The art of listening: Bony lesion in a toddler

To the Editor: It was a typical Saturday morning – I woke up, played with my kids, had my coffee and read the September 2010 edition of Paediatrics & Child Health’s Clinician’s Corner (1). Dr M Rashid wrote about the art of listening to our patients and provided a quote by Sir William Osler: “If you listen carefully to the patient they will tell you the diagnosis”. My wife (also a health care provider) and I discussed this point, recalling many instances in which we experienced and/or witnessed a health care professional rushing through the daily tasks of caring for patients and often failing to truly listen; we were often just as guilty. It was not because of lack of intention, caring or empathy. It was simply because the system in which we work, as well as the patients themselves, demand us to perform promptly and efficiently. Of course we all aim for perfection. After all, we are health care providers and listening to our patients is what we claim we do best. But is it? I am a paediatric emergency medicine physician in my first few years of practice. I work in a large tertiary care trauma centre. Later that same day, I was working the trauma fast-track shift in which all traumatized children are seen. Most have minor injuries but all need careful attention, care and reassurance. I had two trainees with me that day – a new third-year medical student and a senior resident. Both worked diligently, rapidly earned my trust and were afforded autonomy. As the volume of patients increased and we were running between rooms, the medical student reviewed a case with me involving a 14-month-old girl who was referred for a suspected tibia fracture. The parents had noted a bump over the proximal tibia that morning and sought care. They were seen in an outside clinic and referred to our centre with a CD of the x-rays. While listening to the medical student, I loaded the CD. I expected this to be a straightforward toddler’s fracture and the history at this point would be of limited value. However, there was no history of trauma and the parents were also very concerned about fever. The child had presented one month previously with status epilepticus secondary to febrile seizure. She had been transferred to our centre, intubated for a short period of time and did well. The child had completed a course of antibiotics for acute otitis media, and the family was now worried that the fever would recur and their daughter would reseize. While listening to the medical student, I thought to myself about the counselling we should provide before sending the family home with regard to febrile seizures and fever phobia. But in the meantime, the image on my screen finally loaded – what a bizarre lesion. As seen in Figure 1, the lesion was a linear symmetric lucency in the proximal posterior aspect of the tibia with periosteal reaction. It was not typical of any fracture pattern I had ever seen. We discussed the differential diagnosis of osteomyelitis or tumour, and consulted with orthopaedics. Off I went to the next patient. Several hours went by and the orthopaedic resident reported back the same differential diagnosis and said that his staff had never seen such a lesion either. Blood tests, bone scan, computed tomography scan, magnetic resonance imaging and follow-up in one week in the orthopaedic clinic were arranged on an outpatient basis. I still had not met the family. I had seen many patients that day and it was near midnight. The truth was that I was tired and the medical student was doing a great job managing the case and counselling the family. In fact, I was listening in as she explained that the diagnosis is unclear but that all these tests were required to help figure it out. She had broken the bad news on her own. However, I then realized that this was neither appropriate nor fair to the student, so I stepped in to meet the family and counsel them accordingly. There we were, standing in the hallway, trying to reassure the parents – all the while they had just been told that their daughter may have a tumour and nothing else mattered. Figure 1) An x-ray showing a linear lucency in the proximal posterior aspect of the tibia with periosteal reaction But that very morning I was leisurely discussing with my wife how we each pride ourselves in taking time to listen. At this moment, in this hallway, standing while giving bad news, I was failing. Recognizing this, I pulled the parents aside and we sat down. Despite the tibial lesion being discussed, the parents’ concerns returned to the fever and febrile seizure recurrence. I was surprised by the return to febrile seizure discussion while talking about the bony lesion. Nonetheless, this was the concern and I counselled accordingly, handed them the information pamphlet on febrile seizure and reassured them that it most likely would not recur. I moved on to talk about the lesion that they noticed that morning and explained that based on the x-ray, it had likely been present for at least two to three weeks. They looked at me puzzled and asked how I could tell. I explained that periosteal reaction takes several weeks to appear on x-rays and that the margins were corticated. “But we were here 3 weeks ago,” the father said. He was, in effect, telling me that I needed to ‘connect the dots’. Realizing this and not having a clue how to link these events, I moved on to examine the lesion myself. I palpated the bony lesion over her pants and asked if I could see it. What came next was a complete surprise. There was a tiny red dot overlying the lesion. I inquired about bug bites, trauma, skin conditions – all negative – and then it hit me like a thunder bolt! “Did your daughter have an intraosseous (IO) needle placed in her leg?” The parents had no idea what I was talking about. But at this time I knew that the drilled-out lesion in her tibia was from an IO needle that must have been placed three weeks ago when the referral centre needed rapid intravenous access. I confidently informed them that she most certainly had received an IO needle and that this was not an infection, not a tumour and not a fracture. I verified the old chart and buried in small print in the transfer note was the comment about a failed IO access attempt. She didn’t even make it to our hospital with it in place. No one had informed the family of this procedure. I am certain that one can only imagine the relief the parents experienced with this revelation. While many around me praised my arrival at this diagnosis (and it did feel great to help relieve these parents’ worst fears and save our system the costly workup), I actually felt uneasy. As I reflected on the case, I recalled my reading that morning and the quote by Sir William Osler. Once I actually sat down and truly listened to the family, they pointed me to their child’s diagnosis. But in the busy emergency department, can I always take this time? The answer is, most certainly. In the context of medical education and affording trainees autonomy, every clinical encounter can benefit from the added years of clinical experience for both the patient and trainee point of view – and yes, the staff should see every patient. Moreover, if each of the health care professionals involved in this child’s care had taken just a few moments to update the parents on all procedures performed, counsel them appropriately and ensure that all their concerns were addressed, many elements of this encounter – the fever phobia, the concern for bone pathology and the near worst week of their life – would have been avoided. Moreover, perhaps the entire visit would have been completely different if I had spent only a few moments with the parents at the onset of their emergency department visit.

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