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
