The Little Things That Matter Most Part II
Dear Readers,
This is the second of a three part series of interesting medical cases I’ve come across as a physician. In the last article, I described the little girl who aspirated a clove and was nearly discharged home with a collapsed lung. When that case happened, I was sure that it was a once in a lifetime experience. However, I recall my father and uncle Shimon discussing unusual medical cases as well. Once, my uncle described two ladies who had the same, rare diagnosis. I called him tonight and he informed me that these ladies had intra-uterine and cervical fetuses at the same time. When his partner heard the diagnosis for the second time, he thought my uncle was overly cautious and perhaps mistaken. However, tests did reveal that the second lady had the same exact rare diagnosis. I kept that lesson with me and it proved to be a valuable one.
Fresh out of my residency, I joined Ezras Cholim Health Center in Kiryas Yoel. With G-d’s help, the practice became busy and I started diagnosing many interesting diseases. I was always careful to take a few extra seconds to listen to the patients’ lungs and differentiate between asthma, bronchiolitis and pneumonias. The following case happened in the first year of my practice. Mrs. Weiss walked in one day with four children. I checked all the kids in the order of their age, starting with the oldest first. When I got to the youngest boy Usher, Mrs. Weiss mentioned that she felt he had been wheezing for a few days. I asked if he had a history of wheezing and the answer was “no, but all my other kids did.” First time wheezer I thought to myself, let’s get a better history. Did he have any fever? Did he choke on anything? Here Mrs. Weiss paused. "Yes, he did choke on popcorn yesterday, we did see him eating popcorn and he made some “choking sounds,” but his wheezing started a day before this happened. I listened to his lungs and for the most part, they sounded clear. He did have a mild wheeze just as the mother reported. Usher looked happy and calm, smiling for the most part and very excited about getting a sticker. I nebulized him at the office, and his wheezing was still present. I asked his mom to continue nebulizing him at home and gave her an Rx for a series of x-rays to rule out foreign bodies in the lungs. I kept in touch with Mrs. Weiss. Usher was doing well on the nebulizer for a few days, but he was not clear. Usher had the x-rays taken 3 or 4 days after he saw me. I did not mind the delay for two reasons: Usher had been looking playful according to the mom, and I knew Mrs. Weiss was extremely busy at home. Usher was the youngest of 12 children I believe. I did not want to push her too much.
On Wednesday, Mrs. Weiss returned to our center with Usher and the actual x-rays. I like to personally visualize the x-rays rather than just follow a report, so on those very rare occasions that I do order X-rays, I ask the parents to drop off the films. I examined Usher’s lungs. Immediately, I noticed that his wheezing was louder than last time! He still looked happy, but his right lung had a loud wheeze that radiated from the base upwards. I took the x-rays to the lab area where our x-ray viewing board was. My colleague was there and loudly interjected: “David – I see a clear Right Middle Lobe Pneumonia there." Mrs. Weiss heard this and was delighted. Pneumonia sounds much more comforting than popcorn stuck in the lungs. I felt a rush of despair and frustration. I took Mrs. Weiss back to the room and explained that in my humble opinion, Usher did in fact have popcorn in his lungs. In my short career, I had never heard a patient looking so good and wheezing so loudly. What about his pneumonia, asked a puzzled Mrs. Weiss? Personally, I didn’t see any pneumonia. The radiology report didn’t mention it either. Based on my previous experience, an x-ray may not show soft popcorn in the lung unless it is really late in the disease process. I didn’t want to wait for Usher’s lungs to collapse and then prove it by an impressive x-ray. Usher didnt look like a patient with pneumonia – he was afebrile (has no fever), and was not in any respiratory distress. The physical exam and the history were what I based this suspicion on, and the fact that I never failed to resolve wheezing distress for so long!!! Usher had been wheezing for 5-6 days now and that was a first for me.
Seeing specialists was a real hassle for the local residents due to the absence of major pediatric hospitals in Orange County. Most referrals where made to Manhattan Hospitals. It was almost 8pm and the hour was getting late. I gave my word to Mrs. Weiss that I would call and discuss Usher’s case with the specialist that night and try and get her an appointment with a reputable pediatric pulmunologist the next day. On my way home that night, I paged the fellow at a prestigious Manhattan Children’s Hospital, detailed him on the case and asked if he would please have the director of the department examine Usher. He was very helpful and told me to send Mrs. Weiss “first thing in the morning." I called Mrs. Weiss and excitedly informed her that I got a great Pulmonologist to check Usher. I asked her to call me with any questions, she had my cell phone number.
On Thursday, my office hours started at 11am. I was sitting at home in the kitchen when my cell phone rang. It was Mrs. Weiss. I was so curious to know what happened to Usher. But instead of the kind words I was accustomed to hearing, her tone was pretty serious and concerned. “Dr. Simai, this turned out to be a waste of time” she said in a semi-victorious tone. "What happened"? I replied. "Well, I was sent for a special set of x-rays that showed no popcorn, and the radiologist told me there is absolutely nothing wrong with my child and I can take him home immediately!" I was pretty shocked. Not because I was proven wrong. I would have been happy had this turned out to be a simple case of wheezing. But I had never heard that a radiologist had discharged a patient home! Nervously, I asked: “Did the director see Usher at all? Did anyone actually examine him?" It turned out that no one cared to examine Usher. Somehow, he was sent directly to the radiology department and was discharged from there. Mrs. Weiss said that the director was at a meeting. I pleaded with Mrs. Weiss: “I know it’sThursday and you are in a rush to prepare for Shabbos, but I want you to wait for the director to exit the meeting and ask her to listen to Usher’s lungs."
A short hour later, my phone rang again. This time it was the director herself. She apologized profusely on behalf of her department. She listened to his lungs and she agreed – there may be popcorn there after all. She scheduled a bronchoscopy for early the next morning. She was also surprised to hear that the radiologist discharged the patient home.
Mrs. Weiss was very hesitant to let Usher undergo the bronchoscopy, and understandably so. Usher had not one but two negative x-rays and she was told by my colleague and the radiologist that there was no foreign body in Usher’s lungs. Her sister in law in Brooklyn guaranteed her that even if there was something there she could treat it with “Shemen Zais” – olive oil. So, for the first time in my life, I changed my calm, reassuring tone of voice. “Mrs. Weiss, I cannot force you to do this procedure, but I also cannot guarantee that Usher will live till the next Shabbos either." To date, I do not know how I had the courage, or audacity to intimidate a parent like this. I certainly do not recall doing it again.
Friday morning, as I was taking out my Tefillin at the Satmar Beis Medrash in Kiryas Yoel, my phone rang (vibrated to be exact). It was Mrs. Weiss. This time, she sounded emotional and grateful – the director had just come out and informed her this second that a budding popcorn kernel was removed from Usher’s lung. She said that the lungs did look inflamed and that they were on the brink of collapse. She will admit him to the hospital for observation over Shabbos. I just wanted you to know, so you are the first person I called. Shaking, with tears rolling down my cheeks, I felt an overwhelming gratitude to G-d, who answered my prayers, and despite all odds and difficulties, had led me to help Usher.
Three years ago, on Chol Hamoed Pesach, I was at a carnival in Monsey with my family. As I parked my car, I thought I saw the familiar face of a young toddler from Kiryas Yoel. I wasn’t sure who he was, but I noticed that he did stare at me for a few seconds and pointed me out to his siblings. There were so many families from Kiryas Yoel there, I had a hard time remembering all their names. A few minutes later, I heard someone calling my name. I turned around, and there was that familiar boy, who was being held in his father’s arms. The father was so excited to see me and I was wondering, why? Then he said with a big smile: “Do you remember Usher? He is……he is your son!!!” His words hit me deep in my heart, and although it was a joyous day of Chol Hamoed, nothing could stop the tears from rolling down my cheeks once again.
Sincerely,
David Elazar Simai, M.D.