The Little Things That Matter Most Part I

Dear Readers,

This week, I decided to write the first of a 3 article series on some wild cases that I have witnessed as a physician. The main point of the stories is not to point out that very often, persistence on the side of the parents and doctor, is required to avoid medical crisis. It goes without mention that as you will read in these exciting and memorable stories, as I feel so many times each day, there is always divine intervention that guides us healthcare providers in each step that we take.

I will purposely change some details in each case in order to protect the identity of the patient.

The first case occurred in the middle of the third year of my Pediatric Residency at Schneider Children’s Hospital (now known as Cohen’s Children’s Hospital). During my residency at Schneider’s, residents were assigned to cover small community hospitals. As third year residents, most of us had more relaxing time assuming a more senior role and leaving the juniors to do the most of the hard work – drawing bloods, writing notes and reporting to us on the progress of all the patients.

It was on a winter day, that I assumed the role of a senior resident at a small community hospital in Queens. The Pediatric floor was considerably smaller than the one at Schneider’s and the usual census ranged between 2-8 patients per day. Scanning the patients that day, I noticed much of the ordinary, “run of the mill” cases – an infant with bronchiolitis, two toddlers with gastroenteritis (stomach virus), an 9 year old asthmatic and an 11 month old with pneumonia.

The usual arrangement was that the junior residents would gather all the information about the patient and present to the senior resident at 8:30 am. At some point in the day, an outside, attending physician would join us and sign our chart. Most attending physicians were extremely busy, and did not show much interest in teaching us or arguing with us about patient plans (in those days, the hospitals would force outside pediatric attending to cover the pediatric floor for a few weeks every day and would not compensate them for their time).

After being briefed about all the patients on the floor, I decided to personally go from room to room and address any of the parent’s concerns. The first room housed the baby with pneumonia. I always had a meticulous order when making rounds. Before stepping into the room, I would glance over the vital signs recorded on the patient’s clipboard. The vital signs give very important information about the progress of the patient. In this case, my junior resident reported to me that the pt is an 11 month old girl that is in her 3rd day at the hospital for pneumonia. Her chest x-ray was reported negative, but she had a cough and fever, along with a mildly elevated white count. My junior reported that she is doing great, her fever is down and her parents are anxious to leave home. Being that her fever is down, her attending was o.k. with the idea, and will see her at her office after 1-2 days. The clipboard did show that the patient’s fever disappeared and her oxygen saturation was 99% on room air.

I proceeded to peek inside and the sounds of the vital signs monitors caught my attention. The baby was moving a bit, but her oxygen saturation was at a mere 90%. Any level below 92% is considered dangerous. I grinned at the thought that the night nurse may have “fudged” her numbers. But being that I was a senior and had the liberty to spend as much time as I wanted, I took the liberty to do some detective work. I introduced myself to the parents, who appeared to be a young, orthodox family from Kew Garden Hills. They were excited to leave the hospital after 3 days and were thankful that everything went well. I asked them if they mind that I check the baby before they leave. “Sure” they replied, wondering why another doctor wants to “experiment” on their child, but they were kind and allowed me to spend a few minutes listening to her lungs. If you ever had an infant at that age at your pediatrician’s office, you know that it’s quite a challenge to examine their lungs. In order to listen properly, the child has to be breathing regularly, without crying. So, I sat down next to the parents, had the baby sit on her daddy’s lap and spend a few long minutes listening and playing simultaneously. All along, my eyes were looking at that oxygen saturation monitor.

Surprisingly, even when the baby was comfortable and smiley, her oxygen saturation did not exceed 91%. Seeing that, I listened even more carefully. After all, the child did come in with fever, received 3 days of IV antibiotics, and her fever did disappear. Why would her oxygen level be so low? She was definitely not wheezing. But after listening for a full 5 minutes, I was suspicious that one, small area in the lower right side of her lungs, was not moving air at all!!!

I kept my excitement to myself and calmly asked the parents: do u mind repeating the whole story to me? Reluctantly, the mother recalled the entire story: on Saturday night, while performing “Havdala” (blessing at the end of the Jewish Sabbath), they noticed that the baby had a piece of clove in her mouth. A day later, she developed a cough. Their doctor examined the baby and sent her for an x-ray to make sure that she did not aspirate the clove. The x-ray was negative. The next day, the cough worsened and the child developed fever. At this point, the baby was seen at the emergency room at Flushing Hospital. Her x-rays did not show any pneumonia, but she did have an elevated white count in her blood work, that did point to a possible bacterial pneumonia. After hearing these details, I informed that parents that my concern was that the baby’s oxygen saturation is low, along with the findings that one small segment of her lungs was not ventilating well. What do you suggest doctor? The parents both sadly asked, not believing that their departure from the hospital may be delayed. “I would like to do some more tests before sending you home, but I will first discuss this with your pediatrician” I answered.

I called the pediatrician and informed her of my suspicion. “David, she answered, I sent her for an x-ray on Sunday which was negative – but do whatever you want” was her reply. A few minutes later, the x- ray technician came to the floor and performed the test. I descended to the basement of the hospital where the x-rays where developed in order to review the x-ray with the radiologist. This time however, it the diagnosis was pretty clear cut. The x-ray revealed a collapse of approximately half of the right side of the lungs.

Within 2 hours, the little girl left the hospital. No, she did not go home, but via ambulance to Schneider Children’s Hospital. 3 operations later, and the entire clove was removed from the lungs. It seems that cloves are one of the hardest foreign objects to remove from the lungs, because they have a sharp edge that embeds deep in the lung tissue. The baby spent a few weeks in the ICU before being discharged from the hospital. 2 years ago, I came across the baby’s mother and was happy to hear that she is doing well and is almost completely recovered.

Since then however, my wife monitors the passing of the cloves at “Havdala” very carefully. Personally, I feel special gratitude to g-d when I smell the sweet, buoyant aroma of the cloves every week. It reminds me that divine intervention guides us as parents and doctors. It also reminds me to look at the small things in life. These little things are surely a blessing, but could turn to be great dangers!

As parents, we should try and do our utmost to prevent our infants and toddlers from choking or aspirating small toys, nuts, screws and other household items. So when you smell those cloves this week, please have in mind to care about every aspect of your child’s life – from small, to big.

Wishing you and yours much health and happiness,

David Elazar Simai, M.D.