This horrendous cold and flu season has been an exercise in running on auto-pilot. Running from room to room every 10-15 minutes has been a blur of declaring,
“Virus – no antibiotics needed. Virus – no antibiotics needed. Ear infection – here’s your amoxicillin. Flu – Tamiflu sucks and you’re going to feel like dying for the next 7 days, sorry. Maybe take me up on the flu shot next year.”
This was my life for two weeks after making the mistake of not taking any time off Christmas/New Year’s at the end of 2017. (Note to self: Worst . Idea . Ever. Take a vacation already!!!) Just as I was ready to go insane from the monotony, the palest toddler with the most crystal blue eyes brought everything to a screeching halt.
The worst Christmas story
Her father brought her in just before Christmas with the saddest holiday tale. C had been diagnosed with the flu 3 weeks prior at an urgent care, seemed to improve but fevers then returned with a vengeance from a double ear infection. After a course of antibiotics, here she was again, sitting in my office with another raging fever.
She peered at me through a little peephole in her fuzzy pink blanket, strawberry blonde hair flying all around from static. I was struck by bright piercing blue eyes set in the palest face I’ve ever seen. In the background, I could hear her father express his concern at her 5 lbs weight loss in the last 3 weeks. She was refusing to eat and would only drink chocolate milk in small quantities. It was a struggle to even get her to take the tylenol and ibuprofen that were barely keeping her fever down.
Turning to him, I started with the spiel I had been giving all week.
“Well, let’s take a look! She may have gotten another virus back to back or it could that ear infection causing trouble again.”
I looked into C’s ears and there they were – bright red, bulging ear drums with a bunch of white fluid mixed with air bubbles. Easy peasy diagnosis = double ear infection.
“Yup, it’s her ears. Since she’s refusing to take medicine, we can give her an antibiotic injection and we’ll have you come back for 2 more days so we can finish the full course. She’ll be feeling much better soon!”
Dad looked at me with a healthy dose of skepticism. This was clearly something he had heard before in the last 3 weeks. I gave him a reassuring look and instructed him to make an appointment to be seen tomorrow just to make sure things were going well. As I was about to leave the room, C poked her head through her fuzzy blanket and said, “Bye bye!”
That night, I couldn’t get her out of my head. Out of all the colds, ear infections and flu patients I had seen that day, something about her was not sitting well with me. Before I went to sleep, I reassured myself with the thought, “It’s ok, you’ll see her tomorrow.”
The Next Day
Tomorrow was just as hectic as the previous day had been, allowing me to put aside my unease until I saw C listed as the next patient. I had been allotted 10 minutes for this follow up ear infection visit and before walking into the room, I mentally crossed my fingers hoping everything had turned out as I expected. I was already running late and I pride myself for my punctuality – I had no time for any unexpected road bumps.
I was greeted by the whole family this go around – mom, dad and older sister – all of whom were smiling! Dad was much more relaxed today as he relayed,
“Her fever went down within 4 hours of getting the antibiotic shot yesterday! She, and therefore we, actually got some sleep last night!”
I nodded my head all-knowingly, giving myself a pat on the back. This was my personal victory for the day, and it felt pretty damn good! I glanced over at C, still wrapped up in her pink fuzzy blanket enveloped in mom’s arms, but today her piercing blue eyes were trained on her sister who was adorably reading a book to her.
As the nostalgia of sisterhood faded away, I was blindsided by my unrest again. That’s when it hit me – C was TOO pale.
Yesterday, I had thought it was due to her fever but that had resolved. I thought maybe she had taken after her mother’s colouring, but seeing the whole family together this time around, I knew this wasn’t the case. Something was not right.
After I quickly peeked at C’s improving ear infection, I casually asked her parents,
“Hey, is C looking a little pale to you?”
“You know, I was just thinking that today.. I would have expected her colour to come back when the fever broke, but that hasn’t happened,” mom replied.
“This may be overkill, but I would feel a lot better if we just did a finger poke today in the clinic to make sure her blood counts are normal.”
I watched as her parents weighed the choice of an additional sharp object stabbing their daughter, knowing she was already going to get a shot of antibiotics. After a few seconds of silent conversation, dad looked at me and said, “OK. Let’s do it.”
I flew out of the room, informed my medical assistant of the plan to get her blood counts as I ran into the next room so I didn’t fall too far behind. Next patient diagnosis: Flu – Tamiflu sucks and you don’t meet criteria. Sorry, get the flu shot next year.
As I exited, I almost ran into my medical assistant who was waiting for me right outside the door.
“Dr. M… there’s something wrong with the machine. It says her hemoglobin is 3.7! That can’t be right! But I wanted to check in with you before I poked her again.”
My heart dropped
For a brief second I wanted to give her the go ahead, but I knew a second test would tell me the same thing – C was profoundly anemic.
The possibilities of what could be started whirling through my mind: leukemia, bone marrow failure, destruction of her red blood cells.. the list went on and on as the seconds ticked by in slow motion. Whatever the case may be, this child needed a blood transfusion to get her up to the minimum of 7 so she didn’t go into heart failure or some other bad outcome. I needed her out of my office and into a hospital.
As I walked back into C’s room, I could feel the anxious tension that had been brewing while I was away. Her parents were huddled over a phone looking at photos of C from just a month ago, rosy cheeks and full of an energy they hadn’t seen in the last 3 weeks. Before I opened my mouth, they knew what came next wasn’t going to be good. But they didn’t expect this.
“C’s blood counts are dangerously low, and this is why she’s so pale. I’m not sure why – it could be the back to back infections, or it could be something else. But, right now what’s more important is that you take her to the hospital right now so she can get blood transfusions and more labs.”
I paused and watched them yet again as the enormity of what I was saying hit them like freight train. Dad crumpled and turned away from me. Mom sat in shock as she tried to process.
“Blood transfusions? But she’s getting better with the antibiotics! I don’t understand! And, how long do you think we’ll be at the hospital for??
As I answered their battery of questions, I could feel the weight of C’s eyes trying to make sense of why I was making her parents so agitated. Yes, I understand she’s getting better with antibiotics but we still need to address the anemia. Yes, she will need blood transfusions to get a minimum of 7. Yes, you may be in the hospital for several days, maybe even through Christmas.
While I started making phone calls to let the hospital know I was sending C in, I watched her family head down the hall. Blue eyes glared me down over dad’s shoulder, still peeping through the fuzzy pink blanket. No “Bye bye” this time but rather, icy resentful eyes clashed with mine for making her parents cry.
After finishing up my phone calls, I looked at the clock. 25 minutes behind. I steeled myself and mentally tried to shake off the horrors of what I knew were coming for C and her family – that could wait. I ran into the next room and slipped back into my regular spiel,
“I am soooo late! Thank you for waiting! What can I do for you today?”
A few more restless nights
What if I had set myself on auto-pilot and missed the diagnosis?
What if I hadn’t been mindful or present enough in our two interactions that I would have missed the small details that fed into my gut feeling that something was wrong?
What if I had been so intent on running on schedule that I wouldn’t have spent the time needed to talk things over with her parents?
What else have I missed because of lack of attention due to me not getting enough sleep the night before/being distracted by another patient interaction/spending more time typing away into the computer instead of actually looking at my patient in front of me??
These are the little terrifying thoughts that keep me up at night.
The universe tends to throw me these curve balls once every 3-4 months just to keep me on my toes. It’s humbling. It’s unnerving. It’s horrifying.
But it’s so necessary.
I must be present in every interaction. I will not allow myself to become comfortable with auto-pilot. I will take the time when necessary.
Sometimes gentle reminders on living my best life come in the form of nightmares.
I wonder if our patients know we sometimes lie awake at night thinking about them.
Another great post. Thanks
Sometimes I do tell them I worry about them… if only to convince them to do what I’ve advised! Pretty sure that adds the guilt layer quite thick, but you do what you have to sometimes. Thanks for reading and commenting!