PICU Doctor in the Family

Abstract

PICU Doctor in the Family Alexander A. Kon Part 1: The Call Twenty years ago, when I was a fellow in pediatric critical care medicine, I got a call from my brother. It was one of those calls you never want to get, and a call I'm sure my brother never imagined he would make. His school–aged daughter, who was bright, beautiful, and always completely healthy had started having seizures. Her absence seizures had started a few weeks back, and they were getting more frequent. My brother had taken her to see her pediatrician, and she prescribed some anti–seizure medication and wanted a follow–up appointment in a few months. My brother was concerned that it could be something more serious, and he worried that starting medication and waiting to see what happened might not be best for his little girl. He was right. Pediatric intensive care unit (PICU) physicians are trained to hope for the best but prepare for the worst. There is an old saying in medicine: "When you hear hoof–beats, think horses not zebras." In the PICU, when we hear hoof–beats, we think: "Well, it's most likely horses, but what if it is actually a herd of elephants wearing horseshoes just to throw us off?" Yeah, her seizures might be just new–onset idiopathic seizures, that's very possible. But what if it's not? What if it's something bad, something really bad? As PICU physician, my thoughts went wild. All of the possibilities, and none of them good. I was not comfortable with the "wait and see" approach. I had done my pediatrics residency at a great institution near where my brother lived, so I [End Page 16] offered to call the child epileptologist there to discuss her case with him and hopefully get her in to see him, and get an MRI, soon. My brother agreed, and was extremely thankful for the help and support. I called the epileptologist with whom I had worked during residency, told him the story, and asked if he would be willing to see her right away. He agreed, and got her into his clinic that week. He ordered an MRI, and, as we had all feared, they found a tumor. Wow. She was seen by the pediatric neurosurgeon, and scheduled for surgery right away. It was just a few weeks from the time my brother called me to the surgery date. If her uncle weren't a doctor, if her father hadn't made that call, if her uncle hadn't had connections with the child neurologists close by, if her parents had accepted her pediatrician's advice to wait and see what happens in a few months . . . the tumor would have been bigger, maybe much bigger. Her seizures would likely have gotten worse. The surgery would have been more complicated. Her prognosis would have been worse. She might have sustained permanent brain damage. She might have died. I hated the fact that my niece had a brain tumor. I hated that she needed brain surgery. I hated that she would have to endure pain, suffering, and fear. I hated that my brother and sister–in–law were terrified. I hated that my mother was petrified. I hated that my wonderful niece might never be the same. In spite of all those very negative feelings, I also felt great that I was able to get her the workup and care she needed so quickly. In that respect, she was very lucky, and I was glad that I could help. It is sad, though, that so many children don't get that kind of workup and care from experts so quickly. I have seen many children in the PICU whose diagnosis was delayed due to the "wait and see" approach, and too many who now live with lifelong problems that might have been avoided by rapid testing and treatment. That makes me very sad indeed. Part 2: The surgery Naturally, my family was very worried about the surgery. Great hospital, great neurosurgeon, great operating room (OR) team, but having someone cut into your child's brain is always scary. My brother asked if...