Notes from a Healer

Heartbreak

Brian T. Maurer
btmaurer1@comcast.net

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This mother is obviously concerned.  I can read the worry in her furrowed brow and unflinching frown.

Her 10-year-old daughter, on the other hand, looks anything but upset as she sits quietly on the exam table.  She even smiles at me when I greet her as I enter the exam room.

“I understand that Jennifer has had an ongoing sore throat despite antibiotics,” I muse as I scan the medical record.  “How long has she been sick?”

“Last week I brought her in for an infected big toe,” the mother explains.  “The doctor prescribed a round of antibiotics.  The toe started to look better, but then she developed a sore throat.  That’s when he added a second antibiotic.  It’s been three days, and she’s still complaining that her throat hurts.  As a matter of fact, it seems to have gotten worse overnight.”

I review the two previous notes in the chart.  There is no documentation that a rapid strep test was performed.  I reach for the throat lamp and a tongue blade.

“Let’s have a look,” I say.  “Open wide, relax your tongue, say ‘ah.’”

As the girl complies, the palatine arches expand upward, revealing a string of shallow ulcers along the edges.  The tonsils are absent; they were extracted several years ago.

I feel for nodes in the child’s neck.  They are palpable, but not particularly tender.

I reach for a sterile cotton-tipped swab and direct the girl to open her mouth wide once again.  Gently, I stroke the back of her throat with the applicator.

“Let me run a quick test to check for strep,” I tell the mother.  “Be back in five minutes.”

The test, as expected, is negative: this child’s pharynx harbors no virulent streptococci.

“I wanted to run the test just to be sure,” I tell the mother.  “There’s no strep.”

“Then why is her throat getting worse instead of better?” the mother asks.

“Most likely she didn’t have strep to begin with,” I explain.  “She’s picked up a little virus which is running its course, causing the sore throat.”  Then, in an attempt to downplay the issue, I continue, “We’re seeing quite a bit of this virus lately; it makes its rounds through the community every summer.  It’s a type of enterovirus called Coxsackie virus—”

“Oh my God,” the mother whispers, turning pale.  “That’s the virus that trashed my heart.”

I stand stock still, suddenly recalling the saga of the mother’s ordeal.  As a dental hygienist, she had contracted an enteroviral infection from a patient, which coursed through her blood stream and lodged in her heart.  The subsequent myocarditis resulted in dilated cardiomyopathy, which effectively reduced the ventricular ejection fraction to 30 percent and forced her into premature retirement.

I could have couched the explanation for her daughter’s sore throat in less precise terms; I could have brushed it off as something relatively insignificant.  Instead, I’ve only succeeded in causing undue concern for this mother, who now fears that the virus in her daughter’s throat will ultimately go on to affect the child’s heart.

I steady my nerve, settle my voice and look at this mother with an unflinching eye.  “We see a lot of children with this particular virus every summer, and I can truthfully tell you that in 32 years of practice I have never seen a child go on to develop heart problems from it.”

And then a curious thing happens: her facial muscles relax, the furrows fade from her forehead, the tension drains from her body.  “You’re sure?” she asks.

“I’m certain,” I reiterate.

“Do we need to continue the antibiotic?”

I shake my head.  “No, you can safely stop it.  The virus will run its course; your daughter will be fine.”

As predicted, the girl’s illness resolves without sequelae.

The incidence of myocarditis after enteroviral infection is estimated at 1 to 4 percent. Evidence-based reassurance imparted with words of comfort goes a long way toward healing in the practice of primary care medicine.

 

About the Author

  • Photo of Brian T. MaurerBrian T. Maurer has practiced pediatric medicine as a Physician Assistant for the past three decades.  As a clinician, he has always gravitated toward the humane aspect in patient care—what he calls the soul of medicine.  Over the past decade, Mr. Maurer has explored the illness narrative as a tool to enhance the education of medical students and cultivate an appreciation for the delivery of humane medical care.  His first book, Patients Are a Virtue, recently reviewed in The Yale Journal for Humanities in Medicine, is a collection of patient vignettes illustrating what Sir William Osler called “the poetry of the commonplace” in clinical medical practice. Interested readers can read more of the author's writings at his website and blog.

  • Published: July 6, 2011