I know I just wrote an entire post pretty much criticizing my time on the pediatrics floor, but there is one case the will stick with me.
There was a patient who my service inherited from one of the other pediatrics services because the attending on my team was willing to take on this very difficult patient. Ms. M turned out to be a patient that I had seen around the floor on numerous occasions. I always wondered what was wrong with her because the poor girl was always crying and seeming to be in severe pain while walking around the floor. She looked to be about 12, always was hunched over, face contorted in pain, wailing or, on a good day, snuffling as she walked past with a feeding tube dangling from her nose. While working on the floor, I could hear wailing coming from her room on a regular basis.
When my team picked her up as a patient, I was curious to find out what was making this little girl so sick.... Turns out she wasn't a little girl. She was actually 17, looked 12 and acted 3. She had major depressive disorder, severe fear of abandonment and anorexia nervosa as a result. Ms. M was being force-fed through the feeding tube to keep her alive. She would periodically vomit up her feeds due to emotional distress. Her parents would string her along about visiting and then not visit for days on end adding to her fragile psychologic state. When her parents finally did show up the first week we had her, they asked if they could just take her home to let her die. Needless to say, they were sharply reprimanded for that statement by the senior medical staff. Unfortunatley, they had said it to Ms. M as well, which caused two days of the worst wailing and crying I have ever heard -- it was horrible to bear.
I always tell people that there are cases you come across that bring home the severity of a disease for you. Those are the cases that make you respect a disease entity. A prime example is Asthma. So many people have "asthma" (there is a theory, actually, that many who are diagnosed with asthma may not actually have it). There is so much mild asthma out there that it can be easy to brush it off as "not that bad." After seeing my first case of truly life-threatening Asthma, I will never underestimate the disease again.
For me, Ms. M is my bar -- my disease-defining entity for anorexia. To say I was shocked when I learned that she was 17 is an understatement. To watch her suffer with the psychiatric burden to the point that her parents were willing to let her die to relieve her suffering was jaw-dropping. Not only were those things amazing to me -- but to watch how a firm hand, a set of rules, absolute 100% structure could turn a patient around was one of the most interesting things I watched on Pediatrics.
Immediately after the "can't you let our daughter die" conversation, the attending on our team decided to structure absolutely every aspect of M's life -- including demanding and holding her parents to a daily visiting schedule with set arrival and departure times. She had a daily schedule posted in her room with shower time, school, nap, everything written in. She had rules about where she was allowed to do what -- she had to vomit in the bathroom, she was not allowed to have the vomit basin in her bed. There was much more the the elaborate plan, and somehow it worked. I returned from a weekend off to discover that M was eating of her own accord. Another week later, she was smiling as she walked the halls. Another week after that and she had befriended one of the much younger patients and we would seem them laughing as they walked. It was a different person from the one who had caught my eye my first days on the ward.
She has been transferred to a long-term psychiatric care facility specializing in adolescent eating disorders. I hope they can continue the work that was begun in the Children's Hospital and that someday Ms. M can go home to her family.