Well, now I’ve really depressed myself. I was in a pretty good mood when I started recording this, but listening to what I had to say, I have to admit, I must have been pretty crazy to have come back from vacation. I mean, a week at Pocono Castle was a picnic compared to an afternoon at Jonas Bronck.
Monday, October 7, 1985
I think I’ve finally recovered and gotten myself a little better oriented to Jonas Bronck. It was pretty rough there for a while. That’s a real problem with this program: You work at so many places, by the time you feel comfortable at one hospital, they move you to another and you have to start from scratch again. It’s the concept of perpetual confusion, an ancient form of torture developed, I believe, during the Ming dynasty.
Things have calmed down a little on the ward. I was on last Monday and Wednesday and then again on Saturday, but from here on it’s every third for the rest of the month. (Oh, what joy, only every third night! How lucky can I get?) All last week was a blur. I admitted about ten patients, some of them really sick. It was interesting. They kind of came in groups: Monday was Leukemia Day. First I admitted this fourteen-year-old boy whose gums had started to bleed a lot when he brushed his teeth. He also had a slight fever, he was feeling kind of sick, and he had bone pain. He turned out to have ALL [acute lymphocytic leukemia, the most common form of cancer in the pediatric age group], and he’s in the poor-prognosis group for everything—age, sex, race, you name it. He only stayed at Jonas Bronck overnight. On Tuesday we shipped him over to Mount Scopus, where he’ll get started on a chemotherapy protocol.
Next, I admitted this eight-year-old who had had ALL diagnosed six years ago. He had been treated with chemotherapy for four years and had been considered cured. He woke up one day last week with a terrible headache. He was seen at every emergency room in the Bronx, and all the doctors told his mother the same thing: There was nothing wrong with him, and she should try giving him some Tylenol. He finally showed up to see his hematologist here at Jonas Bronck, and she noticed that he had a sixth-nerve palsy. [The sixth cranial nerve, the abducens, runs the longest course in its path from its origin in the brain to its point of action in the eye. Because of its long path, the sixth nerve is sensitive to increased pressure within the skull. If pressure is increased, the sixth nerve will not work properly and is said to be “palsied.”] She arranged a stat CT scan that showed a golf-ball-sized mass in his frontal lobe, most probably a lymphoma but possibly some other terrible horrenderoma. [I don’t think the term “horrenderoma” requires defining.]
So Monday was a really comforting night. I’m starting on a new service in a new hospital, and I picked up five patients who didn’t have adequate off-service notes, so I didn’t know what the hell was going on with any of them, and I admitted two kids with terrible prognoses. And I barely had time to recover from that night when I was on again on Wednesday, and that turned out to be Chromosome Abnormality Night. My first hit was this three-month-old who looked like she’d been dead for a few weeks already except for the fact that she’d just had fresh casts put on her legs to correct her clubfeet. Her mother brought her into the ER with a complaint that she was breathing too fast. The intern who saw her in the ER asked if she had any problems with her health, and the mother said, “No, there’s nothing wrong with her.” Turns out she’s got trisomy 18 [a congenital malformation syndrome caused by an extra chromosome No. 18 in every cell of the body] and severe congenital heart disease, which had caused her to go into congestive heart failure and led to the breathing problem. [Almost every child born with trisomy 18 has congenital heart disease. The heart disease is one of the factors that leads to early death in these patients. Eighty percent of trisomy 18 children will die before their first birthday.] The kid’s got trisomy 18, and the mother says there’s nothing wrong with her! When the intern got the old chart and found out the diagnosis, the mother still denied it. Sounds like she got some top-notch genetic counseling! Anyway, the kid was in congestive failure, so I started her on some Lasix [a diuretic that rids the body of excess fluid; since fluid buildup is a major problem in congestive heart failure, treatment with Lasix often relieves symptoms such as rapid breathing] and suddenly she started looking like a million bucks.
I don’t really understand why this kid’s got those casts on her legs. I mean, if she’s got such a bad prognosis, what’s the use of fixing her clubfeet? It doesn’t make much sense. Of course, that doesn’t mean anything; there aren’t many things around here that seem to make much sense.