Youth

I want to revisit a patient…a lovely face that was only a part of my training for a week. She came back from the dead, literally, in the last week to haunt me. An unexpected ghost.

I must have clerked her on Friday the 26th of December. I remember this particularly because the Registrar that I presented her to was not our usual Friday firm reg. Jo was away for Christmas and Noor, being Muslim, had agreed to do her call in exchange for his New Year call. I remember it was him because next to him she was so weak and small and he wasn’t being very empathetic.

She was 13 years old. Let it sink in.Physically she could have passed for a 15 or 16 year old. She certainly didn’t look terribly out of place in the adult Internal Medicine ward.

She couldn’t have been less out of place though. She had the wide eyed eyes of a child scared in hospital. She cried if I came near her with a needle and pleaded like a 7 year old for another way of doing the transfusion.

She was coming to the end of a summer holiday. She was starting high school in January. She didn’t have a boyfriend. She just kept asking me if she could go home…”I promise I feel better today.”

Actually, in the week that I had left over in Internal Medicine we didn’t have a clue what was wrong with her. She had started feeling weak and tired a few months before…apart from that nothing specific to complain about. She had a positive TB contact and so her lethargy was immediately put down to being TB related and despite any clear symptoms or evidence she was started on TB treatment.(The golden rule in the Western Cape: It's ALWAYS TB until proven otherwise). A few weeks later she presented with pain in her hip and a limp and for some reason the casualty officer did a lumbar puncture, excluded meningitis, did a hip X-ray and excluded anything concerning and sent her home. A week later she arrived back in casualty vomiting blood…not huge, dramatic Greys Anatomy volumes…maybe a cup she said. The only signs of anything being wrong were this profound proximal weakness (basically she couldn’t lift her arms or walk without support and a strange, broad based gait. She also had an unusual tachycardia, which did not improve after 3 units of blood. There was no evidence of infection. She was 13 and a girl…we were still feeding her TB treatment and trying to prove something autoimmune.

I’m pretty sure her Gastroscope came back normal. For some reason she was booked for a bone marrow biopsy…at that stage I changed rotations.

In 4 months of family medicine I often wondered what ever happened to her. I assumed that it was autoimmune and eventually she was sent home, sent back to school, sent back to being a 13 year old in a 13 year olds world.

On my first day of Paediatrics I was in the caeser theatre and the obstetric intern had just finished up in medicine and in the Friday firm.We got to chatting, in-between an elective Caesar for macrosomia/’big baby and another for previous C/S x2 and he mentioned that he had taken over some of my patients. She was one of them.

It turns out she did not have TB. It turns out she did not have an autoimmune disease either. Her bone marrow biopsy had an unusual amount of atypical cells which the cytologists eventually narrowed down to malignant adenocells.

Adenocells don’t belong in bone marrow. Adenocells belong in lungs, ovaries and intestines…mostly. She had a massive colo-rectal tumour and basically it had spread everywhere!!!!

Now for those of you reading for human interest and not medical, 13 year olds don’t get colo-rectal tumours. 30 year olds don’t get colo-rectal tumours. Old people, and by that I mean people over the age of 60 at least, get colo-rectal tumours. There is a very rare group of unlucky individuals who inherit a particularly nasty genetic mutation which predisposes this abnormal growth of cells in their colons and before they turn sweet 16 they succumb to a malignant tumour. On top of that, by the time you figure out that they’ve got cancer almost the last place you look for a tumour is in their colon…because they’re not supposed to have a tumour there.

You could have knocked me over with a feather.

She was 13.

She was discharged from hospital to hospice and died sometime late in March, early in April. Her mom came back to say thank-you.

She never went to high school.

She never kissed a boy.

She never went home.