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Stumbling Into a Diagnosis

August 11, 2018

Written by Clay Smith

I Think She Has Cancer

It had been a rough day in the Pediatric ED.  Some sick kids.  Most not sick.  But the worst part was my own clumsiness seemed to be in full flower that day.  I forgot my wallet in my car and had to go back and get it.  I lost my pen.  Then I rammed my knee into the support beam under my desk, barely stifling the first words that came to mind.  (My colleagues at Vanderbilt can share my pain.)  I come from a long line of clumsy people.  My grandpa was legendary.  His crowning moment was the day he fell crashing from the attic into his living room. That kind of thing was a regular occurrence growing up. Thankfully this autosomal dominant trait has variable penetrance.

As I was still cursing the divider under my desk for being strategically placed to stun and disable unsuspecting physicians, the resident came up with a serious look on her face to present a new patient.  She began the presentation with, “I think he has cancer.”  It was a 9 year old boy with significant weight loss for a month who looked terrible.  There were a few other red flags in the history as well that made me worry this resident was right.  We came up with a plan to get screening labs, and complimented ourselves on thinking to add a uric acid and LDH.  Clever us!  I had a bad feeling about this case.  I hate new cancer diagnoses.  With a sense of dread, I braced myself as I went into the room.

Stumbling Into the Diagnosis

Yep.  He looked bad… emaciated…had to be cancer.  I examined him and my hopes dimmed further.  He had a few bruises, some cervical adenopathy.  Not good.  I was slow-rolling my exam to think of what I was going to tell the family.  I leisurely ambled to the head of the bed to grab the otoscope, lost in thought, when I kicked over his water bottle.  It was metal and clanked across the floor, scaring us all half to death.  Nice…real professional, Clay…dropkicking a child’s water bottle across the room.  Would my grandpa’s curse not leave me today?  I scurried after his skidding water bottle, profusely apologizing.  I finished examining him and was preparing my speech that I had some concerns and we needed to do some more tests when his father interrupted me.

“You know, when you kicked over his water bottle, it reminded me.  He can’t seem to get enough to drink.  We told him he had to put that bottle on the floor when the doctor came in or he would have had it in his hand drinking it.”

I stood there in stunned silence feeling like an idiot.  He had been losing weight.  He looked terrible and emaciated.  And now I learned he had been guzzling water like there was no tomorrow.

He had new-onset type 1 diabetes.  I had literally stumbled into the diagnosis.

Disclaimer: This is a true story. Precise details have been changed to maintain confidentiality. Whether I hit my knee on that shift may or may not be true but is highly likely.

What are your thoughts?