and A Diagnostic Surprise
Diagnostic acumen is the hallmark of great physicians. It requires a mysterious combination of superior knowledge, extensive experience and astute intuition. Fortunately, after a month as a junior intern, I was amply endowed with these qualities. This anecdote describes a rare opportunity that was offered me to demonstrate my diagnostic skills.
As a young intern at the Winnipeg General Hospital, before it became a Health Sciences Centre, one of my first rotations was in the Emergency Room. Now, in 2016, the ER is a formal Department, staffed by specialists, with X-ray and trauma rooms, but at that time it was simply the ER. It was the heart of the hospital, for us a theater of daily drama and tragedy, and it was the service where interns became doctors. In the era before full-time emergency physicians, we junior interns staffed the ER on twelve-hour shifts. If we were desperate we might get a resident to come down from the wards and see a patient but more often they were busy in the ORs and would send a message to admit the patient directly to their ward. There was a qualified surgeon nominally appointed as Director, I think on a part time basis, but he was rarely seen and I doubt I would have recognized him.
I saw 60-100 patients during each twelve-hour shift. Every day we managed cardiac arrests, trauma, and overdoses. All required an accurate diagnosis, sure judgement and decisive action. Within a few weeks I was confident that I could competently manage almost any medical emergency.
The incident that I describe occurred on a relatively tranquil evening in late summer. Thankful for a short respite, we were drinking coffee in the converted storeroom that served as a lounge. The phone call from frightened parents that disturbed our peace was unusual but not enough to warrant more than a routine response. While changing the diaper of her two-year-old child — her first — the young mother had noted a new appendage protruding from his anus. She had thoroughly inspected that orifice, and his other parts, each time she bathed him, and they had always before looked quite normal. She and her husband were bringing him in by ambulance.
Ten minutes later they arrived; both parents were frightened and querulous though the patient was remarkably unperturbed. The parents could add nothing to the brief history they had given by telephone. No problem there for an experienced ER doctor. All that was required was to undress the child, examine the offending appendage and make the diagnosis. We all crowded into a small examining room: fidgeting patient, reassuring nurse, anxious parents and me.
The parents’ observations had been accurate, a small faecal stained appendage, two or three millimetres in diameter and about two centimetres long protruded from the child’s anus. It didn’t look like a diverticulum or a haemorrhoid and I quickly narrowed the differential diagnosis with a few quick astute questions. Had the child had any weight loss, rectal bleeding or itching? Had they recently travelled in the tropics? Were there pets at home? Had they previously examined his stools? Although their responses to all questions were negative it was obviously some sort of intestinal parasite.
I had had the benefit of a traditional medical education with a well organised set of lectures on helminthology (about three years back), delivered by an expert, and with lab sessions in which we examined formalin-preserved specimens of various tapeworms, roundworms and pinworms in jam jars. This rote approach to medical education would horrify a modern educator but I thought I had learned enough about the topic to cope with most problems encountered in a temperate zone. Admittedly I hadn’t viewed this as a high priority in my medical education and had attended the lectures with desultory interest. But I was confident I had enough basic knowledge of the subject to manage this simple problem competently. I had never actually seen an intestinal parasite outside of a jar and this specimen didn’t resemble anything I could remember, but a few simple investigative steps should serve to resolve the diagnosis satisfactorily.
The parents were reassured that this problem, though aesthetically unpleasant and perhaps requiring a little more attention to hygiene, was not life threatening. I explained gently that intestinal worms were not indicative of bad parenting and that a simple antibiotic purge would cleanse the infant’s digestive tract. The next step was to don gloves and carefully extract the offending creature for more detailed analysis. By this time we had attracted a small crowd. All the nurses not otherwise occupied had squeezed into our cramped cubicle to watch this delicate operation. I basked in the aura of an attentive and appreciative audience. The parents’ level of anxiety decreased perceptibly and they withdrew a little, perhaps overawed by the medical resources being mobilised to treat their child.
I pulled very carefully, steadily and gently on the head (or tail) of the thing and it yielded. One or two centimetres of the body slipped out, then a little more. All this was done with great delicacy and finesse since I wanted to extract the creature intact. There was total silence from my intent audience.
About 30 cm. was retrieved in this fashion and coiled on a towel, but it kept coming. The diagnosis, which was becoming painfully obvious to me and had probably been apparent to the nurses all along, came to the parents in a flash of recall. Yesterday they had seen the child playing with a long piece of white packing cord, sucking on one end, as two-year-olds will do. In their panic they had forgotten. Their change in attitude was palpable; they were suddenly much less impressed with my erudition.
The nurses drifted away to more interesting pursuits. Not one said a word or changed her expression of mild curiosity. I left the mother to extract the remainder of the string herself.