Join medical resident Siobhan Deshauer, MD, as she meets Mona, a pediatric rheumatology patient.
(A partial transcription follows. Note that errors are possible.)
Deshauer: Hey guys! I’m Siobhan, a fifth year physician assistant. Now I’m training to be an adult rheumatologist, and part of that process is a month of pediatric rheumatology. For the past few weeks I’ve seen kids in the clinic and it’s so much fun. This morning we are in a pediatric rheumatology clinic and I really hope to introduce you to a 6 year old girl named Mona. And then in the afternoon we go to see any consultations that come to the ward in the hospital.
If you are not sure what a rheumatologist is, we specialize in treating systemic autoimmune diseases such as rheumatoid arthritis or lupus, diseases where the patient’s immune system goes haywire and starts attacking the patient’s body. This leads to a range of symptoms, from painful arthritis to kidney damage or even inflammation in the brain. Good morning guys!
batthis: Good morning.
Debbie: Good morning.
maddie: Good morning.
Deshauer: This is such a skilled and caring medical team and they have been so welcoming to me. There’s Dr. Batthish, a pediatric rheumatologist; Debbie Registered Nurse; Maddie, a live-in physiotherapist; and Amy a childhood life specialist. As you will see, they each play an important role in the treatment of these children.
batthishuh: Hi Siobhan, so our next patient is Mona. She is a 6-year-old girl with a recent diagnosis of juvenile dermatomyositis. Mona was diagnosed in April of this year and has been doing extremely well since starting methotrexate therapy.
Deshauer: Oh good.
batthis: Mona is in today for her methotrexate injection and a physical therapy exam. Hi, Mona.
mona: Hi!
batthis: How are you, honey?
mona: Good.
batthis: Are you feeling good today?
mona: Yes.
batthis: What amazing. What are we doing…?
Deshauer: Juvenile dermatomyositis is a rare autoimmune disease that affects children. Dermato, meaning skin, because they develop marked rashes around their eyes and over their knuckles, and myositis, meaning muscle inflammation, which makes these patients very weak. Eight months ago, Mona became ill. She had so much muscle inflammation that she couldn’t walk and her parents had to carry her to the hospital, a terrifying experience for them. Mona was diagnosed with juvenile dermatomyositis and she was treated with drugs to suppress her overactive immune system called prednisone and methotrexate. As you can see, she’s fine now. Hey!
mona: Hi.
Deshauer: What’s your name?
mona: My name is Mona.
Deshauer: What was it like when you first got sick Mona?
mona: It was boring, because walking is quite fun.
Deshauer: Yes. It was boring not being able to walk.
mona: Because what if we can’t play hide and seek and walk?
Deshauer: What was it like when you were in the hospital?
mona: I’m going to say I was just a little scared because I didn’t know it would be like that needle.
Deshauer: Imagine how overwhelming it must be for a little 5-year-old to be newly diagnosed and need an injection of medication, have regular blood draws, and come to the hospital all the time. We actually have a kind of caregiver who helps kids navigate this whole process and they’re called child life specialists.
Child life specialists like Amy educate children about their illness. They help prepare children for procedures such as an injection or blood test by practicing each step on a stuffed animal. This way they know what to expect, and it reduces some of that fear and anxiety. For Mona, that includes numbing the skin with a bandage before she gets the injection, I wish we’d use this more for adults, then pick out a toy to distract her and a fun bandage for afterwards. Now it’s time for the real work.
Debbie gives Mona an injection called methotrexate. This is a drug given once a week to suppress the immune system and prevent it from attacking her muscles and skin. Right now, after months of receiving the injection, Mona is a pro.
maddie: When I first started working with Mona, she had a lot of difficulty standing, walking and a lot of joint contractures – meaning the shoulders and elbows were on the inside – she was unable to fully extend or stretch her joints. to move. She also had contractures in her hips and her knees and her ankles. Mona has worked hard to stretch all those joints and get her strength back to where it is today. Now she not only walks and stands, but also climbs the stairs and works on jumping and balance on one leg. So she has made great strides since we started working together.
Deshauer: Part of physical therapy is stretching her muscles. Because when Mona first got sick, she didn’t walk or move her joints, so they tightened up, causing contractures. Even after the inflammation subsided, her joints’ range of motion was limited. She has put in a lot of work to get to this point and now look at her. I absolutely love how much fun Maddie makes these exercises. Hey.
maddie: High five. Yes, Mona.
Deshauer: And now? How do you feel now?
mona: Good.
Deshauer: Yes? Do you feel any better now?
mona: Much better than before.
Deshauer: Yes. What is the biggest difference now?
mona: The biggest difference is that I walk normally. All the nurses are nice to me, and they help me feel better, and they take care of me, and they help me feel better. A special thanks to Maddie and Debbie. Peace, guys.
Deshauer: Isn’t Mona great? You can just see how comfortable, confident and safe she feels, which I think is a huge testament to this medical team. It’s amazing to see how well Mona is doing and to hear the difference to her quality of life. But when I see a small child with an illness, you have to wonder, what does it look like for her to move on?
batthis: Well, we’re lucky enough to have a lot of therapy at our disposal for kids like Mona. With early treatment, they generally do very well. Someone like Mona, who’s shown such an improvement so early on, I’m really hopeful that we’ll be able to maintain her state of remission and eventually even wean her off therapy.
Deshauer: Fantastic. Hopefully I can just have a normal childhood and…
batthis: Absolute. She should be able to do what she wants. Any sport or activity in the future will be available to her.
Deshauer: That’s fantastic.
batthis: Thank you very much Deshauer for a wonderful morning. I really appreciate you being at the clinic today. I have heard that there may be a consultation in the department for a possible MIS-C [multisystem inflammatory syndrome in children] case. When you’re ready, why don’t you meet with Dr. [inaudible] to review it.
Deshauer: Absolute. No problem. I’ll just finish my notes, and then I’ll go upstairs. I love how the hospital is full of so much color. It’s so cheerful. Honestly, I wish we did this in adult hospitals. Also check out these cute buggies for pushing kids around. There is even a small parking lot to leave them behind.
This is the hospital map and you can see that it is divided into four colors, which is great fun for kids. It’s actually very helpful if you get lost. This is the red part, as you can see. Now I’m going to try and find the ward where this patient is.
I haven’t read this patient’s file yet. But what I know so far is that she is a 10 year old girl who was previously completely healthy and today comes in with a fever for 4 days, sounds like abdominal pain, diarrhea, rash and has had some sort of red eyes. The question for us today is whether this could be a childhood multisystem inflammatory syndrome, a serious condition associated with COVID-19.
MIS-C can happen to children about 4 weeks after a COVID infection, and they usually develop a fever, rash, and swelling. We still have a lot to learn about the condition. But so far we know that early diagnosis and treatment is important to avoid complications. I walk into the room and see a young girl lying in bed with her mother stroking her hair. Her mother explains that they have been so careful to avoid exposure to COVID.
She does go to school, but there have been no recent cases in her class. The girl won’t talk, but I can examine her. Both eyes are red. Her stomach is slightly sensitive and her hands look swollen and red.
Her lab work shows high levels of inflammation and special tests for her heart, the troponin and pro-BNP, show that her heart is under extra stress. Some of her infectious work is still pending and not back yet, but so far this seems fairly consistent with MIS-C.
One thing that’s really different in pediatrics is that you don’t just treat the patient, but you often talk to parents and advise them. So it feels like there are sort of multiple patients in the room to care for in a certain way. At this point we need a little more information, some blood work to look for antibodies to show if there was any COVID exposure, and an ultrasound of the heart. Because the blood test showed that the heart is under a lot of strain right now, and we want to see how it’s pumping, if there are other problems.
The last step is actually treating her so she can feel better again. We need to treat the immune system that is now so boosted with a drug called IVIG. to give [intravenous immunoglobulin] and steroids. Both should work pretty quickly and make her feel better soon.
I just feel bad because it seems like these parents are blaming themselves. I mean, they’ve been super careful. There is no known COVID exposure, but often it does. We are in a global pandemic, so it is impossible to avoid it completely.
I absolutely love this rotation, seriously a highlight of my training. This medical team is so passionate. They really go out of their way to advocate for all of their patients. It’s just so much fun to play with kids and empathize with parents. I mean, there must have been a few days when I came home, especially after seeing some really sad cases or sick kids, that weighs on your heart and that’s heavy.
But then there are other days when I come home and I wonder why I don’t go into pediatrics because I love this so much. Then I remember this was the way I felt after pretty much every rotation in medical school because there is something amazing to discover in every medical specialty. I would like to say a huge thank you to the entire pediatric rheumatology team and of course Mona for making this video possible. If you want to see more videos like this subscribe and I’ll see you on the next video. Bye for now.
Siobhan Deshauer, MD, is a Toronto-based internal medicine physician. Before medicine she was a violinist, that’s why her YouTube channel is called Violin MD.
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