Clinical Narrative

Did you hear any zebras in there?

“Every child you encounter is a divine appointment.” – Wess Stafford

I made a new friend today. He was sitting on the floor organizing puzzle pieces. I took a seat beside him to take in his perspective. It had been awhile since I joined a patient on this level, but it set the tone of our relationship immediately.

I made a new friend who was excited to share with me. He looked over at me and asked if I wanted to help him sort. “It’s more fun down here, isn’t it? I can teach you where these go,” he offered.

I made a new friend whose favorite things about himself are his freckles, despite what the kids at school say about them. He winked at his mom as we continued to sort the puzzle pieces. “I think your best thing is your smile. It is almost like my mom’s!” he remarked.

I made a new friend who is stronger than most adults I have met. He pointed at a puzzle piece and told me that he has “been sick since he was as tiny as this puzzle piece.”

I realized my new friend just wanted someone to include him in his case. As he recounted his story with vigor, he nodded toward his mother and critiqued, “Usually people like you only want to know what she has to say.”

My new friend showed me the scar on his head and the one across his chest. “I am proud of them,” he stated. “Mom told me I am the superstar of the family… but I think she does more than I do.” He shrugged.

I made a new friend who saw me as an ally. I was amazed at how quickly he trusted me; after all of the doctors he had met before me. “I am not afraid of you,” he said. “Mom says that you want to help me feel better, and mom is always right.”

My new friend had many questions and I did my best to explain why we were meeting. He looked at me with trusting brown eyes and asked, “So are you going to listen to my insides with your special headphones?” I nodded and he held his shirt up for me.

I made a new friend who found humor in a hard situation. “Did you hear any zebras in there?” His eyes were wide with excitement as I put my stethoscope back around my neck.

My new friend challenged me to adapt my exam routine and inspired me to work on my creativity. I let him try my “headphones” out on me. “I think you have some monkeys in you! Let’s see what mom has!” he cheered.

I made a new friend whose heartbeat was weak, but whose heart was full of kindness. As he held the bottle of gummy vitamins above his head, he exclaimed, “These are way cooler than the pills my mom tries to hide in my applesauce! I am going to make you my favorite snack sometime. I won’t put anything bad in it, don’t worry.”

When it was time to say goodbye to my new friend, he gave me a big squeeze and told me he thought we would be good friends. “Next time I will feed the zebras before we come so you can hear them better!”

Featured image:
zebra by SigNote Cloud

Clinical General Opinion Reflection

One Size Does Not Fit All

I recall being fresh out of my first year of medical school and ecstatic to be spending my break not in a class room, but at an actual pediatric oncology unit. The night prior to my first day in clinic, I spent time reviewing immunology and looking ahead at the oncology lectures from the Clinical Medicine class I would take the next year in school. I wanted to be prepared in front of my new mentor.

The next morning, I hardly had time to impress my preceptor let alone introduce myself before we were running around. We stopped at the pathology lab. I gazed through the microscope, trying to remember what I had read the night before about identifying abnormal cells.

“I have a new patient that arrived today. She is very sick. We have to tell the family the definitive diagnosis. Come with me.”

We urgently walked up to the inpatient floor into one of the rooms. A beautiful young girl was sleeping in the bed. Her parents and grandma were diligently by her side. They froze and looked at the doctor. This was the final confirmation they had been waiting for. They held onto the hope that they had been sent to the oncology floor by mistake.

“We have confirmed that your child has a rare cancer.”

4729016997_bc4ec39867_bI watched as any sliver of hope vanished from their eyes. They would not wake up from this nightmare. The moment my mentor delivered the diagnosis, I could feel the world take a 180 eighty degree turn for this family. It was as if their world froze at that moment. How could this be? The child looked so peaceful, fast asleep while hospital monitors blinked around her. Just a week ago, they were running around to sports practices and dentist appointments and going through the everyday motions that we consider to make up a normal life. I’m not even sure that this family was breathing at this moment. The room became deafening silent as all the color drained from their faces. The doctor proceeded to talk about what would happen in the days to come. What did this mean for their child?

Just when the family (and I) didn’t think it could get worse, they were told about the side effects of the medications – the only option to treat their child’s condition. The doctor began with the common side effects like nausea, vomiting, hair loss. Next, cardiomyopathies. Neuropathy. Loss of reproductive function. This is when this family broke. Loss of reproductive function. I always thought the diagnosis would be the hardest thing to hear. For them, the breaking point was learning of the adverse effects of the very medications intended to save the child’s life. These medications are meant to represent hope, protection, and reassurance for a life beyond disease. The doctor paused again, giving this family time to just cry. Tissues went around.

“This is hard. Take your time. I am here for you throughout this entire journey.”

I watched the mother of this little girl look at her own mother. It was a look of despair, yearning for answers that wouldn’t come. Even if her child survives, bits of the future have already been stolen. We left the room after two hours to let the family have time to process.

Outside of the room, I tried to process what I had experienced. The information I read in my textbooks and PowerPoints did not prepare me for that interaction. I looked at my preceptor for guidance.

“This is real. This is hard. We will fight with them, though. We do everything in our power not only to treat the cancer, but to make sure that cancer does not define their life. This is what we do.”

Throughout the rest of my summer, I went on a roller coaster from new diagnoses to the “completion of chemo party”, from being declared cured after a 5-year visit with no evidence of disease to the tragic death of a child. I watched children balancing school with chemo. I watched teenagers struggle with fear and bravery while grasping at any chance to maintain their independence. I watched parents struggle to care for a sick child while still being present for the other children they left at home. The things I learned that summer could not have been taught in a classroom. With every family I met from all over the world, I witnessed raw and vibrant emotions: fear, determination, sadness, and never ending hope, even in the wake of death. It is this hope that I take with me. It is contagious. These are the emotions that makes us human.

At one point during the summer, I asked my mentor what the secret was to enduring such difficult clinical conditions. I had watched him interact with all of his patients each day. Every single one loved him. The mother of that little girl later told me how he was able to comfort them, cry with them, joke with them, and laugh with them with such ease. He was able to guide them through this journey, with the help of hospital resources, to give them a life within this new normal. In response, he said:

“There is no such thing as being the best doctor in the world. You have to be the best doctor in the world for the patient sitting in front of you. That is my first priority, more than my research or my teaching. Get to know you patients and their families. Learn from their stories. Keep fighting to improve. That is how you become the best.”

3377110664_c71de81ebc_zSo much of early medical education involves pouring over books and PowerPoints, trying to memorize as many details as possible. It is important to have that foundation of knowledge, but what I have come to realize is that there are rarely pure “textbook cases” because so much more goes into caring for a patient. One size does not fit all in medicine. This experience brought back the humanity of medicine. I witnessed how knowing and understanding patients enables a physician to be an advocate for their patients, a role I consider to be the most important of the many roles a physician takes. I can never come close to knowing exactly what these families are going through. I also can’t thank them enough for allowing me to be present during their most vulnerable moments, for taking time to talk with me for a brief period to get a glimpse of their journey. Ultimately, this experience was a reminder that the art of medicine can’t be discovered in textbooks. It is learned from our patients and the uniqueness that their individual journeys bring to each patient encounter.


Featured Image

Lou Bueno
Alice Popkorn