Portal de Periódicos da CAPES

The Doctor's Kid

2010; Elsevier BV; Volume: 55; Issue: 4 Linguagem: Inglês

10.1016/j.annemergmed.2009.09.005

1097-6760

L. Yancey,

Blood groups and transfusion

[Ann Emerg Med. 2010;55:378-379.]PrologueGracie was a 3-year-old girl whom I first met during my third year of medical school. She had blond ringlets and dark eyes that saw directly into my heart. She presented with recurrent pneumonia and neutropenia. Initial workup did not reveal a cause for her low white count. As her neutropenia progressed to pancytopenia, she developed bleeding gums and bloody urine. Only after several months did the true culprit rear its head. Gracie had a rare form of acute monocytic leukemia.My resident shook his head. “Too bad. Her mom's a neonatologist.” I looked at him quizzically.“Doctors' kids always have weird things.” He sighed. “And they always do poorly.”The Doctor's KidI am a doctor, and I have kids. My 11-year-old daughter has episodes of abdominal pain. The first time, I watch her at home. Her abdominal exam is benign, she is afebrile, she has no other symptoms. If I saw her in the ED, I'd probably get a urine and watch her. The pain resolves. Skip the urine.A month later. She has another episode, but this time she is crying in pain. My daughter, who has a black belt in te dae kuen do. The kid who walked on a broken foot for 2 days before she complained about it. The one whose abdominal exam was so benign when she had appendicitis that a pediatric surgeon waited 16 hours to take her to the OR after her CT was read as “unequivocally positive” by the radiologist.I take her to our family physician. She suggests blood and urine. I show my daughter how to do a clean catch urine. She grimaces in disgust. Then comes the blood draw. Her lip quivers. “Mom, you know how I feel about needles.”I know. She had to get rabies immune globulin and the entire rabies series when she was 2, after we found a rabid bat in our fireplace. At the time, I was the head of the Rabies Advisory Committee on the military base where we were stationed and had to recuse myself from reviewing the case. Doctors' kids always have weird things. My Bad Mommy tape is lecturing in the background.Blood tests are normal. The urine is pristine, not even a single epithelial cell. The pain resolves.Another month later, and she has another episode. Once again, blood and urine are negative. The pain resolves. There is a gnawing feeling in my gut. My mother's sense knows something is wrong. Given the colicky, left-sided pain, given its radiation to her groin, I take her to work with me and ultrasound her myself in the ED. Her kidneys are normal, no hydronephrosis. Spleen is normal size, no fluid collections or masses. Uterus and ovaries small, tucked away in her pelvis. I have only a little experience at using Doppler flow to look for torsion, but it's irrelevant. She's premenarchal, and her ovaries are tiny. Anyway, the pain has resolved.Her 12th birthday passes without incident. The gnawing sensation in my gut begins to ease. I dare to hope it won't happen again.No such luck. The next time, she is vomiting. Our family physician orders a formal pelvic ultrasound. The ultrasound shows normal flow, left ovary 2.1 cm in size, barely larger than the right. Our physician suggests a CT. I resist. She's already had one CT for appendicitis 3 years ago. What if she winds up with cancer someday? Bad Mommy, it'll be your fault for scanning her twice. Her pain resolves.I scour the pediatric literature for causes of colicky abdominal pain and vomiting in children. Her presentation is reminiscent of kidney stones—the colicky, one-sided pain, the radiation to her thigh, the vomiting. Two negative urines. No hydro on ultrasound. Volvulus? Wrong age. Intussusception? Wrong age. Ovarian torsion? Wrong age.Another month. Another episode. The gnawing unease in my gut is now dizzying, deafening. I capitulate. We do the abdominal CT. It shows a 3-cm left ovary, “possible cyst.” The gynecologist is reassuring. Highly unlikely to be torsion. Ovaries under 5 cm don't torse. Anyway, it would be very rare to have torsion of a normal ovary in a prepubertal child. Besides, her pain has improved. But, if I'm really that concerned, I can bring her in for another ultrasound during an episode.Dinnertime. I head to the kitchen. Pasta with chicken and salad, we need a green vegetable. My daughter is in a fetal position on the couch, crying. The familiar gnawing fear returns. She retches onto the floor.I call the ED. No, the ultrasound tech has not yet left for the day. She'll wait for us. I give my husband instructions about dinner and a bath for our younger daughter. He is frantically trying to fix us some dinner “for the road.” I tell him we can't eat, in case she goes to the OR. Well, I guess I could eat, but I'm not hungry.Another IV. Her eyes bore into mine, accusingly, reproachfully. I take her hand and bury her head in my shoulder. Bad Mommy. Bad Mommy!The ultrasound tech, who was chatty on our arrival, is silent. She scans repeatedly over the left adnexa. I search for the flashing red and blue Doppler of blood flow. The realization is slow.There's no flow, I tell her. She doesn't answer, just keeps scanning. She leaves to get the radiologist.I cannot comprehend. Almost 6 months of normal exams, normal tests. Six months of feeling like the neurotic Doctor Mom. Now my child is going emergently to the OR. A bizarre mixture of relief and guilt washes over me. It's over. No more wondering, no more gnawing in my gut. How could you have let this go on so long? My Bad Doctor tape screams louder than my Bad Mommy tape.The OB/gyn resident arrives to do an H&P. We recognize each other from the ED. She smiles congenially. I force a joke about all the 48-hour quant follow-ups. Now, when did this pain start? She does a double-take. Six months ago? I crumble in shame and misery.The OB/gyn attending strides out of the OR, armed with photos. The left ovary was torsed 1080 degrees—three times around. It was purple and dusky but pinked up within seconds of detorsion. She is elated as she shows me the before and after photos. I imagine a magazine advertisement. This was her ovary before. This is her ovary after.My daughter is finally settled into her hospital room. She sleeps the sleep of the drugged. I make up the small couch into a bed and lie down. My sleep is fractured by dreams. I am walking through a snowy, frozen wasteland, shivering because I have no coat. The snow is filling my shoes. I walk past other people. They wear boots and full-length coats, with fur hats. They look straight ahead. In another dream, it is I who have had surgery. I wander the halls of a gray and dingy hospital, wearing only a thin exam gown, pushing my IV pole. I am looking for my husband, my parents, my doctor, my nurse—any familiar face. It is afternoon, and I am hungry, and I want to be discharged, but there is no one I can ask for help. I awaken exhausted.At home, as my daughter watches Harry Potter on the fold-out sofa, sipping a banana smoothie, I search the literature for possible causes of torsion in a premenarchal girl with normal ovaries. Several authors speculate about sudden, decelerating movements as a possible precipitant. Martial arts? She jumps, rolls, falls … but millions of girls practice martial arts. Surely there would be more reports if this were a risk factor.EpilogueOne spring day as I prepared dinner, I heard the sound of my daughters and their friends laughing and screaming from the backyard. A joyful sound, full of the promise of new beginnings and of youth. One I hadn't heard in months, since they last frolicked in the snow, before the surgery. Their joy was infectious. I left the kitchen to watch them from the back porch.A moment of almost knowing, like the instant when the truck in front of you is spinning across the ice toward the median. Then it hit me.They are jumping up and down, up and down, on our trampoline. The one a neighbor gave us when she moved away. The one that sat, unused and covered with snow, these past several months of winter. The one whose arrival, in retrospect, immediately preceded my daughter's first episode of pain late last summer.I found nothing in the literature about the association between ovarian torsion and jumping on a trampoline. But, without a trial, I convicted and sentenced the offender. An ad on Craigslist, and less than 24 hours later, the trampoline was gone. My n equals 1. For a doctor's kid, that's enough. [Ann Emerg Med. 2010;55:378-379.] PrologueGracie was a 3-year-old girl whom I first met during my third year of medical school. She had blond ringlets and dark eyes that saw directly into my heart. She presented with recurrent pneumonia and neutropenia. Initial workup did not reveal a cause for her low white count. As her neutropenia progressed to pancytopenia, she developed bleeding gums and bloody urine. Only after several months did the true culprit rear its head. Gracie had a rare form of acute monocytic leukemia.My resident shook his head. “Too bad. Her mom's a neonatologist.” I looked at him quizzically.“Doctors' kids always have weird things.” He sighed. “And they always do poorly.” Gracie was a 3-year-old girl whom I first met during my third year of medical school. She had blond ringlets and dark eyes that saw directly into my heart. She presented with recurrent pneumonia and neutropenia. Initial workup did not reveal a cause for her low white count. As her neutropenia progressed to pancytopenia, she developed bleeding gums and bloody urine. Only after several months did the true culprit rear its head. Gracie had a rare form of acute monocytic leukemia. My resident shook his head. “Too bad. Her mom's a neonatologist.” I looked at him quizzically. “Doctors' kids always have weird things.” He sighed. “And they always do poorly.” The Doctor's KidI am a doctor, and I have kids. My 11-year-old daughter has episodes of abdominal pain. The first time, I watch her at home. Her abdominal exam is benign, she is afebrile, she has no other symptoms. If I saw her in the ED, I'd probably get a urine and watch her. The pain resolves. Skip the urine.A month later. She has another episode, but this time she is crying in pain. My daughter, who has a black belt in te dae kuen do. The kid who walked on a broken foot for 2 days before she complained about it. The one whose abdominal exam was so benign when she had appendicitis that a pediatric surgeon waited 16 hours to take her to the OR after her CT was read as “unequivocally positive” by the radiologist.I take her to our family physician. She suggests blood and urine. I show my daughter how to do a clean catch urine. She grimaces in disgust. Then comes the blood draw. Her lip quivers. “Mom, you know how I feel about needles.”I know. She had to get rabies immune globulin and the entire rabies series when she was 2, after we found a rabid bat in our fireplace. At the time, I was the head of the Rabies Advisory Committee on the military base where we were stationed and had to recuse myself from reviewing the case. Doctors' kids always have weird things. My Bad Mommy tape is lecturing in the background.Blood tests are normal. The urine is pristine, not even a single epithelial cell. The pain resolves.Another month later, and she has another episode. Once again, blood and urine are negative. The pain resolves. There is a gnawing feeling in my gut. My mother's sense knows something is wrong. Given the colicky, left-sided pain, given its radiation to her groin, I take her to work with me and ultrasound her myself in the ED. Her kidneys are normal, no hydronephrosis. Spleen is normal size, no fluid collections or masses. Uterus and ovaries small, tucked away in her pelvis. I have only a little experience at using Doppler flow to look for torsion, but it's irrelevant. She's premenarchal, and her ovaries are tiny. Anyway, the pain has resolved.Her 12th birthday passes without incident. The gnawing sensation in my gut begins to ease. I dare to hope it won't happen again.No such luck. The next time, she is vomiting. Our family physician orders a formal pelvic ultrasound. The ultrasound shows normal flow, left ovary 2.1 cm in size, barely larger than the right. Our physician suggests a CT. I resist. She's already had one CT for appendicitis 3 years ago. What if she winds up with cancer someday? Bad Mommy, it'll be your fault for scanning her twice. Her pain resolves.I scour the pediatric literature for causes of colicky abdominal pain and vomiting in children. Her presentation is reminiscent of kidney stones—the colicky, one-sided pain, the radiation to her thigh, the vomiting. Two negative urines. No hydro on ultrasound. Volvulus? Wrong age. Intussusception? Wrong age. Ovarian torsion? Wrong age.Another month. Another episode. The gnawing unease in my gut is now dizzying, deafening. I capitulate. We do the abdominal CT. It shows a 3-cm left ovary, “possible cyst.” The gynecologist is reassuring. Highly unlikely to be torsion. Ovaries under 5 cm don't torse. Anyway, it would be very rare to have torsion of a normal ovary in a prepubertal child. Besides, her pain has improved. But, if I'm really that concerned, I can bring her in for another ultrasound during an episode.Dinnertime. I head to the kitchen. Pasta with chicken and salad, we need a green vegetable. My daughter is in a fetal position on the couch, crying. The familiar gnawing fear returns. She retches onto the floor.I call the ED. No, the ultrasound tech has not yet left for the day. She'll wait for us. I give my husband instructions about dinner and a bath for our younger daughter. He is frantically trying to fix us some dinner “for the road.” I tell him we can't eat, in case she goes to the OR. Well, I guess I could eat, but I'm not hungry.Another IV. Her eyes bore into mine, accusingly, reproachfully. I take her hand and bury her head in my shoulder. Bad Mommy. Bad Mommy!The ultrasound tech, who was chatty on our arrival, is silent. She scans repeatedly over the left adnexa. I search for the flashing red and blue Doppler of blood flow. The realization is slow.There's no flow, I tell her. She doesn't answer, just keeps scanning. She leaves to get the radiologist.I cannot comprehend. Almost 6 months of normal exams, normal tests. Six months of feeling like the neurotic Doctor Mom. Now my child is going emergently to the OR. A bizarre mixture of relief and guilt washes over me. It's over. No more wondering, no more gnawing in my gut. How could you have let this go on so long? My Bad Doctor tape screams louder than my Bad Mommy tape.The OB/gyn resident arrives to do an H&P. We recognize each other from the ED. She smiles congenially. I force a joke about all the 48-hour quant follow-ups. Now, when did this pain start? She does a double-take. Six months ago? I crumble in shame and misery.The OB/gyn attending strides out of the OR, armed with photos. The left ovary was torsed 1080 degrees—three times around. It was purple and dusky but pinked up within seconds of detorsion. She is elated as she shows me the before and after photos. I imagine a magazine advertisement. This was her ovary before. This is her ovary after.My daughter is finally settled into her hospital room. She sleeps the sleep of the drugged. I make up the small couch into a bed and lie down. My sleep is fractured by dreams. I am walking through a snowy, frozen wasteland, shivering because I have no coat. The snow is filling my shoes. I walk past other people. They wear boots and full-length coats, with fur hats. They look straight ahead. In another dream, it is I who have had surgery. I wander the halls of a gray and dingy hospital, wearing only a thin exam gown, pushing my IV pole. I am looking for my husband, my parents, my doctor, my nurse—any familiar face. It is afternoon, and I am hungry, and I want to be discharged, but there is no one I can ask for help. I awaken exhausted.At home, as my daughter watches Harry Potter on the fold-out sofa, sipping a banana smoothie, I search the literature for possible causes of torsion in a premenarchal girl with normal ovaries. Several authors speculate about sudden, decelerating movements as a possible precipitant. Martial arts? She jumps, rolls, falls … but millions of girls practice martial arts. Surely there would be more reports if this were a risk factor.EpilogueOne spring day as I prepared dinner, I heard the sound of my daughters and their friends laughing and screaming from the backyard. A joyful sound, full of the promise of new beginnings and of youth. One I hadn't heard in months, since they last frolicked in the snow, before the surgery. Their joy was infectious. I left the kitchen to watch them from the back porch.A moment of almost knowing, like the instant when the truck in front of you is spinning across the ice toward the median. Then it hit me.They are jumping up and down, up and down, on our trampoline. The one a neighbor gave us when she moved away. The one that sat, unused and covered with snow, these past several months of winter. The one whose arrival, in retrospect, immediately preceded my daughter's first episode of pain late last summer.I found nothing in the literature about the association between ovarian torsion and jumping on a trampoline. But, without a trial, I convicted and sentenced the offender. An ad on Craigslist, and less than 24 hours later, the trampoline was gone. My n equals 1. For a doctor's kid, that's enough. I am a doctor, and I have kids. My 11-year-old daughter has episodes of abdominal pain. The first time, I watch her at home. Her abdominal exam is benign, she is afebrile, she has no other symptoms. If I saw her in the ED, I'd probably get a urine and watch her. The pain resolves. Skip the urine. A month later. She has another episode, but this time she is crying in pain. My daughter, who has a black belt in te dae kuen do. The kid who walked on a broken foot for 2 days before she complained about it. The one whose abdominal exam was so benign when she had appendicitis that a pediatric surgeon waited 16 hours to take her to the OR after her CT was read as “unequivocally positive” by the radiologist. I take her to our family physician. She suggests blood and urine. I show my daughter how to do a clean catch urine. She grimaces in disgust. Then comes the blood draw. Her lip quivers. “Mom, you know how I feel about needles.” I know. She had to get rabies immune globulin and the entire rabies series when she was 2, after we found a rabid bat in our fireplace. At the time, I was the head of the Rabies Advisory Committee on the military base where we were stationed and had to recuse myself from reviewing the case. Doctors' kids always have weird things. My Bad Mommy tape is lecturing in the background. Blood tests are normal. The urine is pristine, not even a single epithelial cell. The pain resolves. Another month later, and she has another episode. Once again, blood and urine are negative. The pain resolves. There is a gnawing feeling in my gut. My mother's sense knows something is wrong. Given the colicky, left-sided pain, given its radiation to her groin, I take her to work with me and ultrasound her myself in the ED. Her kidneys are normal, no hydronephrosis. Spleen is normal size, no fluid collections or masses. Uterus and ovaries small, tucked away in her pelvis. I have only a little experience at using Doppler flow to look for torsion, but it's irrelevant. She's premenarchal, and her ovaries are tiny. Anyway, the pain has resolved. Her 12th birthday passes without incident. The gnawing sensation in my gut begins to ease. I dare to hope it won't happen again. No such luck. The next time, she is vomiting. Our family physician orders a formal pelvic ultrasound. The ultrasound shows normal flow, left ovary 2.1 cm in size, barely larger than the right. Our physician suggests a CT. I resist. She's already had one CT for appendicitis 3 years ago. What if she winds up with cancer someday? Bad Mommy, it'll be your fault for scanning her twice. Her pain resolves. I scour the pediatric literature for causes of colicky abdominal pain and vomiting in children. Her presentation is reminiscent of kidney stones—the colicky, one-sided pain, the radiation to her thigh, the vomiting. Two negative urines. No hydro on ultrasound. Volvulus? Wrong age. Intussusception? Wrong age. Ovarian torsion? Wrong age. Another month. Another episode. The gnawing unease in my gut is now dizzying, deafening. I capitulate. We do the abdominal CT. It shows a 3-cm left ovary, “possible cyst.” The gynecologist is reassuring. Highly unlikely to be torsion. Ovaries under 5 cm don't torse. Anyway, it would be very rare to have torsion of a normal ovary in a prepubertal child. Besides, her pain has improved. But, if I'm really that concerned, I can bring her in for another ultrasound during an episode. Dinnertime. I head to the kitchen. Pasta with chicken and salad, we need a green vegetable. My daughter is in a fetal position on the couch, crying. The familiar gnawing fear returns. She retches onto the floor. I call the ED. No, the ultrasound tech has not yet left for the day. She'll wait for us. I give my husband instructions about dinner and a bath for our younger daughter. He is frantically trying to fix us some dinner “for the road.” I tell him we can't eat, in case she goes to the OR. Well, I guess I could eat, but I'm not hungry. Another IV. Her eyes bore into mine, accusingly, reproachfully. I take her hand and bury her head in my shoulder. Bad Mommy. Bad Mommy! The ultrasound tech, who was chatty on our arrival, is silent. She scans repeatedly over the left adnexa. I search for the flashing red and blue Doppler of blood flow. The realization is slow. There's no flow, I tell her. She doesn't answer, just keeps scanning. She leaves to get the radiologist. I cannot comprehend. Almost 6 months of normal exams, normal tests. Six months of feeling like the neurotic Doctor Mom. Now my child is going emergently to the OR. A bizarre mixture of relief and guilt washes over me. It's over. No more wondering, no more gnawing in my gut. How could you have let this go on so long? My Bad Doctor tape screams louder than my Bad Mommy tape. The OB/gyn resident arrives to do an H&P. We recognize each other from the ED. She smiles congenially. I force a joke about all the 48-hour quant follow-ups. Now, when did this pain start? She does a double-take. Six months ago? I crumble in shame and misery. The OB/gyn attending strides out of the OR, armed with photos. The left ovary was torsed 1080 degrees—three times around. It was purple and dusky but pinked up within seconds of detorsion. She is elated as she shows me the before and after photos. I imagine a magazine advertisement. This was her ovary before. This is her ovary after. My daughter is finally settled into her hospital room. She sleeps the sleep of the drugged. I make up the small couch into a bed and lie down. My sleep is fractured by dreams. I am walking through a snowy, frozen wasteland, shivering because I have no coat. The snow is filling my shoes. I walk past other people. They wear boots and full-length coats, with fur hats. They look straight ahead. In another dream, it is I who have had surgery. I wander the halls of a gray and dingy hospital, wearing only a thin exam gown, pushing my IV pole. I am looking for my husband, my parents, my doctor, my nurse—any familiar face. It is afternoon, and I am hungry, and I want to be discharged, but there is no one I can ask for help. I awaken exhausted. At home, as my daughter watches Harry Potter on the fold-out sofa, sipping a banana smoothie, I search the literature for possible causes of torsion in a premenarchal girl with normal ovaries. Several authors speculate about sudden, decelerating movements as a possible precipitant. Martial arts? She jumps, rolls, falls … but millions of girls practice martial arts. Surely there would be more reports if this were a risk factor. EpilogueOne spring day as I prepared dinner, I heard the sound of my daughters and their friends laughing and screaming from the backyard. A joyful sound, full of the promise of new beginnings and of youth. One I hadn't heard in months, since they last frolicked in the snow, before the surgery. Their joy was infectious. I left the kitchen to watch them from the back porch.A moment of almost knowing, like the instant when the truck in front of you is spinning across the ice toward the median. Then it hit me.They are jumping up and down, up and down, on our trampoline. The one a neighbor gave us when she moved away. The one that sat, unused and covered with snow, these past several months of winter. The one whose arrival, in retrospect, immediately preceded my daughter's first episode of pain late last summer.I found nothing in the literature about the association between ovarian torsion and jumping on a trampoline. But, without a trial, I convicted and sentenced the offender. An ad on Craigslist, and less than 24 hours later, the trampoline was gone. My n equals 1. For a doctor's kid, that's enough. One spring day as I prepared dinner, I heard the sound of my daughters and their friends laughing and screaming from the backyard. A joyful sound, full of the promise of new beginnings and of youth. One I hadn't heard in months, since they last frolicked in the snow, before the surgery. Their joy was infectious. I left the kitchen to watch them from the back porch. A moment of almost knowing, like the instant when the truck in front of you is spinning across the ice toward the median. Then it hit me. They are jumping up and down, up and down, on our trampoline. The one a neighbor gave us when she moved away. The one that sat, unused and covered with snow, these past several months of winter. The one whose arrival, in retrospect, immediately preceded my daughter's first episode of pain late last summer. I found nothing in the literature about the association between ovarian torsion and jumping on a trampoline. But, without a trial, I convicted and sentenced the offender. An ad on Craigslist, and less than 24 hours later, the trampoline was gone. My n equals 1. For a doctor's kid, that's enough.