July 22, 2013

Your Kids at Risk: Three Stories

CHANCES ARE YOU DON'T REALIZE IT, but right now, at this very minute, there is an epidemic racing through the lives of our teenagers. This epidemic literally threatens their very lives. I am a pediatrician. I see and treat these youngsters every day. I'd like you to meet some of my patients.

As I swept the gray drapery surrounding Lori's emergency room bed behind me, I was startled by the intensity of pain I saw on her young face. Her mother said she was having abdominal discomfort, but clearly either she understated the situation or something had happened on the car ride over. This was one sick kid.

I glanced at the cardiorespiratory monitor above her head and noted that her heart was racing dangerously fast. Her breathing was labored and her blood pressure was beginning to drop. If we didn't act quickly, I realized that Lori would go into shock and die. But what was wrong? The ER physician thought she had acute appendicitis. "High fever, right-lower-quadrant pain, otherwise healthy fourteen-year-old girl—I'll bet she may have ruptured." He reassured me that the surgeon was on his way in for an emergency appendectomy.

While intravenous fluids rushed into her small veins and antibiotics were pushed into the plastic tubing by the nurse, I laid my stethoscope on her chest. Her heart was racing too fast and I didn't like her breathing pattern. I gently placed my hands on her abdomen and pressed—it felt like a piece of oak floorboard. Stiff. I was sure she'd ruptured something inside, and we needed to act immediately.

"Where are those guys? She should have been in surgery half an hour ago!" I barked at the ER nurse. "Is anesthesia ready, do they have an operating room prepared?"

"Sorry, Dr. Meeker. We had to call in another surgeon. Dr. Townsend's in surgery right now with an auto accident case," the nurse told me.

The next ten minutes felt like two hours, but finally the other surgeon appeared and whisked Lori to the OR. As I spoke with her mother and father, trying to reassure them that she was in good hands, I worried. I knew that once an abscess ruptures in the abdomen, time is of the essence.

So I changed the subject while the surgeon worked. That's all I could offer. We talked about her last basketball game, when her team played my daughter's and beat them. We all smiled at the thought of the kids playing basketball, and I felt a warmth then that I knew they didn't feel. My daughter was home in bed; theirs was struggling for her life on a steel table upstairs.

When the surgeon came out of the operating room he motioned to speak to me privately. That unnerved me, as it did her parents.

"How'd it go?" I queried.

"She's in serious danger. I have to be honest. She didn't have appendicitis." He said firmly.

"When I opened her, she had an abdomen full of pus. She had a tubo-ovarian abscess which had ruptured. I had to take her right ovary and her left one doesn't look so hot. Frankly, she'll be lucky if she pulls through," he told me.

What his findings told me was that Lori had pelvic inflammatory disease, caused by either chlamydia or gonorrhea. The infection began in her cervix and climbed to her uterus, then through her fallopian tubes and out to her ovaries. It formed an abscess on her right ovary that had ruptured, spilling the infection into her abdominal cavity. This type of infection is always life-threatening. How had she gotten the infection in the first place? Whether she had had sex once, twice, five times—it didn't matter.

When I told her parents they were shocked and frightened. Her father's instinct was to blame her boyfriend. After all, he said, he was 16 and should have known better than to harm his young daughter. Then he became angry with me, the surgeon, himself, then Lori. Then he just broke down and sobbed.

Two days passed and Lori finally turned the corner. Her heart rate returned to normal, her blood pressure rebounded, and the antibiotics we pumped into her veins seemed to be winning the battle against chlamydia. She didn't have gonorrhea, as it turned out, and this was good. Chlamydia is stubborn enough.

After a week, Lori went home from the hospital. She would live with the scar tissue surrounding her one remaining ovary and fallopian tubes for the rest of her life. It is highly unlikely that she will ever bear a child.

"Oh, no! Dr. Meeker, you can't see me. Where's the other Dr. Meeker? I'm supposed to see him, not you!"

"Sorry, Alex. You get me today. My husband's busy with other patients. Do you want to wait until the end of the day? He may be able to see you then."

"No. I need help, like, now. This pain is killing me."

"Okay, Alex. Why don't you tell me what's going on? Where is the pain, and when did it start?"

" I don't know what happened," said Alex. "I woke up yesterday and started feeling kinda sick. Then I felt achy all over. When I woke up today I had bumps all over my...my...private areas." He winced as he spoke and grabbed his thighs, pounding them. "I don't know what's going on. Do you think I've got cancer or something? I mean, this is bad."

"Well, let me take a look," I said. "I don't think you're going to die, and I don't think you've got cancer, but let's figure out what's going on."

Alex undressed and I indeed saw three or four blistered vesicles on his scrotum and penis. They looked like chickenpox and his genitalia were red and inflamed. I knew the signs. Alex had genital herpes.

After I finished examining him, I told Alex what he had. I told him that I could give him strong pain medication and medication to help keep the herpes under control, but that antibiotics wouldn't kill it because it was a virus. When he realized what I was saying, he sank in his chair.

Alex came back again and again. Usually he saw my husband, and I learned from him that after about five days, the herpes receded into his nervous system, as herpes typically does. My husband contacted Alex's three girlfriends and told them that they too needed to be on the lookout for genital herpes. One of them was 13 years old.

The next time I saw Alex was a year later. He was 18. He came in because he had a sore throat and, like the last time, saw me as a last resort. He was embarrassed. I could see it in the way that he hesitated to make eye contact with me. Whenever I looked at his eyes, they darted toward the floor.

As I peered down his throat, I tried to make light conversation, pretending I'd forgotten all about our last visit. But something about his inflections, his body language, and his facial expressions led me to believe that he was more than just embarrassed. After I gave him a diagnosis for his illness that day, I asked him if he was okay.

He sat silent for a few moments then broke into tears. As he cried, his whole body shook. When he quieted, I asked him how long he'd been struggling with such sadness. He told me that it started "that day." Another outbreak.

I learned more: "Something's wrong with me," he said. "I wake up in the morning and feel like someone's kicked me in the stomach. I don't care much about playing soccer anymore. My folks are on my case. We fight a lot, then I leave the house and just try to stay away."

Sleeping was an issue, too. "Once I get to sleep I don't stay there. I wake up and can't get back to sleep," Alex confessed. "By the morning I'm so tired I can barely get to school." On dating: "I don't want to date or anything. I mean, I do, but I don't. Get it? I just feel sorta messed up. I mean, I've got this DISEASE. It's scary. I don't want to have to tell a girl. If we start dating and then start having sex, what if...what if she finds out? I mean, she'll think I'm dirty. I guess that's it. I just feel dirty."

"Have you ever thought of killing yourself?" I asked him quietly.

He stared at me and paused before he answered. " I got some pills from my mom's bathroom and started to take some....I chickened out, though," he said.

"When was that?"

"Coupla weeks ago."

 When I answered my page, I was startled to hear Marion's curt tone on the other end of the phone. Marion is the mother of my long-time patient Holly, and she was half angry, half upset. I had known her for years and had never heard her sound this way.

"Meg," she started, "I know you haven't seen Holly in two years and I know that you think she needs an internist now because she's gotten older. But you need to see her as soon as possible."

"What's up?" I asked.

"Holly came home from college two weeks ago and saw the gynecologist you suggested. He's scared the daylights out of both of us—he says she needs surgery. As if that weren't enough, the reason she's having problems is because of HPV. The worst part, he told me over the phone, is that she's probably had numerous infections with it over the years. Meg, she's only nineteen years old, and she could have cancer! Nobody told her this could happen. Nobody told me." I could hear Marion begin to cry.

"I'll see you both on Wednesday, end of the day," I said.

Marion and Holly were in the exam room right on time. I felt guilty and sad. I had known that Holly started having sex when she was 17, a junior in high school. I had told her the dangers and recommended that she tell her mother. I didn't think that this would be difficult because she and her mother were very close. She agreed, and said that she'd think about it.

Holly told me then that college and a career were very important to her, and that she certainly was going to do everything in her power to avoid getting pregnant. On at least two previous visits, Holly and I had thoroughly discussed the importance of postponing sex as long as she could. But then Holly didn't come back for office visits.

That Wednesday, we pieced together what had transpired in her life since she went away to college and moved out of my care. She decided that she really didn't want to postpone sex. She had a steady boyfriend at 17 and had felt that she was mature enough to have a sexual relationship. She got on oral contraceptives, and they had fairly regular sex for about a year. Then another "serious" boyfriend came along, and they had a sexual relationship for about six months. "Any others?" I queried.

"Well, since it's out in the open. Yeah. Two. They weren't a big deal, though. Just had sex a coupla times with each." she admitted. "After I started, I thought it was fine to just keep going."

As Holly spoke, Marion sat beside her silent.

"What did Dr. Reynolds tell you?" I asked.

"I went to see him while I was home on spring break. He did an exam and asked me a bunch of questions. About a week after I got back to school, his nurse called to say that my Pap smear was abnormal, that he wanted to see me back in his office as soon as possible.

"I was too chicken to tell Mom or anybody else. When I got there, he told me that my cervix showed signs of cancer and that I needed a LEEP procedure. I still don't get what that is. Anyway, I asked him how in the world all this happened to me. He said that I had HPV—probably several different strains of the virus—and I guess I still don't really know what that is either. No one talked about it at school that I can remember."

Holly's mom was quiet but tense, with a mixture of anger and fear. "Meg," she said, "walk us through this. What is this procedure?"

"Well, the LEEP is a fairly simple procedure done by gynecologists. LEEP stands for 'loop electrosurgical excision procedure.' Holly will go to the outpatient surgery department of the hospital and Dr. Reynolds will meet you there. He may give her a local anesthetic beforehand. Then he'll take a laser instrument and remove part of her cervix. He does this to make sure that any precancerous cells are removed so that they won't turn into more dangerous ones. Does this make sense?" I asked, to make sure that they were following everything I was telling them.

"How much will he remove?" Marion asked.

"That depends. Every woman's cervix is shaped differently and he could remove a small portion or quite a large piece, depending upon how large an area is involved."

"Will this hurt a lot?" Holly asked nervously.

"It will be uncomfortable and you'll have some cramps. You'll be able to go home shortly after it's finished," I said, trying to sound as reassuring as I knew how.

"What about children?" Marion asked.

"I'm not a gynecologist, but I will tell you that she'll be at a much higher risk for complications during her pregnancy, particularly if Dr. Reynolds has to remove a lot of tissue. The cervix helps the baby stay within the uterus during pregnancy. If he has to remove a large portion of it, she might have trouble holding her pregnancy," I said.

"But let's take one step at a time," I said. "Let Dr. Reynolds get rid of the precancerous cells. If Holly doesn't have this procedure done, untreated cervical cancer is nothing to fool around with. It is life-threatening."

"Cancer, from sex," Marion said, to nobody in particular. "She's only a freshman in college." Marion's disbelief and sadness were obvious.

Four days after our conversation, Marion held Holly's hand while Dr. Reynolds burned a piece about the size of a thick quarter out of Holly's cervix. That fall she went back to college to finish her studies in biochemical engineering. She will, I learned, have trouble bearing children, and it's likely she'll go into premature labor when she does become pregnant. "But," as Dr. Reynolds said, "it sure beats aggressive cervical cancer."

As of this writing, a year and half later, I learned from Marion that Holly's recent Pap smear results were again abnormal.