Pediatrics and theatrics

Howard Fischer
Uppsala, Sweden

 

Doctors in a hospital cafeteria after time on the ward
Chicago, Illinois. Provident Hospital. Doctors and interns in the cafeteria. Photo by Jack Delano. 1942. Library of Congress Prints and Photographs Division 

1. Initiation.

I had had a busy night on call in the city’s largest women’s hospital. I was a second-year pediatric resident assigned to the Neonatal Intensive Care Unit. My pager went off while I was in the hospital cafeteria. I called the unit, and one of the fellows told me that if I wanted to take care of a pair of “Siamese [conjoined] twins” I needed to come to the unit now. I arrived in a hurry.

The head nurse asked me if I was the one who was going to take care of the twins. When I said yes, she pointed to a bed under a radiant warmer with two babies, back-to back in it. I washed my hands and forearms, put on a clean gown, and went to look at my patients. Two good-sized babies were lying under the warmer, looking comfortable and well. A quick auscultation of two sets of lungs and two hearts assured me that nothing worrisome was happening. Now, it was time to see where they were joined. The babies were back-to-back, covered in vernix, with one diaper covering their two bottoms.

Starting at the shoulders, I proceeded caudally, separating them to find the site of connection. They were easy to separate. When I finished this maneuver, there were two separate infants. “What the hell!” I yelled. The whole unit, that is, nurses, fellows, and residents burst into laughter and so did I. It had been a very well-planned and executed joke. Everyone was in on it, and no one gave it away prematurely.

 

2. Information

It is astonishing with how little reading a doctor can practise medicine, but it is not astonishing how badly he may do it.

—William Osler, 1901

Around 1990 I was the attending physician on a general pediatric ward in an academic children’s hospital. When I arrived for rounds, a resident informed me that a child had been admitted with possible Kawasaki disease.

Also called mucocutaneous lymph node syndrome, Kawasaki disease was a multisystem disease, a vasculitis of unknown origin that sometimes involved the coronary arteries. It was named after Dr. Tomisaku Kawasaki, who reported the first cases in 1967 in Japan. In 1974 the first patient diagnosed in our city was diagnosed by an astute pediatrician in private practice. It was also the year that Kawasaki disease was described in the English language literature.

The residents, medical students, and I discussed Kawasaki disease and its treatment (intravenous immunoglobulin to prevent coronary artery lesions). The child’s pediatrician arrived. “I hear I’ve got a kid with Kawasaki disease,” he said. “I looked in my pediatric textbook and there was nothing about it.” This was, of course, the pre-internet era.

How old, I wondered, is the doctor’s textbook that does not mention a disease that has been described and known for the past twenty years? A resident gave him a copy of a review article that she had found during her night on call.

I wondered about one more thing: Could the doctor’s textbook have been older than the youngest medical student on my ward team?

 

3. Interpretation

Grand rounds at our hospital were often a virtuoso performance. Usually the professor was presented with the details of a patient’s problem and was permitted to ask questions about the history, physical examination, and other diagnostic test findings. She then had to discuss the case and propose a diagnosis. The audience, consisting of scientists, physicians, nurses, and medical students filled the auditorium.

In the course of her discussion, she mentioned histoplasmosis, a disease caused by the fungus Histoplasma. This fungus is found in bird and bat droppings, which she summarized as follows: “Histoplasma is found in bird and bat droppings, which is called guano, or guava—I can never keep them straight.”

By the end of the hour she had correctly diagnosed the patient’s problem, which had nothing to do with Histoplasma.

Later that day, knowing her healthy sense of humor, I emailed her: “Renée (not her real name), if you don’t know the difference between guano and guava, I’ll never send you shopping for me.”

She found it hilarious.

 


 

HOWARD FISCHER, MD, was a professor of pediatrics at Wayne State University School of Medicine, Detroit, Michigan.

 

Summer 2021  |  Sections  |  Education