Consumption (42 page)
Authors: Kevin Patterson
“So she can come home now?”
“Well, I wanted to talk to you about that. Mrs. Robertson, I’m worried about how thin she is.”
“That’s why we sent her to you.”
“Yes, I have Dr. Balthazar’s referral note in front of me. I think we should admit her to hospital and get to the bottom of things that way. I wonder if she might have a malabsorption problem—that’s out of my field. But if she’s an in-patient, we can have different specialists see her quickly.”
“I think I better come down there then, if she isn’t coming right home.”
“I think that would be a good idea, Mrs. Robertson.”
“Okay.”
“Mrs. Robertson?”
“Yes?”
“Is there anything you think we should know about your daughter that Dr. Balthazar didn’t mention? Why do you think she’s so thin?”
“I had TB at her age and was the same way, that’s what I’ve been thinking it is. I don’t even want to say this, but could it be some sort of cancer?”
“Well, we’re going to exclude every possibility we can think of.”
“Okay, I’m coming down there.”
“I look forward to meeting you.”
“The only reason I didn’t before was it was just going to be a clinic visit and some tests.”
“I understand.”
“I’m sorry I’m not down there now. Is she frightened?”
“I would say that she is, a little.”
“Is she there, can I talk to her?”
“I’m in my office now. She’s up on the ward.”
“I’ll see you soon, I’m on my way.”
Dr. Balthazar’s office at the hospital was as lovely as the South African diamond money could make it. His window gave out on the sea ice and adjoining his office was an examining room with a table and matte-black German ophthalmoscopes, otoscopes, sphygmomanometers, shining rubber and stainless steel everywhere, reflex hammers and minor surgery trays laid out as if for imminent carnage. When he and the rest of the staff first walked through the building, they had all gaped. On this day he was not scheduled to see patients and so he reviewed the piles of lab work that were waiting for his assessment. He had started a folder for the newly diagnosed diabetics, and every time an elevated blood glucose came back he filed it there, in order that the person be brought back for treatment and further evaluation. The file was now inches thick and Balthazar sighed wearily as
he shuffled another half-dozen sheets of lab values into it. This disease had been unknown here when he first came to the Arctic. Kerry Nautsiaq, thirteen years old—heavens.
Marie Robertson’s results were being copied to him, at first as a trickle and now as a deluge. Sputum sample after sputum sample was negative for acid-fast bacilli, however, and TB had been ruled out early. Nevertheless, they went ahead with the bronchoscopy—you go to see the barber, you end up with a haircut—and that too was negative. CT chest abdomen and pelvis were all normal except for the upper-lobe scarring from remote tuberculosis infection. A marked decrease in both visceral and cutaneous adiposity was noted on the CT scan report. The things they could tell now—soon the radiologists would be offering opinions on whether the patient’s footwear clashed with their shirts. She was skinny, very very skinny. That’s why they did the scan. Here was the infectious disease service’s consultation:
May 8, 1992
Miss Robertson is a sixteen-year-old girl of mixed Inuit and Caucasian (English-Scots) descent. She was admitted to hospital after being seen in the respirology outpatient clinic with a view to investigating her for active tuberculosis infection. This concern was occasioned by a long-standing history of mild haemoptysis and, more pressingly, by marked and progressive cachexia noted by her family doctor, Dr. Balthazar, in Rankin Inlet. Serial sputum studies were normal in Rankin Inlet, but given that she is known to have suffered primary pulmonary
M. tuberculosis
infection as an infant, it was thought that the likelihood remained high that she had reactivation infection. At age three she completed six months of directly observed isoniazid and rifampin therapy for treatment of drug-sensitive bacillus. She did sustain some right upper-lobe scarring and has been occasionally troubled by mild haemoptysis as a consequence of limited bronchiectasis; she has
not been known to suffer extra-pulmonary disease. She has not suffered from antibiotic-related toxicities.
Miss Robertson seems to be substantially emancipated. She presents here unaccompanied by her mother; her father died last year. The history obtained is therefore exclusively from her. She reports that she has always been thin, and that she has never thought she was ill, but that recently, “a lot of people have been riding her” about her weight. She thinks she has not lost weight lately but has grown in stature, and this accentuates her appearance of thinness.
Miss Robertson denies diarrhea or abdominal cramping; she has no personal or family history of inflammatory bowel disease. She has never suffered dermatitis herpeteformis, and she has not been anemic. She reports no recent fevers or night sweats; she has noted no changing moles or lymph nodes. She reports that there are frequent outbreaks of active tuberculosis infection in her school, and she thinks she has had frequent contacts with such patients since she was a baby.
She takes no medications on an ongoing basis. Her immunizations are up to date, and she does not smoke. She has no allergies, either environmental or pharmacologic, to her knowledge. This is corroborated by Dr. Balthazar’s note.
On physical examination, she weighs 40.2 kilograms and is 1.62metres tall. Her BMI is
15.3
. Pulse is 54 and regular, temperature 35.1 degrees Celsius, respiratory rate 16. She appears profoundly cachectic, and rather anxious.
Examination of the head and neck demonstrates normal retinal vasculature, and unremarkable anterior chamber structures. The direct and consensual pupillary responses are normal. There is no lid lag or droop present. The oropharyngeal examination is unremarkable. The cervical lymph nodes are unenlarged. The thyroid is normal to palpation; she is clinically euthyroid.
Respiratory examination demonstrates the absence of digital clubbing. Breath sounds are auscultated throughout the lung
fields; rales and ronchii are absent. The central arterial pulse volume and contour is normal. The jugular venous pulse is two centimetres above the sternal angle and falls physiologically with inspiration. The apical pulse is readily palpable and is undisplaced. The first heart sound is normal, the second widely but physiologically split, there is a soft flow murmur present and the third and fourth heart sounds are absent.
The abdomen is scaphoid and her ribs and hips rise strikingly above her umbilicus. Normal bowel sounds are present, the liver and spleen are unenlarged, and both kidneys are easily palpated. A gynaecologic examination was not performed. Examination of the extremities reveals extensive laguno, but no other abnormalities.
Review of the available laboratory data reveals no suggestion or evidence for active infection of any sort. One wonders whether an eating disorder might underlie her weight loss; she will be referred to the eating disorders clinic for assessment on an urgent basis. She will require hospital admission to expedite this, as clearly matters have not been able to be addressed in her home community.
The dry, information-packed language of the medical consultation brought Marie’s face into sharp focus; that poor, poor, girl. He did not know why she was so thin; he wondered if it wasn’t simply a grief response to her father’s death and her brother’s disappearance. Victoria had been so adamant that she was fine from a mental health point of view, but he was glad he had got her to the city anyway, where they could all have a look at her, see what they thought. He remembered the day she was born, in 1975, another one of Victoria’s precipitous deliveries. Marie was smaller than the other two, but active; he remembered how she had squirmed in his hands as he passed her to her mother. These are the memories that keep old family doctors going. God, he hoped that little girl would be okay, that whatever was going on was treatable. He hoped he hadn’t missed anything dreadful. Her body fat was 8 per cent, for Pete’s sake.
Feeling suddenly and deeply weary, he stood up at his desk. His chest was heavy with anxiety and he suspected he’d overlooked something pivotal. He squeezed his eyes shut. He walked out of his office and into the hallway of the echoing, nearly empty building.
His office was in the physicians’ wing. As the sole physician there, he was without neighbours and so he walked up to the nurse practitioners’ offices and looked about to see if there was anyone having tea whom he might join. Here there was a hum of activity as children with scabies or colds or in need of annual immunizations were seen and weighed and assessed by the efficient women in this hallway. He was nodded at with a certain amount of impatience, and he retreated back to his office. The pharmacy was on his way and he stopped to look in; there was no one there. He opened the door with his key and walked inside. He looked for Tylenol. He picked out a bottle.
As he was leaving, Melinda Peterson, the new nurse-administrator, approached him. He smiled at her. Beside Peterson was a young bespectacled and serious-looking woman he didn’t know.
“Are you needing something, Keith?”
“Just some Tylenol,” he said, holding up the bottle. “Headache. How are you?”
“I’m well,” she said. “I want to introduce you to Diane Richards, our first-ever pharmacist. Dr. Balthazar here has worked in Rankin Inlet for more than twenty years. He knows everyone,” she said as the new pharmacist held out her hand.
“Wow, this is turning into a real hospital. Our own pharmacist—soon we’ll have to get some real doctors up here,” he said. And they all laughed at that.
“So we’ll be controlling the access to the pharmacy a little more rigidly,” Melinda explained, “now that we have a real pharmacist. We’ll be writing prescriptions and she’ll fill them. Which should save you a lot of work.”
Balthazar nodded.
“So maybe we should collect all the outstanding pharmacy keys, I’m thinking,” said Melinda, as if the idea was just occurring to her now.
“Okay.” And he detached his key from the key ring and passed it over.
“Thanks.”
“You’re welcome.”
He walked back into his office and thought about that for a little while.
The phone rang and it was Milt Henteleff, a paediatric psychiatrist in Winnipeg. “Hello, Milt,” Balthazar said. They had had a few patients in common over the years.
“Keith, I’ve just seen this Robertson girl you’ve sent us. She looks awful.”
“I know, that’s why I sent her. What do you think is going on?”
“Well, she’ll hardly talk to me, but I gather that her father was killed up there last summer, and her brother was lost on the land this winter?”
“That family has had a terrible year, Milt. I’ve been wondering if the girl isn’t depressed, but her mother doesn’t want even to talk about that. And you’ve seen how voluble Marie is.”
“Yeah. I dunno if she’s depressed, Keith. Maybe somewhat. But she keeps herself up, you know? She isn’t very neurovegetative.”
“I’m just a country doctor, Milt.”
“I know,” Henteleff replied impatiently. “I’m wondering if she doesn’t have an eating disorder.”
“We never see those up here.”
“Well, maybe you do.”
There was a pause.
“It would be more treatable than cancer or some malabsorption problem.”
“Which is one way of looking at it.”
“Has she ever been sexually or physically abused, Keith?”
“Not that I know of, Milt, but who knows?”
“I know. It’s a wonder we don’t see more of this stuff, when you think about it.”
“We see a lot of self-abuse—it’s not like the theme of self-punishment is rare up here.”
“Yeah. I’m gonna go talk to her some more. Thanks, Keith.”
“You too, Milt.”
He hung up the telephone and felt, as he always felt after talking to the city, clumsy and blind and inept. He laid his head down on his desk. And what was that Melinda getting at, anyway?
This used to be so much easier a job, he thought to himself. Then he thought, No, it wasn’t.
