BMJ  2003;327:817 (4 October), doi:10.1136/bmj.327.7418.817

reviews

PERSONAL VIEW

A tight squeeze

Although most pathology in paediatrics is psychosocial, once in a while a constellation of clinical signs triggers a dim recollection of something learned long ago. Staring through the glass darkly, you suddenly see the light.

It was a slow afternoon on a brilliant summer day. A father walked in with his four year old son for an appointment. The only problem was that he had come to the wrong place. Although the boy was our patient, his mother had made an appointment for his physical examination elsewhere, as he needed a physical before starting kindergarten and we couldn't fit him in before then. The office manager said we could squeeze the boy in, and so it was that I saw him after all.

Our newest and youngest medical assistant took his vital signs and escorted him and his father to an examination room. I recognised the name when I saw the chart. A bit of a tragic situation: the boy and his elder brother had both shown severe behavioural problems at young ages. Autism had been diagnosed in the elder boy, and I suspected that his brother fell somewhere along the autistic spectrum as well.

"Is your cuff on its last legs, Doc?" the father asked, with a concerned smile

"How have you been?" I greeted the father. "Haven't seen you in a while."

"That's a good thing," he smiled. "The boys have had a stretch of good health these past few months."

I glanced at the chart. "Ricky's here for a physical today. Looks like he'll be starting kindergarten this year."

"Yeah, finally. Hard to believe, with all we've been through."

I thought of the extensive developmental evaluations, the trials of drugs to control Ricky's violent behaviour (which sometimes resulted in self mutilation), the heartbreak of knowing something was very wrong, yet not knowing why, and then the heartbreak of finally knowing why.

I looked quickly over the data on the examination form but stopped short when I saw the blood pressure: 140/90 mm Hg, borderline hypertension for an adult, let alone a four year old child. Perhaps the assistant got it wrong, I thought. She was just starting out after completing her internship. I decided to check Ricky's blood pressure. I wrapped the paediatric cuff around his right arm. "There we go," I said, "a little bit of a tight squeeze, then we'll let it go again."

I popped the stethoscope into my ears, inflated the cuff past 160, opened the valve, and watched the needle sweep back across the face of the dial. At 136 the first Korotkoff sounds surged in my ears, then muffled at 84.

"Let's try that again," I said. I repeated the process, but the result was the same.

"Is your cuff on its last legs, Doc?" the father asked, with a concerned smile.

"Maybe," I smiled back. "Let's check the other arm."

This time I had to listen intently to pick up the first distant sounds at 100. I pumped up the cuff again, just to make sure. Something stirred in the back of my brain.

"Let's have you lie down on the table."

My fingers fumbled at the waistband of Ricky's underwear then rolled over the femoral canals. Two times, three times I moved my fingers. I could barely detect the femoral pulses. I checked the radial pulses. Sure enough, there was a marked difference: the left was diminished.

I straightened up and pulled the stethoscope from my neck. "There's a definite difference between the arms, and I can barely feel the pulses in his groin."

The father quietly searched my eyes. I noted the slight shoulder shrug. "So, what's up? Could it be something to do with his growth? He's grown a lot this past year."

"I think Ricky needs to see a heart doctor. He may have a narrowed segment in his aorta."

"Is his heart OK?"

"Near as I can tell. But we really need to have a better look at his aorta. The heart doctor can do that with ultrasound."

"How do they fix something like that?"

I cleared my throat. "Surgery, usually. They have to take out the defective section, then sew the ends back together."

"So we're talking open heart?"

"Not exactly. But they would have to open the chest, yes."

A stillness descended on the room. Neither of us spoke. I knew the father was beginning to fall apart inside. Ten minutes ago Ricky was a healthy child who hadn't been ill for months. Now he had a coarctation of the aorta and would probably need major surgery.

Once I would have been ecstatic in diagnosing such a condition. My colleagues would have clapped me on the shoulder. "Nice pick up!" they would've said. Some might have turned away, jealous at not having had the chance to step briefly into the limelight.

But now, after 24 years of practice, having raised four children of my own, I know that in paediatrics every diagnostic coup translates into a potential tragedy for a parent. Instead of that surge of pride I feel something I can't quite put my finger on—call it humility perhaps. Or call it grace.

---

Tariffville, Connecticut, USA btmaurer1{at}comcast.net

CiteULike    Complore    Connotea    Del.icio.us    Digg    Reddit    Technorati    What's this?

Rapid Responses:

Read all Rapid Responses

Sobering thought

Anna Turnbull
bmj.com, 4 Oct 2003 [Full text]