"The next patient is a 5-year-old who is unable to walk," reports the overnight resident at the morning sign-out. "He had a day of fever 4 days ago, leg pain beginning 2 days ago, and yesterday he awoke with refusal to bear weight."
As we get to the differential diagnosis, I try to expand on the list of possibilities rather than merely accept the working diagnosis of myositis developed in the emergency department.
We start with the common paradigm, "If you hear hoof beats behind you, you turn around expecting to see a horse, not a zebra. However, beware the hard-charging rhinoceros that will run you over if you don’t turn around fast enough." What is the rhinoceros in this situation? A septic hip. That needs to be ruled out emergently. If suspected, you get an immediate orthopedics consult and probably an aspiration of the hip, as destruction of the joint can occur in less than 24 hours. Physical exam had excluded this possibility. The hip was nontender.
The physical exam had revealed some mild tenderness of the calves.
"What if there were decreased or absent reflexes?" I ask. Several people jump on the diagnosis of Guillain-Barré syndrome. Correct, although I lament that only one of the four history and physicals obtained in the ED or by the admitting team had documented testing any reflexes. Teaching point made – do thorough physicals.
"What if," I asked, "you had detected weakness in the legs?" The room is silent as people consider the options. I hint, "It’s mostly of historical interest." After more silence, a medical student proffers polio. That is correct. A resident admits that she would never have thought of that diagnosis. Years of training had matured her book learning into a more honed clinical judgment. To a modern resident, polio isn’t a zebra, it’s nearly a unicorn.
I had the opportunity to check my e-mail prior to going on family-centered rounds. It contained two reminders that on that date in 1954 large-scale immunization with the Salk vaccine had begun.
The purpose of my column "Beyond the White Coat" is to provide updates, news, and perspective from the fields of law, philosophy, and the humanities that have an impact on clinical medicine. Historical events provide perspective. I was acutely aware that morning of the difference between what I faced and what one of my predecessors in the 1950s would have faced.
In that bygone era, the nightmare for many parents was putting an infant to bed with a fever, not knowing whether the baby would wake up paralyzed. Because of medical progress, I didn’t have to deliver such a grim diagnosis. I had good news to give. "Your child has a muscle inflammation that occasionally occurs after influenza and some other viruses. The muscle enzyme test this morning is improved from yesterday. The clinical exam is also better. He is now bearing weight. He’s going to be fine. I expect full recovery in another 1-3 days."
Parental refusal of vaccines remains a significant and growing problem. The Wall Street Journal last month carried yet another article about pediatricians who fire from their practice parents who refuse vaccines ("More Doctors Fire Vaccine Refusers," Feb. 15, 2012). The American Academy of Pediatrics has a policy statement discouraging such a response (Pediatrics 2005;115:1428-31), but many physicians disagree with that policy (Arch. Pediatr. Adolesc. Med. 2005;159:929-34). A wide variety of reasons are given to justify the practice. Other physicians, working locally such as in this Missouri article, are encouraging the virtue of accommodation ("Responding With Empathy to Parents Fears of Vaccinations," Missouri Medicine, Jan/Feb 2012). (Full disclosure: I’m proud to say I work with those two Missouri doctors.)
I have a research interest in parental refusals of care, as indicated in my September 2011 column ("A Parents Refusal and the Harm Principle," September 2011, p. 32). I won’t try to settle the vaccine controversy here. For me, this isn’t an issue of parental authority, parens patriae, and medical liability. The real motivation for spending the extra time educating and guiding parents who are worried about the safety of vaccines is rooted in my gratitude that I will never have to walk into a room and break the horrific news of polio to a family. It is a debt I owe those who came before me: the scientists, clinicians, parents, and children, who conquered polio. For those efforts, thank you.