Poisoned – A patient encounter
I recently saw a patient with a platelet count of 12,000. This is less than ten percent of a normal platelet value. HIV sometimes does this, and when it does, the risks of uncontrollable bleeding are significant.
In this case, HIV did this to an adorable 4 week-old baby. When I saw the value, I was worried.
To give you an idea of how worried, let me say this: I think I would personally rather contend with swallowing a teaspoon of rat poison than a platelet count of 12K. (I need to research this further, as rat poison comes in differing strengths.)
In any case, the patient was adorable, but in a perilous condition, and I was worried.
Some of you might believe that all month-old babies are “adorable”.
Well, the way I see it, human beings (including you) are wired to perceive this, or else why would we ever want to make more of them?
After all, young infants are loud. They smell. They are forever wriggling as if they can’t get comfortable (which I find unnerving). Above all, they are poor communicators.
I trust you agree with all this.
If not, before you question my potential to some day become a loving father, let me explain.
During pediatric residency, it is frequently your assignment to usher a ward full of infants safely through the night. At some point during your umpteenth sleepless night surrounded by a screeching chorus of someone else’s offspring, you realize that the categorical assumption that babies are “adorable” is false.
This realization is profound, and when it hits you (usually at around 3:30am), your wiring changes, and the change cannot be undone.
The first step after this transformation is simple: because the word “baby” is essentially synonymous with “adorable”, it becomes necessary to refer to them as something else. My favorite four euphemisms were “urchin”, “peanut”, “booger” or “the one in that crib over there”. I used these terms with discretion, of course.
The second step after the renaming the “babies” is the realization that some peanuts are not as attractive as others. Though I will admit that the determination as to which “ones” are adorable and which “ones” are not so adorable is a matter of personal taste, I consider myself quite skilled at judging adorability.
Please do not consider this an affront to your intrinsic loyalty to the urchins, and realize that I am [partly] kidding.
This is just my post-training confession about how some babies are definitely not adorable, ugly even.
I was certainly ugly, for I was 6 weeks premature. I had a head like a toaster. As a matter of fact, if I were to shave my head (I have no plans to), you would likely find that it is still a bit boxy.
Fortunately, my mother and father are wired to find me adorable, and were from the beginning.
Speaking of the beginning, my confession, though it may seem a unnecessary aside, is meant to emphasize something I wrote in the second paragraph above:
Four-week-old Nonhlanhla was indeed “adorable”, at least a 9.5 on “Ryan’s 10 Point Scale of Adorability”. (I scored a two at birth, and am still fighting my way up towards three.)
Nonhlanhla was also very well-appearing. Fat, alert, active, making those strange, senseless noises that healthy babies make, squirming for no reason in particular, probably wanting to stool or something.
I picked the baby up to check her muscular tone. It was normal.
In pediatrics training, you handle little “babies” often. Picking up tiny human beings is initially anxiety provoking, as you don’t want to drop ‘em, bump ‘em, or do anything at all that might make ‘em cry.
I have almost dropped plenty of babies, usually because they are born slippery and I am the one who has to catch the shiny, writhing (or worse, limp) bundle of slimy joy. Suffice to say obstetricians would make miserable quarterbacks.
However, by the end of my three years of training, I figured out the best grips. Thanks to the stars above and my dexterity, I never once had to hear that unfortunate “thump”.
Despite my highly evolved grabbing skills, handling Nonhlanhla made me slightly nervous. Normal platelets are in the hundreds of thousands, meaning that this baby was at least 47 cards short of a full deck (hematologically speaking, of course).
Content that the baby had normal neurological tone, I laid her down gently, and told the parents that the baby was adorable.
(I emphasized that the complement was sincere by pointing out that the baby was actually the most adorable I had seen all month, which the mother seemed to appreciate. The translator was slightly less appreciative, as I had seen her “baby” in the waiting room earlier that morning. I back-pedaled until both mothers were satisfied.)
After completing my exam, I explained that Nonhlanhla needed to start antiretrovirals as soon as possible, because she has thin blood with very few glue cells. I explained to her that HIV was likely the culprit. I told her to be very gentle with the baby, and to come to the clinic immediately if the baby seemed to be acting differently (less active, less pink, less hungry, less alert, less symmetric, etc.), or if Nonhlanhla had bruising or bleeding of any kind.
The baby is coming back early next week, when I plan to review both mom’s and baby’s chext x-rays for signs of TB (mom and baby have been coughing), complete the requisite adherence counseling, and initiate ARV therapy.
I hope the next visit goes well, for Nonhlanhla’s blood will not regain its stickiness as long as HIV is poisoning it.
Labels: Patient encounters