Breathing fast. That was the only thing obviously different. The symptom I couldn’t explain. T’s mom emailed me on Saturday and said that the two year old wasn’t eating well but was drinking lots and that he was breathing faster than normal. I asked my usual questions back: Fever? No. Cough? No. Vomiting or diarrhea? No. Any obvious pain? No. I suggested that they give it some more time and see if he was evolving into an illness and fever or cough would come. They waited. Sunday came and with it T’s breathing got more rapid and even seemed a bit labored at times. By 5 o’clock, his mom called my cell and we talked about his symptoms. They were nonspecific it seemed. He was a little more tired than usual and didn’t want to eat at all that day but would still drink his fluids. He was peeing fine and having normal stools. Still no fever or cough or runny nose or anything that would explain his increased work of breathing so after going back and forth about whether or not he should be seen that night in the ER, T’s parents took him in. He had plenty of oxygen in his blood, his chest xray was ok too and his throat looked nasty. Perhaps the discomfort from the sore throat or the swelling in the back of his throat were the reason for the rapid breathing…..perhaps. They went home and we agreed that T would come to the office in the morning for reassessment. Lucky for T, his parents were smarter than all the docs (including me) and when he was laboring more with his breathing as the night progressed they took him back to the ER. He remained a mystery even then for quite some time. He had the chest xray repeated along with the oxygen saturation level. No change. The resident and I talked and planned to get an EKG to see if he had a viral heart infection causing early heart failure as a reason for his rapid breathing and then an experienced RN gently asked the parents if T’s breath usually smells fruity…..and suggested to the resident that she do a blood sugar. T’s blood sugar was over 500 and his body was so sick and overwhelmed, acid had built up in his blood and he was breathing quickly to eliminate some of that acid. T was diagnosed with juvenile onset diabetes then and there and was transferred to the Pediatric ICU to get his blood sugars and acid build up under control.
When many people think of diabetes, they picture an overweight adult who has gone for months, maybe years, with his illness undiagnosed. This is a very accurate picture of adult onset diabetes. It is insidious and subtle. It can sit in the background and lead to a general sense of malaise and little else. Juvenile onset diabetes is different. It is aggressive and potentially lethal if not diagnosed quickly. Children when they first have it are like T; in a matter of days they go from being themselves to being very, very sick with weight loss and excessive thirst and hunger and eventually become so acidotic that they are breathing really fast to compensate. Because T was so young, he just seemed to be getting sicker without other symptoms and couldn’t tell us how he felt in words. He could only drink a lot and breathe really fast and had he been seen over a couple of days, his weight loss would have been apparent and this cardinal sign of juvenile diabetes would have triggered the diagnosis.
T’s illness and diagnosis reminded me of many things. It reminded me that juvenile onset diabetes is rapidly progressive, over days not months or years, and yet can be subtle at times in its symptoms. It reminded me that when there is a symptom that doesn’t fit your theory of an illness, you have to rethink the theory and think beyond the obvious causes. It reminded me that parents have an uncanny and unparalleled ability to know intuitively that something is really wrong with their child. It reminded me that a great RN is an amazingly valuable member of the team. It reminded me that listening is the most important part of my job.
Listen, shut up and listen and each day will be your best!
Molly O’Shea, MD Birmingham Pediatrics + Wellness Center