by Barbara Ebel
“Hi, Toby, I’m Dr. Palmer, a medical student in training. Sorry to see you laid up like this, but I’m glad you are not more injured from the car accident. Hopefully, Dr. Castle will have you back on your feet in no time.”
Toby curled his lips with displeasure. “I don’t ever want to be in an accident again. Totally scary. Anyway, a physical therapist is supposed to come by later today to show me how to walk with a cast and crutches.”
“You’ll do fine, especially since you’re at the age when you’re playing sports and are fit and growing. Are your parents around?”
“They went to eat. They stayed all night long.”
“Can I ask you some questions? The orthopedic doctor asked my team to look over your medical care during your short stay in the hospital and I’ll report back to my chief resident. We cover pediatric patients in the hospital.”
Toby nodded and looked back up at the IV bag.
“I suspect they’ll shut that off soon,” Bob said. “Especially since you’re probably famished and will be eating soon. Breakfast should be on the way.”
“The nurse and I talked about that. I don’t really want to eat because I feel nauseous.”
“Maybe that’s because of the anesthesia you had and it’s still wearing off. They can give you a medication to alleviate that sensation.”
“She did. Anyway, they don’t want to ditch the fluids until my stomach settles down and I eat something.”
“Maybe by lunch time, then. So, looking at your chart, it appears like you’ve been healthy growing up. Do you have a regular pediatrician?”
“Yeah. Dr. Gillespie’s my doctor. I just saw him this week for my school physical. Do you know him?”
“No. But my medical school friend is with him in his office for two weeks and I will be soon. I guess you’re up to date with all your shots.”
“Besides Dr. Gillespie, my mom makes sure of it.”
“Super.” Bob pulled his stethoscope off from around his neck and stepped up to the bed. “Mind if I examine you?”
“You don’t need to stick your finger up my butt, do you?”
A woman’s and man’s voice approached the door, and Anne and Jack Owens entered. “Another doctor?” Anne asked.
Bob finished raising his eyebrows at Toby’s remark and turned around. “I’m one of the medical students on the pediatric service. We’re going to offer assistance to the orthopedic service in taking care of Toby.”
“Good,” Anne said. “Obviously, we’re his parents.”
“Toby was just telling me of his nausea after his surgery.”
Mrs. Owens moved to the head of the bed beside her son. “Too bad because he’s missing out on the hospital’s scrambled eggs. He’s not one to complain or look downtrodden; despite the broken leg, I assumed he would be better natured and well this morning.”
“But I was already queasy yesterday before the doctor set my leg and I had anesthesia.”
“What are you talking about? You mean after the accident, don’t you?”
Toby avoided her eyes. “Kind of before.”
“When before?”
“Like when we went shoe shopping.”
Mrs. Owens right arm showed no restraint and she clunked him on the head. “Why didn’t you tell me?”
“Anne,” Jack said, “leave him alone. He’s at that age where he can’t tell his mother everything.”
Bob stayed out of the family squabble and pressed on with his short but diligent physical exam.
CHAPTER 11
Bob raced downstairs to catch up with rounds and found Rick Mares at the head of the team hurrying down the hallway. “We’re finished, slow poke,” Dr. Mares said. “We’re going to the office to talk about all our patients and you can tell me about our consult.”
Rick nodded for the last medical student in to close the door.
Nell squeezed into the couch, making a contiguous line of medical students as Rick pulled up a chair. “If I didn’t know any better, you four look like green first-day medical students.”
Bob wiggled in the upholstery. Nell was so close, their thighs and hips bumped alongside each other.
“We are still green to pediatrics,” Nell offered. “We need your supervision and leadership.” Her dark almond-shaped eyes darted to Bob as if she was buttering up their chief resident for all of them.
“Take your pediatrics rotation very seriously,” Rick said. “Think of pediatricians as the gatekeepers to springing kids into healthy lifestyles for the rest of their adult lives. There is no other specialty that can impact the future of patients like peds. During their formative years, children are open to the suggestions of their doctor. Often the parents are the ones who steer kids the wrong way by setting bad examples. Also, a friendly, skilled, and nonjudgmental doctor is important, as is the way he or she performs a physical exam. Children are developing self-worth and are coming to grips with wanting privacy over their own bodies. The physical exam must be executed with sincerity and respect.”
Rick wiped his brow and leaned forward. “So, Dr. Palmer, we’ll start with you. I want you to follow Dr. Castle’s patient now that you’ve seen him. Fill us in, please.”
Wishing Nell would afford him more space, Bob wiggled his hand into his pocket and took out the index card on his new patient. “Toby Owens is an eleven-year-old male, status post an MVA late yesterday. He suffered a fractured fibula and Dr. Castle did a closed reduction in the OR early this morning. He has no allergies to medicines and no prior medical or surgical history. To the surprise of his mother in the room, he mentioned a bout of nausea and vomiting yesterday before the accident.
“On physical exam, he is a well-nourished young male who was a bit groggy from his night of events and anesthesia, and is wearing a cast on his right leg. His vital signs were normal except for a temperature that has been creeping up. A tech just took one while I was leaving and it was 101.2. His lungs and chest sounded fine and abdomen felt normal, as well as his ears and nose.”
He checked the index card to make sure he had Toby’s temperature correct and flipped it over.
“Dr. Crystal confirmed that he set the bone in the right position with an X-ray after the procedure. The little lab work ordered on his admission was normal.”
“Thank you,” Dr. Castle said. “Nice job and I’ll jump in here. Obviously, the cast was put on to keep the bone in the correct position and to protect it while it heals. So, I want to say a word about post-operative fevers in children. A surprising fact is that they are a common occurrence after surgery. Testing for infectious sources of fever is not usually required, it can be costly, and most of the time not diagnostic.
“In addition, according to a recent large study, patients undergoing orthopedic surgeries have one of the highest incidences of postoperative fevers, but they were no more likely to have an infection. Even children who stayed in the intensive care unit or who suffered high fevers were more likely to undergo testing. And lo and behold, they were no more likely to have an identified infection. The vast majority of kids with an infectious source of fever had an identifiable risk factor, such as a urinary catheter or central venous catheter in place.
“All of this has told us that a post-op fever may be part of the body’s expected inflammatory response after surgery. It is rarely due to an infection!”
Bob scrunched his eyebrows. “But my patient didn’t undergo a real surgery.”
“Exactly. Yet he had a bone break, which is still an insult to his body; there is always a risk of an infection in the bone. So it’s confusing, and a good doctor must weigh the clinical picture. Toby’s fever may be from an infectious etiology or a normal response. To compound the issue, he didn’t feel well yesterday. But heck, he may have been swimming in a pool all morning and became dehydrated and nauseous.”
Dr. Mares rose and wrote Toby’s name to the team’s list of patients on the wall board as Bob slightly moved his upper body to stick the index card back in his white jacket. Nell
plucked it from his hand and slid her hand into his pocket and left the card. Her gesture surprised him, but he kept his expression neutral.
Rick turned around. “For sure, Dr. Castle is aware of literature surrounding post-orthopedic surgical fevers, yet he knows that we are the bible when it comes to children’s medical care and the most recent information such as the study I just cited. He is being diligent in asking us to oversee Toby’s hospitalization. I’ll write a note on the chart to recommend a ‘watch and wait’ plan.”
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Annabel woke before her alarm clock startled her out of bed. She decided to get up, get ready, and use the time to study. It was Friday and she was headed into an entire weekend off when attending a county fair would be like stepping back in time and enjoying the sights and sounds she’d experienced as a kid. Tomorrow’s excursion, she thought, may prove to be the best ever. Bringing Oliver and showing him off in a ring was going to be an absolute adventure. Whenever she took him on walks, everyone commented about how gorgeous he was. Would those remarks be substantiated by the judges of a dog show? Highly unlikely, but it was going to be fun anyway.
Since Bob was back on call for the night, she also had to retrieve Oliver later from his apartment so he could be walked. They were fortunate they didn’t live on opposite ends of Cincinnati. She finished in the bathroom, opened the blinds to the front street, and poured a one-cup French vanilla brew. Before she sat down to read, she schemed about her travel arrangements for the day. She needed to use her own car; later, she would be transporting a dog and, other than service dogs, car transport services probably didn’t allow them. She blocked out all extraneous thoughts other than Type 1 Diabetes for almost two hours and then scurried out the door with one more cup of coffee.
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The techs and nursing staff were still preliminarily checking in patients and putting them in exam rooms. Dr. Clark cluttered up the kitchen doorway, so Annabel stopped and waited there for Dr. Gillespie’s arrival.
“Don’t be shy to tell me what you really think,” Heather said. “How do you like pediatrics?”
“It’s fine,” Annabel answered truthfully. “Too early to tell if I will consider it as my specialty. At least Stuart and I are with seasoned pediatricians good at their jobs. Dr. Gillespie seems thorough with his history and physicals, succinct with shorter exams for patients with specific chief complaints.”
Heather brought her hands up to her mouth. Her fingers were extended in thought. More like a prayer-like hand gesture, Annabel thought.
Dr. Clark turned, stepped inside, and poured a cup of coffee. “Would you like one?”
“No thank you. I had two at home. I woke early and studied. It was marvelous.” Anabel leaned against the counter. “What percentage of your patients are Type 1 diabetics?”
“You bring up a good question. Not as many as you would think. Yes, Type 1 is the juvenile diabetes that develops in childhood, but the peak age of diagnosis is more often made around fourteen years of age.”
“Hmm. I didn’t realize that.”
“It’s a terrible disease, one that I consider to take over a patient’s lifestyle … both Type 1 and Type 2. Of course, the prevalence of Type 2 is way higher at around nine percent of the adult population. The obesity epidemic in America doesn’t help.”
“Too many of the patients I helped take care of on internal medicine had diabetes. I ended up considering it a disease process, because it rarely presents in a patient just by itself.”
“Yes. Hypertension, heart disease, eye problems, cognitive dysfunction,” Dr. Clark added. “Ha, that’s one reason I stayed out of internal medicine. Trying to take care of those diagnoses wore me down. There is something about children that makes my heart bleed a lot more, so I reach down into my gut to try and help them over and above what I would do for the adult population.”
“Makes sense.”
Stuart walked in, followed by Dr. Gillespie.
“I’m finishing the coffee before you two get here,” Heather said. “They’re still putting my patients in the back rooms, so I’ll be happy to put on another pot.”
Stuart stayed quiet and Dr. Gillespie was in his own world and not listening.
“Stuart never asks for a thing,” Annabel said.
“Then I’ll make a pot and hope that he’ll sample some.”
Becky poked her head in. “Feel free to wander back and start seeing patients,” she prodded. “Mr. Miller is here with his daughter, Stephanie, in Room One.”
“We’re on, Dr. Tilson.” Dr. Gillespie pointed a stubby finger towards the door and they left Dr. Clark brewing coffee. He went straight to his office and thumbed through the neat pile of lab work on his desk. Annabel waited by the door.
“Here we have it,” he said, waving some papers. “Do you remember three-year old Stephie?”
“Yes. With raccoon eyes and a lump in her belly.” Annabel took a deep breath. Maybe Dr. Gillespie had an answer to the little girl’s symptoms; she could only hope that it was something minor or easily remedied.
At home, Annabel had done a meager online search of Stephie’s symptoms after coming up negative with possibilities in her pediatric paperback. In addition, history had taught her “online” medicine was not the way to approach diagnosing real patients and real situations. Medical school was the proper way to learn what was needed.
She cocked her head. “Did the testing give you any answers?”
Dr. Gillespie cracked a smile, noting his success for being on the right track. “Let’s go talk to Mr. Miller so I won’t need to repeat everything.”
Mr. Miller jumped up when they walked in, but Stephie remained next to him in a plastic chair, where her knees were bent into her chest.
“I brought my panda bear today,” she said, extending the stuffed animal towards Annabel.
“She’s beautiful, like you.”
“There are panda cubs at the zoo, so Mommy bought me this one to take home.”
Annabel squatted down, held her toy, and then gave it back. “Does he have a name?”
“Panda.”
“He’s easy to remember.” She looked over at Dr. Gillespie, knowing she was digging into the time allotted for the office visit. However, she rationalized, if this little girl and her father were going to receive a bad diagnosis and prognosis, she should not go away remembering the entire appointment as being doom and gloom. No matter what, medicine should allow room or time for the little girl to continue what little girls do.
George Gillespie waited a moment. “Stephanie’s urine that you collected over a twenty-four hour period was very important.”
Mr. Miller continued standing, his muscular arms propped behind him on the examining table. He bit the inside of his lip. “Why?”
“I was looking for certain metabolic markers. Have you ever heard of catecholamines?”
“Sure. My wife and I split our care with Stephie. She works during the day, and later, I head to the gym. I’m a trainer and studied biology, so I know about the fight-or-flight response that stems from the catecholamines released in our body. Our sympathetic nervous system pumps up, increasing our heart rate. Sometimes I monitor my clients’ heart rates so I don’t overstress them. But that’s all I know, doc. I don’t remember what part of the body they come from.”
“You understand their role, however. Better than starting from scratch.”
“What does this all have to do with my daughter? Certainly children her age are not doing strenuous physical activity or exercise that would cause an outpouring of these ‘metabolites,’ as you call them.”
Dr. Gillespie nodded. “As far as where they come from, catecholamines are hormones made by the adrenal glands, which are located in the abdomen, above the kidneys. There are three: epinephrine or adrenaline, norepinephrine, and dopamine. A urine test more accurately measures them than with a blood test. Unfortunately, two of the catecholamine metabolites called VMA and HVA, for short, are elevated in Stephanie’s resul
ts.”
Mr. Miller’s concern grew and he shot a glance at his daughter. Annabel wasn’t sure about the final diagnosis either.
“Stephanie’s history, examination, and laboratory results are consistent with a neuroblastoma. It is not uncommon, Mr. Miller. It is the most prevalent solid tumor outside of the cranium in children.” He waited, wanting the man to grasp the term “tumor,” although not all tumors are malignant. He wanted Mr. Miller to ask the question.
“Tumor? What kind of tumor?”
“In all pediatric malignancies, neuroblastomas are the third most common, and almost all are diagnosed before the age of five.” There. He said it, the word “malignancy.”
The cast-iron man almost buckled at the knees. He clasped his hand over his mouth to hide his trembling lips. Stephie didn’t understand why her father was all of a sudden sad and she stopped playing with her panda.
“My wife should be here. Spit it out. What do we have to look forward to?”
Annabel thought it best to distract Stephanie. She picked her up, sat on the chair, and put the child in her lap. Next, she whispered in her ear, “Does Panda like to dance?”
“A little bit. I’ll show you.” Stephie held the stuffed toy by both arms and popped him up and down on her lap.
Dr. Gillespie kept his voice low. “We should order imaging to ascertain the extent of the tumor and any impact on surrounding structures. We must stage the tumor, which will help guide our decision regarding any chemotherapy or radiation treatments along with surgical excision.”
Mr. Miller grasped George’s recommended plan, but he balked at the next, most important question.
“What are we talking here? What’s her prognosis?” He tilted over, close to George’s ear. “Is there a chance she could die from this?”
Dr. Gillespie maintained his stoic expression. “Overall, the five-year survival rate is over ninety percent. However, for higher risk patients, the statistic reaches fifty percent.”