Having been in the practice of general pediatrics for the past 16 years, I could not imagine a more rewarding specialty in all of medicine. The excitement of meeting expectant parents who are looking for a doctor for their soon to be born child; the joy of the first visit to the nursery when the baby is just hours old; watching the child grow and develop into childhood and then adolescence; being there for all the illnesses, broken bones, stitches and school problems — is part of the joy and magic of pediatrics. And while there are illnesses, some of them quite serious, for the most part children are resilient and bounce back quickly. They don’t like to be sick and do not seek secondary gain from their illness...unlike many adults.
But every once in awhile, you get a case in pediatrics that tears at your heart. It comes unexpectedly, without warning. Such was the case of Billy. Billy is an eleven year old boy with a loving and caring family. I saw him for the first time a little over a week ago. Billy was relatively new to our practice and had just passed his yearly physical with flying colors a few months previously.
As I grabbed the chart I noticed that the chief complaint was "a swollen gland in his neck". Then my eyes moved over to the temperature which was recorded at 98.4 degrees...no fever, I thought to myself. When I entered the room, I saw Billy, his father, and his little brother. Billy is a handsome and polite sixth grader who looked to be the picture of health. After getting a detailed history from Billy and his father, I could not elicit ANY pertinent symptoms. He denied fever, chills, sore throat, cough, night sweats, weight loss, fatigue, cold sores, canker sores or dental problems. I even pursued a history of cat exposure in the event this could end up being cat scratch disease. This proved to be fruitless.
Billy’s exam was absolutely normal with the exception of a firm 1 1/2 by 2 inch lymph node on the right side of his neck. It was a solitary node that was not tender or warm to touch. In fact, it was dad who noticed it when Billy turned his head to the left. Billy didn’t even have a clue that it was there. After two days of watching this lump, dad made the appointment for Billy.
A lymph node like this is not at all uncommon in children. Although he did not have any symptoms, I did do a strep test because group A strep (the cause of strep throat) can present just like this. It was negative. I also did a "mono test" for infectious mononucleosis even though he didn’t have any symptoms...it too was negative. I then told dad that I wanted Billy to have an ultrasound done to see if this was anything other than a lymph node, or if there was anything suspicious about it. The next day the ultrasound doctor called me to inform me that it was, in fact, a solitary lymph node with no fluid inside.
I called dad and said it was time for Billy to see a surgeon. Before his appointment I had him get a CBC and a chest x-ray. The CBC was to look for any signs of infection that might be reflected by a high white blood count, plus I wanted to be sure that there were no suspicious (malignant cells). The chest x-ray was to be sure that Billy did not have any lymph nodes in his chest. Both tests came back completely normal and this should have put my mind at ease, but there was a little voice in the back of the head that concerned me about Billy. I thought to myself, Billy is healthy and happy...with no symptoms...and all of the tests were normal. Yet I had an unsettled feeling about this.
The surgeon called me while Billy was still in her office. She was equally concerned by this node and told me that she was going to have a needle biopsy of the node done to "put this whole issue to rest!" I was relieved to hear this because I wanted to know just what we were dealing with. I again thought...logic would tell that this was probably "much ado about nothing" but by now I was worried.
I got the call while I was taking my team of residents and medical students out to lunch after a busy month on the wards together where I teach. I got a lump in my throat when the voice on the other end of the phone told me that Billy had lymphoma — a type of cancer. The news came crashing down like a ton of bricks. As I looked at the table of bright and enthusiastic residents and future doctors, an image of Billy and his loving family was embossed in my mind. I immediately called my office and had them bring Billy’s parents to the office first thing that afternoon so I could tell them what the diagnosis was, and the plan of action that was necessary. I then called the surgeon and the oncologist (cancer specialist) to coordinate our thoughts and plan. While I was on the phone, I looked at the residents and medical students who were enjoying their short break from the hospital. I looked at their bright and enthusiastic faces and wondered how many of them would have to do what I was going to have to do in around 30 minutes. There are no books or articles or lectures to truly prepare you to do such a thing. As a pediatrician, it is one of the most difficult things you have to do...tell a parent that their child has cancer.
As I drove to the office my thoughts turned to Billy. I envisioned how he was probably sitting in class, anxious for the school bell to ring as some teacher droned on about English grammar. Little did he know that in a matter of hours his life would be greatly changed.
His parents took the news very hard but I sense that they sort of knew — or feared — that something was wrong. Call it a sixth sense, or call it parental intuition. They were devastated as this confirmed their worst fears.
The oncologist and the entire oncology service were wonderful. They deal with this every single day, and their "matter-of-factness" is comforting. When I spoke to the head of oncology he told me, "We need to find out what we are dealing with as soon as possible, and then just take care of it!". He said this with a refreshing confidence. In a very short while the mood went from despair to optimism and certainty. He WILL beat this!
Billy should start chemotherapy in 1 or 2 days. He is in excellent hands and complete cure is the goal. The next couple of years will be most difficult and trying for Billy and his family — there will be highs and lows, peaks and valleys as he climbs to the summit. Their lives will never be the same, they just couldn’t. You could not pass through something this horrendous and come out unchanged, yet I pray that Billy and his family will be stronger and closer as a result. I am confident that Billy will make it.
Cases like Billy’s do come along but thankfully not too often. We are fortunate to live in a time when the oncologists are using the word cure, and not just five year survival. When I see a patient like Billy it gives me pause. It puts things in such incredible perspective. Life is so fragile...so precarious. One day Billy is a vibrant and happy sixth grader with his entire life ahead of him, and in one fell swoop he is fighting the battle of his life. Billy could be any one of our children. I have learned long ago to not take my children’s health for granted. There is an often used cliché that is so appropriate in this context: "There but for the grace of God go you and I!" I urge those with children who have read this article to go home tonight and give them a hug and tell them that you love them...I plan to.