Index of Suspicion

9 year old with fever. 9? Why do you bring a 9 year old to the Emergency Department with a cold? A 9 month old maybe, but 11 hours into a 15 hour moonlighting shift, I had no patientce for a 9 year old. Since I had finished residency and could see patients independently, I was working "non-acute," a small offshoot of the main ED where those judged not in need of significant intervention were seen. All day it had been a steady stream of upper respiratory infections for which I could offer nothing but symptomatic care with the occasional strep throat.

I went in to see my patient, who had been waiting several hours already. They were Haitian immigrants, son's English better than mom's. I went through the standard questions: fever was 101.5, not dangerously high, he complained of mouth pain but was able to eat and drink, a sibling was also ill at home. For some reason this was the 3rd time she had sought medical attention for him, convinced something was wrong.

I started through my quick exam. He was well hydrated, but had ulcers on his gums, unusual but not unheard of. His throat looked fine his lungs were clear. I put my stethoscope to his chest quickly, just to be complete. He had a murmur, a LOUD murmur, and was tachycardic. Hmm, I thought, that's unusual, given he didn't look dehydrated.

Between mom's conviction something was wrong, the oral ulcers and the murmur, something struck me as not quite right. I figured 90% chance he was fine, just a kid with a virus, but decided to check a CBC (complete blood count) and electrolytes just to make sure. I drew the blood and sent it off to the lab, then went back to all the viral infections and strep throats who were waiting.

30 minutes later a nurse from the acute side pulled me out of a room "the lab just called, Patient X has a hematocrit of 19 (just about 1/2 of normal), were you expecting that."

My heart sank, "What was the white count?" I asked.

"Not back yet, I'll let you know" she replied.

But I already knew the diagnosis. Sure enought 5 minutes later I got paged by the lab with the news: the white blood cell count was almost 100,000, more than 10 times normal and most were an immature form of cells called blasts that don't normally appear in peripheral blood.

He had leukemia

My remaining 3 hours flew by as I called the onc fellow who came in, at 10PM on a Sunday, to see the patient, broke the news to the patient and mother, put in IVs, drew a million labs and signed him out to the onc resident.

I got an e-mail the next day from the ED attending, congratulating me for picking this up and pointing out I could have saved the patients life (the leukemic cells packing his bone marrow crowd out everything els,e leaving him deficient in normal white blood cells, despite his high total number, and susceptible to overwhelming infection).

I wish I could say I was smart enough to have figured it all out in advance, that I knew what I was looking for. In retrospect, the ulcers were a sign of neutropenia, the murmur his heart beating harder and harder to keep up with the decreased number of red cells. But I can't, I wasn't that smart. I was just smart enough to realize something might not be right and look a bit harder.

A priori, I would have thought this experience would have reassured me about my clinical abilities. I had picked the needle (leukemia) out of the proverbial haystack (fundametally healthy kids with minor illnesses). Instead, it terrified me. How close I had come to reassuring the mom and sending the kid home. I became increasingly, painstakingly thorough with my histories and physicals, like being a 2nd year medical student all over again. Of course after a couple weeks that faded too and I was back to churning through patients

Follow up: He did well, achieving remission with standard doses of chemotherapy and was still doing in remission last time I checked.