Saturday, December 13, 2014

Shannon & Dr. Shapiro

Today, I'm doing something a little different.
I'm going to tell a story. A true story.
This happened about 20 years ago.

Shannon & Dr. Shapiro
By Michele Carlon, MD
     As a resident physician at Michael Reese Hospital in Chicago from 1988-1991, I had an extraordinary teacher. His name was Charles Shapiro, MD.
     Picture a gentleman in his sixties with white hair in a comb over. He was about 5 feet 6 inches tall, and slender to my recollection. He pilfered flowers from patients daily to wear in his lapel. It was his signature and patients vied to give Dr. Shapiro a flower for his lapel.
     Dr. Shapiro was an oncologist and of the “old school.” To be a great diagnostician, he believed one needed to use his memory and reason and to develop extraordinary history taking and physical exam skills. He would spy into patient’s rooms while I was examining them and yell things like, “Never listen through someone’s gown!” as he passed by.
     Dr. Shapiro taught us to be thorough. I recall him running into a Tumor Board meeting (Tumor board is where all of the specialties involved in the care of a cancer patient meet to discuss the cases and make plans for the patient’s care, and to teach each other). The case was of man in his twenties with a cancer that had spread. No one knew where the tumor had originated, where the “primary” was from. Dr. Shapiro came flying into the meeting, breathless and late, his white hair and coat flying behind him in his rush.
     “I know where the primary is! I thought I’d take a look to see if someone had missed something,” he announced, standing at the back of the conference room, near the door.
     Everyone sat in stunned silence as he stated, “It’s testicular cancer.”
     “How did you find it?” asked the lead physician running the meeting.
     “I simply lifted up his gown. No one had looked at his testicles. He had a grapefruit sized testicular tumor.”
     He proceeded to lecture the group of residents and students in the room on the importance of NEVER forgoing a genital examination out of embarrassment or modesty, yours or the patient’s. At that meeting he said the words that have stuck with me all of these years:

“If you don’t look, you won’t find it.”

     Fast forward to the mid 1990’s.
     I grabbed the chart from the pocket on the door outside of the examination room and quickly perused it. 
     Shannon, a 16 year-old female. Here for sports physical.
     “This should be pretty quick,” I thought to myself. I assembled my features into a welcoming smile and opened the door to the exam room.
    ."Hi, I'm Dr. Carlon."  I grabbed the round stool hidden underneath the desk and settled myself down upon it.
     "I understand you’re here for a sports physical, Shannon?" I asked, looking up from the chart.
     It was late summer and the high school volleyball season was ramping up. The girl before me looked fit with long blonde hair pulled back into a messy ponytail. She was wearing a t-shirt and and sweatpants. She had freckles sprinkled across her nose and cheeks and blue eyes framed by long lashes covered with mascara too dark for her coloring. She smiled and shook my hand. “Hi Doc.”
     I exchanged a few pleasantries with Shannon and her mother and then said, "Okay, I need to have you change into this gown so that I can examine you properly. I'll also need to ask you and your mother a series of questions."
     Shannon looked at me askance. "Dr. X never makes me put on a gown. He just signs the form for me."
     "I need to do a proper exam to do my job correctly. That means that you need to take off your clothes and put on a gown. You can leave on your underpants but I need to do an examination."
     Her mother gave me a sidelong glance of parental exasperation with her offspring, and repeated to Shannon what I had said. I stepped out of the room while they duked it out. I knew for a fact that Dr. X ALWAYS did an exam. Teenagers love to exaggerate, and are very modest as a rule, and this girl was no exception.
     I heard the paper stop crinkling, signaling that she was in the gown and atop the examination table. I knocked.
     “You ready?” I asked.
    I heard a sullen, “Yeah, I guess so.” I opened the door and entered the room. Shannon was sitting atop the examination table in a blue cloth gown, hands across her chest in a closed posture. I decided to draw her out a little.
   "So you're playing volleyball this year?" I asked as I sat down on my stool and started taking notes. "What year are you?"
     "I'm a sophomore. This is my second year playing volleyball." She seemed to relax and told me about what position she played, how she served, (overhand) and how the team did last year.
     I decided to move forward with the history taking, now that she was less upset. When we do physicals, there are a series of questions called the “Review of Systems” we use so that we don’t miss anything. Generally we start at the top of the body and work our way down the body or “systems”. Each doctor has their own ways of asking these questions. They are often abbreviated for the problem the patient comes in for. I asked all about the head and neck, next coming to the respiratory and cardiac systems.
     "Have you been having any shortness of breath, coughing, or wheezing? Any chest pain or palpitations?” I asked.
     "Well I'm out of shape after not doing much this summer. I've been working out really hard lately, but I’m pretty tired after doing my ladders and lunges. More than I should be."
     "Are you wheezing? Do you have asthma or lung disease? Do you smoke cigarettes or marijuana?"
     I realized my error as the girl glanced at her mother. I had forgotten to ask her mother to leave the room. I corrected myself and asked her mother to step out for a while. Her mother agreed and left to go read a magazine in the waiting room.
      I again asked the girl, "So, about those cigarettes and marijuana?”
    Incensed, Shannon huffed, “I don't smoke. Smoking is for idiots."
     "I'm glad to hear you say that. It certainly wouldn't help your volleyball game."
    I asked her a few more questions and went through my litany of Review of Systems questions. After I finished, I asked, "Shannon, do you mind if I examine you now?"
     I usually ask permission before starting to examine someone. It surprises them, but I find that it improves rapport and trust. . She nodded assent.
     “Okay I'm going to start at the top and work my way down," I explained, as I reached for the oto-opthalmoscope, an instrument with a strong light and various heads on it, used to peer into ears, eyes, nose, and throat.
     I did just that and then I examined her neck for swollen glands and for thyroid enlargement. I listened to her lungs to see if she had any wheezing or decreased breath sounds, which she did not.
    “Okay, please lie back now. I'm going to listen to your heart, do a breast exam, and examine your abdomen." Shannon dutifully followed my instructions and lay back on the exam table.
     I did a breast exam querying her as to whether she had been taught how to do it herself. She blushed bright red, and shook her head. I explained what I was doing, and why, and how she should do a self breast exam.
      Next I placed my stethoscope on her chest to listen to her heart sounds.
A very troubling abnormality in the heart sounds caught my attention immediately. Normally there is a comforting “Lub-dub, lub-dub” sound emanating from the heart.
Her heart made a loud and harsh shooshing noise, a murmur. I kept my facial expression even and flat, so I wouldn’t alarm her, but felt my own heart rate pick up as the possibilities raced through my mind. I considered all of the valvular abnormalities and their consequences, and asked her to do some special maneuvers; breath holding, bearing down like with a bowel movement, squatting, and fist gripping. These maneuvers can make the sounds louder or softer and help physicians to figure out which valve is damaged. In this case, I was having difficulty figuring out which valve was involved.
     I finished examining her abdomen, then checked for lymph nodes in the groin. I examined her hips and knees and watched her walk and duck walk, checking her gait.
     After I was finished, I asked Shannon to dress, and I stepped out.
Her mother was sitting in the waiting room, reading. I asked the staff to bring her back.
I knocked on the exam room door to see if Shannon was dressed. She was and her mother and I walked in.
    Giving bad news is never easy, and I have found that it is better to spit it out and let it be absorbed. Once absorbed, you can continue and explain.
     "I heard an unusual heart sound in Shannon’s chest," I said looking first at her mother, then at Shannon. "Has anyone ever told you that your daughter has a heart murmur?" I asked, looking back at her mother.
     "No.” She paused, then asked, “What’s a heart murmur? Should I be concerned?"
     “A heart murmur is a noise heard with a stethoscope when blood flows with turbulence through the heart valves. Normally the blood goes through smoothly and makes no noise.” I continued, "Shannon’s is a loud heart murmur and I don't know what's causing it. The fact that she has never been told she had a heart murmur in the past makes it more concerning. We need to do some more testing on her."
     "What kind of testing?" they asked simultaneously.
     I spoke directly to Shannon. "We don't have a Pediatric Cardiologist here in this town. We’ll need to send you down to the large medical center an hour away to get the testing done.”  I turned to her mother. “She needs a special ultrasound of her heart called an ‘echocardiogram.’ It doesn't hurt. They just rub some goo and a microphone around on your chest and take a picture of the heart with sound," I explained.
     “What about playing sports?”  asked Shannon’s mother.
     "Until we know what's going on, I don't want her playing any sports. I don't want her exercising either. No running, no jump-roping, no biking, no weight lifting. Nothing.”
     "Why can't you just sign the stupid form like Dr. X does? I'm fine! If I don't start practicing with my team I won't be able to play for the season!" sputtered Shannon.
     "I understand your frustration, Shannon, but this might be a very serious heart problem and I don't want you to die."
     Sometime shocking people into understanding the seriousness of a problem is the only thing that works. Her mother got the message though. Initially, her mother had also been concerned that her daughter wouldn't make the team.
     I gave Shannon’s mother the order slips to get the echocardiogram at the medical center.
     A few days later I got a phone call from a doctor who identified himself as a Pediatric Cardiologist from the medical center.
     "Are you the Doc who ordered the echocardiogram on Shannon?" he asked. "What made you order the test?"
     "Well, she had an extremely loud murmur that I was quite concerned about. She came in for a sports physical and this was new. Also, she was having shortness of breath with exertion.” I went into more history and examination findings with him.
     "Well, it's a good thing that you did order it because she has a large mass in her chest pressing on her pulmonic outflow tract,” stated the doctor, excitedly.
     I stopped. She had a big mass in her chest that was pressing on the arteries that emptied the right side of her heart going to her lungs. No wonder she had been short winded.
     "I'd like you to refer her down here to get further testing done. Do you mind if I take over the case?" He asked me.
     "Of course not," I stated. “We couldn't handle it here anyway.”
     "Well I'm first going to order a CT scan of her chest. We'll go from there, but the most common cause of this is a lymphoma I'm afraid,” he stated, grimly.
     I hung up the phone feeling depressed. If this was lymphoma, it was likely curable, depending on the type, but she’d run the risk of other cancers later in life, and side effects from the treatment. She’d never be the same.
     Several weeks went by. I was in the middle of a busy afternoon of clinic when Shannon’s mother came into the back escorted by one of my staff. She was holding a bouquet of dried flowers wrapped with purple tissue paper.
     "Hi, Dr. Carlon. Sorry to interrupt, but I just wanted to tell you what happened to Shannon. Had you heard?"
     "No. I hadn't heard anything. Last I heard, they thought she might have lymphoma."
     "Well that's what we all thought. They did a CAT scan and found a huge mass in her chest that had almost completely shut off the blood supply from the right side of her heart. They took it out and you'll never believe what it was!" exclaimed Shannon’s mother.
     I braced myself.
     “It was a teratoma. It wasn't cancer! They were able to get the whole thing out and you saved her life!” exclaimed her beaming mother. She handed me the bouquet of dried flowers and hugged me.
     I was stunned. A teratoma? A teratoma is a usually non-cancerous tumor that is a disorganized mass full of hair and teeth and skin and bone and other organ fragments. It's a very odd, usually benign tumor but it can grow. Often one is born with it but it is not detected until it gets big enough to compress organs near it, causing symptoms. At any rate, it’s fairly uncommon.
     "I wanted to give you these flowers as a token of our family’s thanks. Nothing I could do or say would express how grateful we are to you. You saved her life. We just wanted to say thank you as a family."
     I took the flowers home and put them in a vase in my bedroom where I could see them. I kept those flowers until they literally disintegrated into dust. I threw them away, reluctantly, ten years after recieving them.
     I thought of Dr. Shapiro’s words, every time I looked at those flowers.
“If you don’t look, you won’t find it.”
     Shannon had not wanted me to do an examination, but I did it anyway. How often did a sixteen year old have something seriously wrong, enough to keep them from playing sports? Not often. I could see how someone might be tempted to take a shortcut and just look at previous exams and sign the form without doing a physical.
     I work with medical students and residents. What I teach them will ripple out from me and through them affecting their care of others. Although the flowers are long gone, I think often about Shannon and the fact that she will have a long and healthy future, because I looked.
     Thank you Dr. Shapiro.

Michele Carlon

December 7, 2014