A Big Decision

By , June 29, 2010 11:13 am

The woman looks at her son.  Then she looks at me, then across to her own mother, and then back at me.

“Oh,” she says finally, wringing her hands like she’s on a quiz show, “I really don’t know.  It’s such a big decision.”  I take a breath, quietly.  “I mean – you’re the doctor.  You tell me what to do.”

“Okay,” I say, “let’s go through it again.”  She nods in agreement.  “Jonah has enlarged lymph nodes in his neck, yes?”  I point across at Jonah, his neck as wide as a bullfrog.  He waves at me comically.

“Yes.”

“And he’s been treated with antibiotics for over a week, with no change.”

“There has been a change,” corrects Grandma.

“Okay, there’s been a little change,” I concede, “but not a lot?”

“Not a lot,” she agrees.

“Your GP sent you to the paediatrician for a second opinion.  He did some blood tests, a screen for glandular fever, and a blood count that came back looking perfect.

“Perfect?” Mums asks.

“The white cells were normal.  We look at these for signs of infection, and…for other nasty things.”

“Nasty things?”

“Like leukaemia,” I say, not wanting to get bogged again.

“Leukaemia?” Grandma pipes.

“Yes, one of the things we look for with this is leukaemia.  And there was no sign of leukaemia.”

“So it’s not cancer?” Mum asks.

“No,” I hear myself saying as a reflex.

“And it’s not an infection?”

“No, it probably is.”

“But you said that the blood test showed no infection?”

“The white cells were all normal…”

“…Which you said meant no infection.”

I pause for a moment, counting sheep.

“This blood test was done two weeks ago.  At that stage, his neutrophils were in the normal range.  I don’t know about today without a repeat test…”

“…If we agree to that test,” Grandma says, shaking her head.

“That’s right.”

“But you said that he looked fine, and that he wouldn’t need antibiotics?” Mum says.

“I said that if this a viral thing, then antibiotics wouldn’t make any difference.”

“And you think this is a viral thing?”  They say it together.

Looking at them, they’re like twins, except that one of them has been kept in a time capsule for twenty years.  Wrinkles aside, they are the same person –  same disposition, same head tilt, same cross-examination technique.

“It probably is.”

“Why?”  Again together.

“Because…”  I pause to gather my thoughts.  “Because he looks so well.  Because he’s never had a fever.  Because he has green snot coming out of his nostrils, and a slightly reddened throat.  And because if this was a bacterial lymphadenitis, he wouldn’t be able to turn his head, his glands would be hot and tender, and he’d be as sick as a dog.”

“But glandular fever is a virus?” says Grandma.

“Yes.”

“And it’s not that?” Mums chimes.

“Well, it may be.”

“But the test was negative.”  Grandma’s turn.  “I thought this was the one thing we did know.”

“The screen was negative, but it’s an imperfect test.  We’d need to do serology for a more accurate test.”

“Why can’t you people give a straight answer for anything?”

“Because unfortunately, medicine isn’t straight.”

They look at me like I’m mad.  Maybe I am.

Through all of this, Jonah has been watching, slightly amused.  I look directly at him and he grins widely, like he’s watching a spectator sport.  I get the feeling that I’m not the only male to get this kind of grilling.

“Oh, oh, I really don’t know about this,” Mum says, “I think I need to talk to Greg.”

“Sure, go for it,” I say.

“You know Greg?”  I look at her, confused.

“So he doesn’t have to be admitted?” Grandma asks, hijacking the conversation.

“You don’t have to do anything,” I say, slightly exasperated.  “It’s a free country.”

“It’s just that Greg is a naturopath, and I think he’d want to know if we were going to pump him full of antibiotics.”

There is a halt in proceedings.

“But he’s already getting antibiotics,” I say finally, confused.

“Yeah, he’s swallowing them,” Mums says, adjusting her woollen headscarf, “he’s not being pumped full of them!”

“Right,” I say, pretending to understand.  “I’ll let you guys talk to Greg, and then have a think.”

* * * * *

I head back in, fifteen minutes later.

“We’ve decided we want the blood test, but not the drip,” says Grandma.

“We want to go home after, and we want the paediatrician to follow us up if it’s not getting better.”

“And at that point, if it’s no better, he’ll come back for further investigation?” I ask, trying to clarify.

“We’re just trying to avoid the trauma.”

I find these people genuinely confusing.

“Which trauma?”

“Of staying in hospital.”

“Oh, that trauma,” I say, a little too candidly.

“It’s no laughing matter,” Grandma says shortly.

“No, fair enough,” I say.  “I guess…most people are worried about needles.  That’s the trauma people are usually scared of…”

“…Oh, we’re fine with that,” Mum says.  I look at Jonah, who does in fact, seem fine with that.  With everything, really.

“If we’re getting the blood tests, we often leave the drip in, in case anything else needs doing, so we don’t have to use another needle…”

“…We don’t want the drip.  We don’t want it to stay in…”

“Okay,” I say conceding.  “Let’s do the bloods, and a chest X-ray, and then we’ll see what they show.”

“And then we can go home?”

“And then you can go home.”  These people have a knack for getting me to say what they want to hear.  “But if things still aren’t improving in five days, you’ll come back in for the drip then?”

“Yep,” they say together.  “And Greg agrees, too,” says Mum.

“Great to have Greg on board,” I say.  “We’ll do the glandular fever test…”

“…I thought we did that one?” Grandma asks.

“Shut up Mum.”

“…And we’ll do one for CMV, and Cat scratch disease and a couple of other infections.”

“Sure.”

“And we’ll just get that chest X-ray as the last thing before you go, hey?”

“No problem.”

* * * * *

Jonah is a delight throughout the blood test.  He’s a special kind of kid.  A bubble of mucus plays at the edge of his nostril as he happily chats about his holidays, not even noticing as the needle goes in.  He then heads off to radiology, excited by a new adventure.  Even Grandma manages a smile, basking in the rays of this joyful child.

I’ve already printed their discharge letter by the time they return from Radiology.  I’m keen to get them out, happy for the paediatrician to sort this out another day, my own head throbbing from diplomacy.

“I’m back from getting my X-ray, Dr Mark!” Jonah yells on return.  I salute him, which he returns with a giggle of innocence that only goes with being eight years old.  His mother smiles, rubbing at his hair, knowing it won’t last forever.

I log into the computer to check the bloods.  The FBE is pristine.  The other tests sit there pending, not due to return till another day.

I minimise that screen, logging into the radiology program.  I punch in numbers, checking them against the name that pops up.  I click on it, and immediately pops up a black and white image.  A Rorschach ink blot.

My heart falls through the floor.   I feel sick.

I drop my head in my hands.

* * * * *

“Hey,” I say.

“Hey,” they all say together.

“Jinx!” Jonah shoots back, clapping his hands in delight.

“What is that?” I ask, pointing at the half-eaten chocolate bun, sitting on a plate beside Jonah.

“Dessert,” Grandma sighs.

“Leah and Trina,” I say, keeping my voice light, “can I just have a chat to you for a second?”

“Sure.”  They both rise and follow me.  “We’ll be back in a jiffy,” Mums says.  Jonah smiles, biting down on his treat.

They follow me into another room, another cubicle;  this one with a door.  There are three mismatched chairs laid out for interview: one covered in red vinyl, strings of cotton coming from it’s edges, one an anaemic green in hard plastic, and a third made of wood, designed for a toddler.  I’ve pre-arranged them so the two adult chairs face the baby one.

“You two take those ones,” I say, “I’ll take this one.”

“Are you sure?” they both ask.

“Quite sure,” I say.

We sit, the silence of the room suddenly very loud.  Those two seconds of deathly stillness sit in the pit of my stomach for a very long time.  Still now.

I take a breath, about to start.

“This doesn’t seem good,” Leah says, laughing nervously, looking across at her mother.

“It’s not,” I say.  Leah looks at me;  her head tilting and her brow knitting.  Trina looks up, mid-ruffling through her handbag.  I take another breath.  “When we did the X-ray, we saw a mass in Jonah’s chest.  Something that will be related to the lumps in his neck.”  They look at me, their eyes yet to register.  “We’ve seen a growth, sitting above his heart.”  I find myself touching my own chest, like I’m playing a piano chord on my chestbone.  “Right here.”

Leah lets out a little sigh, like a cough, like she’s just been winded.

“A growth?”  I see her eyes dancing, searching.  I say nothing, waiting for her to comprehend.  “What do you mean?”

I pause for a moment.  “We don’t know exactly, but I’ve been talking to the oncology team…”

“…Oh, Jesus,” Trina says.

“And we want to admit Jonah, so that we can investigate further.”  There is another silence.

“Is this cancer?” Leah asks.

I feel the acid in my mouth.  I can see my sadness reflected in her eyes.

“It could be.  We’re worried that this is lymphoma.”

Leah stands bolt upright, putting her hand to her forehead.

“No!  No!  No!” she barks, each word getting louder.  She walks around in a tight circle.  “Oh, Jesus.  Oh, Jesus, oh, Jesus,” she breathes.  She sits again, and then looks up.  “But it could be okay?  This might be nothing?”

“We really just need to bring him in to do some more tests,” I say.  “Maybe to get a bone marrow and a needle sample from the node.”

“This is not happening,” Trina says, as she dissolves into tears.  We all listen to her sobs for a while.

“How big is it?” Leah asks finally.

“About eight centimetres,” I say, measuring between my thumb and forefinger.  Trina continues to sob.  Leah is quiet and still.

“Who ordered the X-ray?” she asks.

“I did.”

“Thank you.”  I feel my own lip wavering, tears at the edge of my eyes.

“I’m sorry about before.  I really am.”

Leah moves forward, and takes me into a hug.  It leaves me totally thrown.

“It doesn’t matter,” she says, her voice now monotone.  “Nothing matters now.  All that worry about doing the right thing?  Thinking everything else is such a big decision?  It all just fades to bullshit, when this happens, doesn’t it?”

I frown, nodding.

“So he’ll need to come in now,” I say, eventually, quietly.

“Of course.  Of course,” she whispers.

She stands again, her hand returning to her head.  “I’m in a nightmare.  I’m in a fucking nightmare.  Somebody wake me up.  Please, somebody wake me up,” she groans.  “My poor boy.  My poor boy.  It couldn’t have happened to a better kid.”

I hear those words.  I think of Jonah, of his laughter, and his innocence, and I really hear those words.

I look back at Leah, a study in grief reaction.  In less than two minutes, I’ve seen her go through denial, anger, bargaining, and now depression.  She finally lifts her head and looks straight at me, her eyebrows folding at their edges.

“Why, Mark, why?”

I feel myself frown, trying to remain calm and professional.  But I can’t.

“I don’t know, Leah,” I say, finally, my voice cracking.  “I…I don’t know.”

Sack Taps 101

By , June 18, 2010 10:02 am

It seems that Sack Taps aren’t confined to Melbourne.  Thank you to Clare for alerting me to the story reported by news.com.au just over a week ago, following a teenager who had his testicle amputated after playing sack taps with his friends.

Urban Dictionary explains that a sack tap is:

1. A trick played on a fellow athlete where the open hand smacks the target’s testicles with the knuckles in a sharp, wrist flicking motion.

“Dude, I sack tapped Brandon, and now he has the whole team trying to sack tap me.”

2. A Skateboarding Move:

a) Ollie out of a transition or a lip or even off the ground if you got enough hops.

b) Grab the board and pull it away from your feet.

c) Slam the board into your nuts…well you don’t have to slam it.

d) Pull the board back and put it under your feet.

This is, of course, to be differentiated from sack tacs, sack tack, and sack taffy, all of which, while equally disturbing, are far less dangerous.

On YouTube, there are any number of entries glorifying sack tapping – it seems, mainly by teenage boys and the military.  In fact, there are more video posts by military personnel than by school boys.

Studies have shown that the average mental age of a sack tapper is usually between the ages of 6 and 8, unless they are a member of the armed forces.

In that cohort, the number is likely to be lower.

Click here to read about how stupid kids can be…

http://www.youtube.com/watch?v=TH_WoiIOX0k

Behaviour Clinic

By , June 10, 2010 2:02 pm

I sit here, wondering how it has got to this point.  Well, not so much wondering.  Just trying to meditate, to make peace with the universe, to understand, to somehow sympathise.  To circuit break.  But my blood just refuses to settle.  It spills out of me, invisible lava.  But in a far more controlled manor than Candace’s spit, which flicks from her bottom lip.

“It’s just not fair, you see,” she slurs, her cogitation slowing, the dopamine receptors blocking and unblocking in a clunky way, “and I think what you did was really not right.”

There you go.  There we have it.  She said it.  She managed to name it.

Welcome to Behaviour Clinic.

“What was it that you objected to most?” I say, as Declan swings upside down on his chair, his feet threatening to kick the X-ray box off the wall.

“He’s good at home.  He doesn’t have any of the problems like he’s having at school.”  I look again at Declan.  She doesn’t notice.

“Okay, Candace, but he had to be physically restrained.”

“That’s right, they were ganging up on him.”

“He had a knife, Candace.  Anyway…”

“…They were picking on him!”

“Yes.  Okay, that’s okay,” I say, my hands moving like a slow motion bongo drummer, “but we keep getting distracted.”  Declan kicks again at the lightbox.  I look at him.   He grins.  I dare.  He stops.  “I still don’t understand what it is that you object to about what I did?”

“I just don’t think it was right.”

“Which bit?”

“All of it.”
“I’m sorry Candace, you’re going to have to give me a little more specific than that…”

“…And then you talked to Robyn, which I never gave you permission.”

I pause, her non-sequitur speaking style making me dizzy.  I take another breath.

“She’s his worker.”

“I never gave you permission.”  Again, I pause.  Declan kicks the box.  I don’t even look.

“No, I guess you’re right.”  Declan somersaults back, bored by the lack of reaction, the chair falling as he does.  He jumps up and onto the bed, the sheet sliding to the floor, dirty shoe prints planted on white.  “But these appointments are often distracting,” I continue, “and I guess I assumed that – as his worker – you would be okay with that…”

“…And I just don’t think it’s right.  I think what you did is shit.”

I pause for a second and look at Declan.  This is the hard bit.  This is the really hard bit.  I’ve busted my arse for Declan.  I’ve had repeated conversations with his school, with his principal, who is also busting her arse.  She is currently trying to gain extra funding for Declan.  He is so disruptive at school that he needs one-on-one support.  But in the Government schools, this is a real battle.  Over the last few weeks, the principal has even started bringing her retired husband to sit with him.  To just be with him.  At our last appointment, Candace told me she was worried that Declan was going to give him a heart attack, and I don’t blame her.

Now that is commitment.  That is novel, and inventive, and committed.

“And the school has done nothing,” Candace chimes.

The kid is a mess.  He really is.  But it’s not his fault.  His mum has bipolar disorder.  She is on multiple psychotropic medications, which does few favours to her, and even fewer to her unborn infant – her fifth child to a third partner.  At least they don’t affect her fertility.

“And you’re doing nothing,” she adds, a piece of tooth-food landing on the edge of the desk.  “And I’ve been speaking to my lawyers about the whole thing.”

Okay, okay.  Like I said, this is the hard bit.  I do it to help the kids.  I really do.  But with this level of venom, a degeneration in a relationship that has gone this far, a threat of legal action, and I’m pulling the pin.  I’m here to help;  I’ve worked hard to help to this point.  But I’m not a punching bag.

“Look, Candace.  I have no problem – absolutely no problem,” I stress, the umpire hands again in action, “with you going and seeing someone else.  Of having a new Paediatrician.  I’m totally fine with that.”

She freezes.  Even Declan stops pumping up the blood pressure cuff for a moment.

“Oh, I didn’t mean that,” she says.  I can’t help but shake my head.

“Well, what am I meant to think, Candace?  You’re bringing in lawyers because I spoke to his worker.”

“I only spoke to one.”  That she’d seen advertised on daytime television.

I nod, and look at Declan again.  He smiles, and I feel it – a damaged, growing child trying to break out of his hell.  But my heckles are raised, I’m feeling the heat.  We’re done.

“Let’s just call it a day, Candace.  I don’t think we’re getting anywhere today.  Let’s just…”

“I only spoke to one!”

“I’ll call you in a few days.”

I open the door, and Candace looks stunned, muted, admonished.  I wonder how her addled brain will remember this interaction.

“Time to go, Declan.”  He bows his head, before jumping off the bed, his demeanour mirroring his mum’s, his feet making two more foot marks on the bedsheet next to the others.

“I’ll call you, Candace.”

“To say what?”  It’s the plea of a little girl, trying to understand what she’s done wrong.

“I’m not sure.”  I pause, waiting for something to come.  “I’m not sure.”

I shut the door, and hear the noise travel away, a gust of sounds that follows them always.  I look back down at the floor, at the impressions on the linen, like dance-step instructions;  an intro to break dancing.

Spud

By , June 2, 2010 7:05 am

I walk into the cubicle, with Ken in tow.  There I find an eight-year-old boy, hoeing into a packet of chips.

“Hey, Daniel.”

“Call me Spud,” he says, without looking up.

“Hey Spud.”

With that, he raises his head, and smiles from ear to ear.

“This is my Mum,” he says, gesturing across the cubicle.

“Hi Mum.”

Spud lets out a laugh.  “She’s not your Mum!  She’s my Mum!”

I look across at Mum.  She holds her head in her hand.  “He was sick when we brought him in here, I swear.”

“Hey, I believe you.  Kids turn around quickly,” I say.

I look around at the intern, who has been taking down everything I’ve said.  He looks confused.

“Kids turn around quickly?” he parrots.  I nod.  He scribbles some more.  It’s like owning a puppy that can write.

“These are admission notes, Ken.  You don’t have to write everything.  In fact, nothing that we’ve said yet should go in the notes.”  Ken looks deflated.  I look back at Daniel.  “In fact, just put the pen down, Ken.  I don’t even know that Spud is going to need admission.”

Spud lets out another little laugh, a delighted cry.   His Mum rests her head in her hand, shaking it some more.  Ken looks at me like I’ve scolded him.  It’s like the Charades Olympics.

“It’s okay, Ken,” I repeat.  “Let’s…just…listen.”  Reluctantly, he puts the pen on the bench.

I turn back to Daniel, just as he begins to pull the auroscope off the wall.

“So you weren’t crash hot this morning, Spud.”

“Nup.”

“What was going on?”

“Sore eyes.  Stiff neck.”  He fiddles with the expensive equipment, bouncing it up and down by the cord, oily finger marks trailing all over it.

“So I heard.  The emergency doctors were worried that you might have meningitis.”

“That’s what they said, yeah.”  He tires of the auroscope, letting it go by his side.  It springs back up like a bungy, hitting the wall, before bobbing up and down on its coil.  Its tip scratches the wall, making a sound out of a B-grade horror movie.  Ken looks frightened.

“Cool,” Daniel says.

I grab the auroscope, putting it back in its holder.  “Not that cool, mate.  Six hundred bucks cool if it’s broken.”

“I don’t care.”

“Sure you will.  Once mum pawns off your iPod, X-Box, Wii and PS3 to pay for it you will.”  He looks at me and frowns, stopping dead.  “That’s right.  All of them.  So let’s just settle down a bit, okay?”

I glance around the room.  Spud gives me his complete attention, his Mum has lifted her head out of her hand, and Ken now stands motionless.  We’ve gone from Charades to Statues.  Ken gives me one more pleading look.

“You can write if you need to, Ken.”  He smiles, picking up the pen, touching it quickly to the page.

“So Spud,” I continue, “the sore eyes and the stiff neck.  What happened?”

“Gone.”

“Headache?”

“Gone.”

“Problem with light in your eyes?”

“Nup.”

“Nausea?  Vomiting?  Lethargy?  Sore joints?”

“All gone,” says Mum.  Her head returns to its rightful place.

“So they all just kind of disappeared, hey?”

“Yup.”

“And no fever at any stage?”

“No.”

I shine a torch in Daniel’s eyes.  He doesn’t blink.  I stare at the back of his eyeball with the ophthalmoscope, the non-greasy companion-piece on the wall.   His eyes stay open.  I complete a neurological exam, testing his tone, power, reflexes and sensation.  Perfect.  I check his abdominal, respiratory and cardiovascular exam. Everything is completely normal.

Ken takes notes the whole time.

“There’s one more thing I want to do Spud.  I need to raise your leg while you lie still.”

“Yeah?  You really need to do that?”  He looks genuinely excited.

“I do, yes,” I say, a little confused.

“Then watch this.”

With that, Spud takes his leg, holding it at the ankle.  He takes it in a grip that looks odd, initially.  It begins to make more sense when he takes his leg and places it over his head.

“Is that what you wanted me to do?” he asks, a little breathless.

“Well, not exactly, Spud…”

“…What, you need it to go further?”

“No!” I yell, worried about what comes next.  “No, I was not going to take your leg and put it over your head.  I just wanted to lift it up off the bed a little bit.

“Oh,” he says, disappointedly.

“Did you know he could do that?” I ask Mum.  She shakes her head some more.

“Well it’s not meningitis,” I say.

“Are you sure?” asks his Mum.

“That last test is normally called the ‘Straight Leg Raise’, or – in Spud’s case – the ‘Over the Head Raise’.  It puts a stretch on the lining around your spine, the meninges.  With meningitis, raising the leg causes a lot of pain, as it puts pressure on the meninges.   The fact that Spud can stick his leg over his ear gives me a fair indication that he doesn’t have meningitis.  In fact, it gives me a fair indication that you’re somewhat of a freak, Spud.”

The Straight Leg Raise

Spud's Leg Over the Head Raise

Spud slaps his thigh like a good ol’ boy.  I just which he had a piece of wheat between his teeth.

“So I think you’re okay, partner.  You haven’t got meningitis, and you are free to join the circus.”  He laughs again.

“So why the headache?” Mum asks

I look at Ken.  He looks at me with fear, before returning to the safety of his page.

“Don’t know,” I say shaking my head.  “Headaches come and go.  Maybe it was a first-presentation migraine.  Maybe just a bad headache.  I’m not sure.  But what I am sure is that it’s not meningitis.  I’d suggest going home and having a good rest, Spud.  And try to keep your legs in front of your head, at least for today.”

“Sure,” he says, taking my hand in a shake.

“Thank you, Doctor,” says his Mum.

“Pleasure.”  I look down at the cheeky cowboy on the bed, the one who almost tore the equipment apart, until I threatened to confiscate his electronic pacifiers.  After that, he turned into a real character.  A real little lad.

“See you Spud.  It’s been a pleasure.”  He slaps me on the back, and winks at me.

“Pleasure was all mine, doc.”

I frown, looking at his mother.  She laughs.

“Just one more question for you Daniel.  Why do they call you Spud?”

“We live on a bit of property,” Mum says, interjecting, “and Daniel has always been interested in growing things.  So we got an empty wine barrel, cut it in half, and filled it with soil.  And Daniel grows potatoes in it.”

“I love potatoes,” he says shaking the chip wrapper like a talisman.

I pause for a second.

“What were you doing this morning?”

“Tending the spuds.”

“You do it every morning?”

“Most mornings,” he says.

“Do you use fertiliser?”

“Of course, man,” he says, “Dynamic Lifter.”

“And you used that this morning?”

“Yep.”

“How much?”  He looks back at me with confusion.  “How big is the packet?”

“Well, it was pretty big, I guess.”

“It was?” asks his Mum.

“You used the whole packet?”  He looks off to the side.  It’s the first time I’ve seen him look anything but confident.  “How long after you poured the whole pack of Dynamic Lifter over your barrel did you start to get sore eyes and a headache?”  He furrows his brow some more, before grinning sheepishly.   He raises his arms in a shrug.

“At least the spuds will grow though,” he says, finally.

Mum’s head returns to her hand.  Spud laughs.  I leave. Ken continues standing there, writing something.

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