Finding the Horse among the Zebras

"What do you do when an elephant sits on your refrigerator?" asked the five year old girl during clinic.

After she asked this question, I started thinking.
Well, I suppose there is a logical next step. But no matter how logical, I also know jokes coming from a five-year old usually have some punchline that becomes clear after it's mentioned.

"I really do not know," I said.

"Get a new fridge." she responded.

Of course, that makes sense now that she mentions it.

***
I completed my pediatrics rotation over one week ago, after which I rolled right into the winter vacation. And with vacation comes a completely altered state of mind-you get caught up in the simplicity of life-- eating three meals at home, spending time with family and friends, watching movies, running in the bitter cold, relaxing and getting away from anything medical. Hence, the hiatus from writing.

My last week in pediatrics was spent in the primary care clinic, a completely different world from the inpatient setting, where I had spent the three previous weeks among a team of providers handling the care of more "complicated" patients.

In the outpatient world, the clinic visits focus on well-child visits, anticipatory guidance, growth charts, and immunizations (among other things). It's an opportunity to verse parents about developmental milestones in motor, social, and language areas. You see mostly healthy patients of all ages, from newborns to teenagers.

***
Before starting my third year of medical school, I was told by a master diagnostician that there are two types of patients at extremes. There is the "horse," which represents the common conditions who follow the text books and can be diagnosed by relying on history, physical exam, and certain studies. And then at the other end of spectrum exists the "zebras," which are the diagnoses that are unusual and bizarre. They follow no text book description and often represent a diagnostic dilemma- the types of cases that have become glamorized by television shows, such as House.

When I spent time on the pediatric wards, I was surrounded by many zebra diagnoses with some interspersed horse diagnoses. Only at a tertiary care center...

The medical complexity of their conditions coupled with juggling multiple social factors and medical consult services, makes providing care challenging and rewarding. While on service, I took care of patients with a myriad of conditions, including Guillain-barre syndrome, asthma, whooping cough, inflammatory bowel disease, recurrent arteriovenous malformations, and encephalitis.

While some of my patients were acutely ill, others were recovering and undergoing intensive rehab after suffering neurological injuries. While admitted, these patients meet with the physical therapists, attend school, and participate in social events. In many ways, the hospital becomes a transient home. And it's remarkable to watch how these patients improve, slowly regaining the ability to stand, walk, swallow--exceeding our expectations.

Some of the patients were well-differentiated, having been diagnosed prior to transfer, while others came undifferentiated and were transferred from an outside hospital for further work-up (or because initial work-up did not point to any particular diagnosis).

As the hospitalist team on the wards, we certainly had our share of diagnostic puzzles, which become more complicated when you have to rely on other sources, namely the parents, for an accurate medical history. As the result, the eyeball tests becomes even more paramount in helping guide the diagnostic work-up. And when you add multiple consultants, who have very specialized expertise into the mix, you face an entirely different problem. It's just like having too many cooks in the kitchen. The primary team then becomes charged with coordinating care for the patient, managing the consultants requests and completing a barrage of blood tests and imaging studies.

In many ways, the "horses" (the more common diagnosis) become the "zebras."

Despite the complexity of diagnosing patients who present with an atypical presentation of a disease or patients with uncommon conditions, there is something rewarding about making the diagnosis and being able to make our patients feel better.

One of the most memorable parts of my rotation was the patients. I am simply amazed by children and their ability to cope and heal despite the challenges.