of patience and steely nerves that I certainly admire.