Dr. Andy

Reflections on medicine and biology among other things

Sunday, March 12, 2006

Two girls named Sam

This week's grand rounds at Geek Nurse will feature a "glass half-full/glass half-empty" theme. I don't generally try to post to conform to specific criteria, but I've been mulling over this post for some time.

The first Sam came to me while I was still in Boston. She had egg allergy. On her first bite of scrambled eggs at age 2 she had gotten classic symptoms of anaphylaxis: hives, swelling and shortness of breath. Her pediatrician had gotten the labs to prove that it was egg, prescribed an Epi-pen and told her parents to have her see an allergist. Her parents brought her all the way from New Hampshire. She was precocious, although I soon learned that some of that was that she was extremely small for her age, well under the 3rd percentile for both height and weight. Otherwise everything was straightforward.

I asked about her size, but the parents assured me neither they or her pediatrician were worried. As a specialist, you always face the question of how much to just focus on your area (her egg allergy) and how much to worry about other problems. With Sam apparently healthy and thriving, albeit small, and both parents and pediatrician seemingly on the ball and unconcerned, I figured there wasn't much to add.

I saw her several more times, before the parents told me they were moving back to Tennesee, where they were from. Two weeks after they moved I got a tearful call from the mother. Sam had been diagnosed with cystic fibrosis. Their new pediatrician was worried about her size and checked a sweat test, standard protocol for failure-to-thrive. Ouch. Massachusetts screens newborns for CF, so most kids I saw had already been screened; of course Sam wasn't from Massachusetts.

I still think about Sam frequently, still kick myself for not picking up her CF. From then on, I vowed I would do what I thought best for my patients, even if it meant stepping on a pediatrican's toes. Luckily, Sam saw a better doctor than me before any serious damage occurred.

The second Sam is the worst asthmatic I follow here in Pittsburgh. I first met her when she was 18 months and intubated in the ICU secondary to a horrible asthma exacerbation. She had coded in a small ER in a small town way north of Pittsburgh and been life-flighted in. They lived on a farm, far from good medical care.

She was lucky, the outside ED doc had intubated her quickly, she had avoided prolonged hypoxia and fully recovered. I saw her and started her on an aggressive regimen to control her asthma, but it didn't help much. She had two more hospitalizations that winter along with a couple more courses of oral steroids. 98% of asthmatics I can make better, if they take their medicines; Sam I couldn't. I tried treating her for gastroesophageal reflux, looked for sinustis, even though she was young but couldn't find anything. I sent her to pulmonary for a sort of "second opinion" but they didn't have any brilliant ideas, either. Sam's mom would call me when she was sick to get advice, and we'd discuss if she just needed to see the pediatrician or go to the hospital or even come straight to Pittsburgh. I was afraid she might have another horrible attack and die.

The parent's best friend was a chiropractor so they'd also take Sam there to get "adjustments." They claim it really helps, although I'm skeptical. I told them it is okay as long as they also give the medicines that really do help, which they do

A few weeks ago I realized I hadn't heard from Sam's mom in several months. I'd been wondering what had been up. So I called up mom, who told me she was doing great, and thanking me for making her better. I pointed out that Sam had mostly gotten better on her own, maybe with a little help from me. We see that sometimes; the young asthmatics get better as they get older, probably because the airways get a bit bigger, less prone to close off. Either way, we are both thrilled with how well she's doing and I sleep a little bit better at night, not so worried about getting awoken about Sam.


At 12:02 AM, Blogger filmwidow said...

Your first Sam really got my attention because my daughter as similar percentiles. What are some other symptoms of CF? And what's the best way to mention this to either my pediatrician or pediatric allergist (she's allergic to dairy and eggs.)?

At 10:26 AM, Blogger Flea said...


Did you sweat the second Sam?



At 5:06 PM, Blogger Dr. Andy said...


Food allergies are not correlated with cystic fibrosis. Other symptoms besides poor growth are malabsorption with foul smelling diarrhea, a salty taste to the skin (poor man's sweat test), frequent ear, sinus and lung infections, chronic cough and unusually formed (clubbed) finger nails.

Flea, I can't remember if I did it or it was already done, but she has had a negative sweat test.

At 4:22 PM, Blogger filmwidow said...

Thank you for your response. While she does have some of the other symptoms of CF, some of the questions that my pediatrician has asked in her tri-monthly weight checks make much more sense. It's unlikely that she has CF. It's more likely that she's just going to be little.


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