Lessons Learned From a 7-Year Old

When I was in graduate school, a guest lecturer named Lauren started teaching our orthopedics class. Her topic was pediatrics. Lauren herself worked with a unique population: special needs pediatrics.

I was particularly interested in this section of the course, because my dad is a pediatric occupational therapist who works with developmentally delayed children in the New York public school system. I always went with him on 'take your daughter to work day' (it was waaaay more interesting than my mom's finance job in Midtown Manhattan). I didn't plan to work with kids, but always found the cases fascinating.

Dr. Lauren described the population of children and adolescents that she saw for care; primarily kids aged 4-18 with cerebral palsy, autism spectrum disorder, paraplegia and quadriplegia.

One day in class, Dr. Lauren presented an interesting case study: a 7 year old boy named David with cerebral palsy and autism spectrum disorder, non-verbal. He had been seeing Dr. Lauren for over a year for care. He had come to trust her and enjoyed their appointments together.

Dr. Lauren shared that recently, David came into her office in a wheelchair. He had never needed one before. He had to crawl up the stairs to her office and was dragging his legs behind him, barely using them. The question she posed to us students was: what could possibly cause a 7 year old boy, who just last week was fully mobile and able to walk on his own, to suddenly stop being able to use his legs?

The assignment was to come up with differential diagnoses to what could cause this sudden regression, and how/if we could treat it. Since this was something that actually happened, Dr. Lauren would respond to the best of her recollection.

We asked question after question, spitting out differentials - spinal cord infection? No. Blood work was negative.

Trauma? No evidence of a fall, and all imaging had come back normal.

Child abuse? Perhaps. But Dr. Lauren had been working with the family for some time, and never found any evidence to suggest he came from something other than a loving home.

What did the pediatrician say? Well, sometimes children can go through developmental regression periods, and perhaps David was just acting out. With no evidence of illness or injury, they could take him to a child psychologist or 'watch and wait'.

We concluded that it had to be some kind of nerve compression. But what was the cause?

As a non-verbal child, David couldn't share what his legs felt like, if he was in pain, when he first noticed it, if it was progressive or sudden, if anything made it worse or better.

All questions needed to be directed to the child's parents. The parents couldn't think of anything that would have caused it, as their son hadn't been doing any physical activity that was different than his 'usual'. The physical exam was also very limited.

My classmates and I were stumped. In Year 2 of school, our knowledge base was limited, and 'outside the box' thinking hadn't really started yet. If it wasn't on our list of conditions and syndromes, we didn't know what the heck was going on.

Dr. Lauren let us wear ourselves out with guesses, and then shared what she discovered.

After careful questioning of his parents, Dr. Lauren learned that while he hadn't done any new physical activity, they had been trying to toilet train him. To do that, he was made to sit on the toilet for prolonged periods of time to condition him to go there whenever he got the urge.

Turns out that sitting on the toilet for hours at a time severely compressed his sciatic nerve. So, David's legs basically fell asleep!

His parents felt terrible. They hadn't thought the toilet training was relevant, and were uncomfortable when Dr. Lauren started asking questions about their sons bowel and bladder movements. Her office had mainly been a place where he would go to move and to play, not a typical 'doctor's office'.

They also had no idea that this method of training training was the cause of his issue, because it was progressive. It happened over time. David was never able to adequately recover because of course, he was doing this for hours a day every day.

(While it sounds mean, it actually is a tactic that some families in situations like David's are advised to use when children are toilet trained later in life.)

My mind was blown by this case study. This hadn't occurred to me, or to any of my classmates.

Granted, Dr. Lauren worked with a population that we did not. She had specialized in pediatrics and then gone on to learn more about working with children with developmental disabilities. She was far more prepared to encounter a child like David 10 years into her career.

Still, I will never forget that class. What it taught me is that every single detail of a person's life can be relevant to a diagnosis, and it is about asking the right questions. It's also about being humble when you are unsure, and seeking opinions and referrals from others. Aspiring to be the best is about recognizing your own shortcomings and knowledge gaps. The patient comes first. Ego has no place in medicine.

Whenever I am stumped about a case, I think about Dr. Lauren and David, and it reminds me to keep digging until I get my answer.

-Amanda