Pediatric Medical Case

Saturday, April 09, 2005

CASES
In a Pile of Papers, the Ghost of a Once-Healthy Child
By PERRI KLASS, M.D.

I was about to go on vacation, so I was winnowing my guilty pile of patient follow-up papers, trying to act on anything that looked time-sensitive, when I came across a printout, a lab test result, and found myself wondering why this was even in my pile: a completely normal blood count on a 2-year-old from months and months ago.

This wasn’t a child who needed to start taking iron drops; all the indices were normal, reflecting a proper number of normally sized and pigmented red blood cells. I couldn’t have kept the paper on my desk to remind me to talk to a hematologist because nothing looked out of whack. The numbers would have long ago been entered automatically into the computerized record. Why had I held on to the paper backup record? Was this my clumsy way of reminding myself that this child needed follow-up for some other reason? His name rang no particular bell; common first name, common surname. I looked at his blood count irritably – what did I need with normal test results? But I clicked my way into the medical record and clicked in his number, and waited for his chart to appear on the screen.

In the microseconds while the computer called him up, I remembered who he was: he was the 2-year-old who had died in a house fire, the 2-year-old whose family had awakened smelling smoke, whose father had grabbed him up and leaped with him out of an upper-story window.

The father was injured, the son was killed in the fall. Other children in the family were badly hurt by smoke inhalation. And only a day or two before all this happened, my 2-year-old patient had come to see me for a checkup, and as part of the checkup, I had sent him to have his blood drawn.

By the time the official printout came into my box, the child was dead, and I hadn’t known what to do with the piece of paper. I should have initialed it and dropped it into the medical records box for filing. But I couldn’t sign off on it. It was like holding on to one last tiny thread linking me to the vigorous 2-year-old who had let me listen to his heart and lungs and then protested loudly when I tried to look into his ears, who had looked at me with profound suspicion from the safety of his father’s arms the 2-year-old whose suspicions I had, of course, then justified completely by sending him off to the lab to have his blood drawn.

I had done the test because this was a child who had in the past been quite anemic. At his 18-month visit, I had checked his hematocrit, a simpler, cheaper test requiring less blood, and a routine test for children this age. Children are particularly vulnerable to iron-deficiency anemia from just before their first birthday to the age of 2 or 3, especially those who are still getting much of their protein and other nutrition from milk.

So we check the blood count at 9 months and at 18 months, and when it’s low, I start the children on iron drops and talk to the parents about adding iron-rich foods to the child’s diet. I say, "Start the children on iron drops," as if it were no sooner said than done. The fact is, it’s a rare child who likes the taste of any of the available iron preparations, and a rare parent who is up to what is supposed to be a dosing schedule of two or three times a day. And just to make the whole thing more appealing, many children get constipation from the iron supplements.

So I calculate the iron doses carefully, and I write the prescriptions, and I know that many parents try their best, but often the child comes back for the next visit and the hematocrit hasn’t budged and the parent admits, sheepishly, that the iron has not been a regular daily feature.

But not this child. His father had told me proudly at the checkup that he had given the iron drops faithfully, day in and day out. That he had decreased the number of daily milk bottles, and started letting the boy feed himself a variety of table foods. And so I sent him off for the more complete blood test, thinking that he had now had a fair trial of iron, and I wanted to see what his hematologic indices looked like.

They looked terrific. The iron drops and the changed diet had worked. He was no longer anemic. A tiny everyday pediatric victory, a small step for parental commitment and consistency. The only thing was, by the time I got those encouraging lab results, the child was dead.

I held on to the lab results – and I’m still holding on to them because I couldn’t bear to let them go. I guess they said something to me about the daily work and trouble of being a parent, of tending a 2-year-old, about the ways that love translates itself into detail and caretaking. Or maybe they said something about the twists and ironies of life – that the worries that preoccupy you are not necessarily the dangers that are actually lying in wait, or about the strange juxtapositions of parental power and parental powerlessness.

I thought about that bitter medical student joke, the "Harvard death," in which all the lab results are perfect, all the electrolytes and body chemistry numbers "in the boxes" – as the patient dies.

But mostly, I suppose, I held onto those lab results because right after the child died, when I could still remember so clearly his healthy 2-year-old vigor in my exam room, I didn’t want to see this last tiny medical link disappear.

So I put the paper on my pile, and then months went by, and more children passed through the exam room, and my memories faded, and whatever faint link I might have claimed faded, so much so that I blanked when I looked at the lab sheet and initially couldn’t even remember the story that went with it.

He was a little boy who drank too much milk and developed iron deficiency anemia, and his parents treated him and he got better. They tended him and protected him because that is what parents do – that is what I am supposed to help parents do.

We all did our jobs, including the 2-year-old, who ate his iron-fortified cereals and his spinach, swallowed his iron drops and protesting, yielded up a little blood for us to test. But by the time I got my piece of paper, the story was over.

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