.........Perhaps we should catheterise her. She had not been seen to use the toilet for hours although she was not drinking much. She was still going round in her room – we gave her the side room and a nurse – and we put on an input output chart so we knew. The new junior doctor’s car broke down so she was late in examining her.
Bother, I forgot it was changeover time, when new doctors came in for their new six-month rotation. This is one of the days of the year not to be ill.
“Good work Sister. What do we do without you?”
Sister did the catheterisation but only got about 150ml. The mass was still there.
I phoned Ob-Gyn. The consultant had left for home, but I got her Senior Registrar.
He came over. Yes, it was possible that she was pregnant but unlikely as there were no breast changes. He would hate to do an X-ray but that seemed justified in the case of an undiagnosed abdominal mass.
My mind was racing now. Sometimes you do have to believe what you see. Sometimes you have to believe the parents. She was not one of those girls. She could not be pregnant. So now we had to go through the differential diagnosis for abdominal mass in a young girl of thirteen.
Ovarian cyst was the obvious one.
This big?
Possible.
No. It cannot be.
The x-ray came back. The tell tale tooth was there and yes – a Teratoma, the distinctive type of tumour that can include teeth, hair, sometimes, even a jaw and tongue. I guessed just a split second before the results came back. How annoying.
Working diagnosis: Teratoma with possible toxic psychosis.
Emergency operation was arranged. Yes, she would be fine a little while after the operation, I reassured the parents.
Junior Doctor arrived:
The junior arrived and took some history and did a quick physical before she was prepared for the theatre. This petite doctor with a very babyish face told me that on her first day in her last job she had to do an emergency tracheotomy. This time she had been on call for the last three nights and the battery in her old Mini could not cope with the heavy frost so she had to wait for AA before coming. She was most apologetic for not having got in earlier.
She asked if I had seen many toxic psychosis cases and I asked if she had come across any in her psychiatric placement. As with all good psychiatrists answering a question with another is in our blood and here it worked well.
Neither of us knew what was to hit us next.
At 2 A.M. I had a call from her.
“Your patient – I mean our patient could not be aroused after the operation. Yes they removed the teratoma, complete and intact. It is bigger than any specimen I have seen but she could not be aroused. Any ideas?”
“Call the paediatrician on call in the regional paediatric unit and I will be in.”
What happened? I asked myself as I drove to the hospital.
What had we done? This was fast becoming a nightmare situation.
What was I going to say to the parents?
Something else was going on here, and I was not happy because I did not know what it was. I was supposed to know and I generally did. After all I was the consultant now.
Thank goodness she could breathe without assistance. That was the first thing I noticed. I saw mother in the corner obviously in tears. She asked if her daughter would be all right. I cannot remember what I said but knowing myself I could not have said anything too discouraging. But then I knew I was in tricky territory and it was unlikely to be the territory of a child psychiatrist.
A good doctor is one who is not afraid to ask for help but he must also know where to ask.
“Get me Great Ormond Street.”
“I already did.”
She is going to be a good doctor.
“Well, the Regional unit said that they had no beds so I thought I should ring up my classmate at GOS and she talked to her SR who said “send her in”.”
Who needs consultants when juniors have that kind of network? This girl will do well.
“Everything has been set up. The ambulance will be here in about half an hour and if it is all right I would like to go with her.”
“Yes, you do and thanks a lot.”
I told mother that we were transferring her daughter to the best children’s hospital in England if not in the world and the doctor would stay with her in the ambulance. She would be fine.
.........She was impressed with mother’s faith and trust in God.
She said mother was near to tears. It was bad enough to have such a large Teratoma and then to have the patient unconscious with no one knowing what was going on was very frightening.
“I have seen some deaths as a medical student but never since I was registered. I do not want this to be my first.”
I knew the feeling well but what could I say? A doctor has to face it some time.
“Do you believe there is God?” She asked
“Do you really think I can answer that one?”
“Well, you have more experience.”
“To me it is like reading a good book. You would not know until the end.”
“So you mean I am not going to know until then.”
“Interpret whichever way you like. I remember Jung in his Memoir gave quite an account on the Holy Trinity. There were seventeen bishops in Jung’s family including his own father. Jung had always been puzzled by deity and the bible and most of all by the concept of the Holy Trinity. I know many religious philosophers struggle with that too. By some accident he had access to his father’s inner library. He saw this folder clearly marked Holy Trinity. The relief was phenomenal. He could now have the answer. He hesitated before opening the folder.”
“What did the folder contain?”
“See, you want the last chapter. I wanted to know as well. The folder contained pieces of blank paper.”
“That was it?”
“That was it.”
A reprint:
NHS & Ham: World Class Medicine without trying!
Those doctors that grew up here may not know but those of us from overseas looked forward to coming for our specialist training in this country. A number of us went to the US and they did well too. There was little doubt that for many the years of training in the top hospitals here will guarantee them nice top jobs in Hong Kong or the rest of the commonwealth.
Why?
We provided World Class Medicine without trying. A quote from a fellow blogger, Dr. No.
Excellent post - and yes, that is exactly how it used to be. World class medicine without even trying - we just did it, because that is what we did, just as the dolphin swims, and the eagle soars. A key, even vital feature was that the doctors looking after their patients did not need to worry about money or managers. They just got on with it. There was no market to get in the way of truly integrated care. Some may point out that 13 year olds with teratomas are rare, and that is true, but what this case shows us, precisely because of its complexity, is just how capable the system was. And most of the time (of course not always), it dealt just as capably with more routine cases. "How is (sic) the new Consortia going to work out the funding and how are the three Foundation Trust Hospitals going to work out the costs." Exactly. And then: who is going to pay for the staff and their time to work out out all those costs and conduct the transactions?
What many politicians may not know is that pride in what we do is often more important than money or anything else. Our pride is one sure way to ensure quality of practice.
Do we really want to take that away now? Years of heartless re-organisation has left many of us dedicated doctors disillusioned. Many young ones have left. Poorly trained doctors that have no right to be practising medicine now even have jobs in some of these well known hospitals.
Can we continue to practise World Class Medicine even if we wanted to?
Back to the patient:
Would my patient be dealt with in the same way in 2015?
GP to Paediatrician: 13 year old with one stiff arm. Seen the same day.
Paediatrician to me: ? Psychosis or even Catatonia.
Seen same day and admitted to Paediatric Ward, DGH.
Child Psychiatrist to Gynaecologist: ? Pregnancy or tumour. Still the same day.
Gynaecologist to Radiologist: Unlikely to be pregnant, ? Ovarian cyst.
Radiologist (Hospital & no India based): Tell tale tooth: Teratoma.
Gynaecologist: Operation on emergency basis with Paediatric Anaethetics Consultant. Still Day 1.
Patient unconscious and transferred to GOS on same day. Seen by various Professors.
Patient later transferred to Queen’s Square (National Hospital for Nervous Diseases),
Seen by more Professors.
Regained consciousness after 23 days.
Eventually transferred back to local Hospital.
None of the Doctor to Doctor decisions need to be referred to managers.
How is the new Consortia going to work out the funding and how are the three Foundation Trust Hospitals going to work out the costs.
The danger is that the patient may not even get to see the first Specialist: Paediatrician not to say the second one: me.
Not to mention the operation etc. and the transfer to the Centres of excellence.
Of 100 patients with anti-NMDA-receptor encephalitis, a disorder that associates with antibodies against the NR1 subunit of the receptor, many were initially seen by psychiatrists or admitted to psychiatric centres but subsequently developed seizures, decline of consciousness, and complex symptoms requiring multidisciplinary care. While poorly responsive or in a catatonic-like state, 93 patients developed hypoventilation, autonomic imbalance, or abnormal movements, all overlapping in 52 patients. 59% of patients had a tumour, most commonly ovarian teratoma. Despite the severity of the disorder, 75 patients recovered and 25 had severe deficits or died.
Related paper:
Post Script:
“Ten years later mother came to see my secretary and left a photo. It was a photo of her daughter and her new baby. She had been working at the local bank since she left school, met a very nice man and now she had a baby. Mother thought I might remember them and perhaps I would be pleased with the outcome.
I was very pleased for them too but I would hate for anyone to put faith or god to such a test too often.”
See also:
