Day in the Life of a Doctor: Pediatric Rheumatology

Join medical resident Siobhan Deshauer, MD, as she meets Mona, a pediatric rheumatology patient.

(Following is a partial transcript. Note that errors are possible.)

Deshauer: Hey, guys! I’m Siobhan, a fifth year medical resident. Now, I’m training to become an adult rheumatologist, and part of that process is doing one month in pediatric rheumatology. For the last couple of weeks, I have been seeing kids in clinic, and it is so much fun. This morning we are going to be in a pediatric rheumatology clinic, and I’m really hoping to introduce you to a 6-year-old girl named Mona. And then the afternoon we are going to see any consults that come up on the ward in the hospital.

In case you aren’t sure of what a rheumatologist is, we specialize in treating systemic autoimmune diseases like rheumatoid arthritis or lupus, diseases where the patient’s immune system gets confused and starts attacking the patient’s body. This leads to a whole range of symptoms, from painful arthritis to kidney damage, or even inflammation in the brain. Good morning, guys!

Batthish: 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 is Dr. Batthish, a pediatric rheumatologist; Debbie registered nurse; Maddie, a resident physical therapist; and Amy a child life specialist. As you’ll see, they each play an important role in the treatment of these kids.

Batthish: Hi Siobhan, so our next patient is Mona. She’s a 6-year-old girl with a recent diagnosis of juvenile dermatomyositis. Mona was diagnosed in April of this year, and she has done tremendously well since starting therapy with methotrexate.

Deshauer: Oh, good.

Batthish: Mona is in today for her methotrexate injection and a physiotherapy assessment. Hello, Mona.

Mona: Hi!

Batthish: How are you doing sweetie?

Mona: Good.

Batthish: Are you well today?

Mona: Yeah.

Batthish: How wonderful. What do we do…?

Deshauer: Juvenile dermatomyositis is a rare autoimmune disease that affects children. Dermato, meaning skin, because they develop distinct skin rashes around their eyes and over their knuckles, and myositis, meaning muscle inflammation, which makes these patients very weak. Eight months ago, Mona got sick. She had so much muscle inflammation that she couldn’t walk and her parents had to carry her into the hospital, a terrifying experience for them. Mona was diagnosed with juvenile dermatomyositis, and she was treated with medications to suppress her overactive immune system called prednisone and methotrexate. As you can see, she is doing so well now. Hello!

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 like boring, because walking is kind of fun.

Deshauer: Yeah. It was boring not to be able to walk.

Mona: Because like 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 bit scared, because I didn’t know it was going to be like that needle.

Deshauer: Just imagine how overwhelming it must be for a little 5-year-old to get a new diagnosis and need an injection medication, getting bloodwork regularly, and coming to the hospital all the time. We actually have a type of healthcare provider who help kids navigate this whole process and they’re called child life specialists.

Child life specialists like Amy educate kids about their illness. They help prepare children before procedures like an injection or bloodwork by practicing each step on a stuffed animal. This way they know what to expect, and it decreases some of that fear and anxiety. For Mona, that includes numbing the skin with a patch before getting the injection, I wished we use this more for adults, and then picking out a toy to distract her and a fun band-aid for after. Now it’s time for the real deal.

Debbie is giving Mona an injection called methotrexate. This is a medication that’s given once a week to suppress the immune system and prevent it from attacking her muscles and skin. At this point, after months of receiving the injection, Mona is a pro.

Maddie: When I first started working with Mona, she had a really hard time standing, walking, as well as a lot of joint contractures — which meant inner shoulders and elbows — she wasn’t able to fully extend or move her joints. She also had contractures in her hips and her knees and her ankles. Mona has put in a lot of hard work to stretch all of those joints and get her strength back up to where it is today. Now, she is not only walking and standing, but she is also climbing the stairs and working on jumping, and single leg balance. So she has made huge strides since we started working together.

Deshauer: Part of physical therapy is stretching her muscles. Because when Mona first got sick she wasn’t walking or moving her joints, so they tightened up, causing contractures. Even after the inflammation had resolved, the range of movement of her joints was limited. She has done a lot of work to get to this point and look at her now. I absolutely love how fun Maddie makes these exercises. Hello.

Maddie: High five. Yay, Mona.

Deshauer: What about now? How do you feel now?

Mona: Good.

Deshauer: Yeah? Do you feel all better now?

Mona: Much better than before.

Deshauer: Yeah. What’s the biggest difference now?

Mona: The biggest difference is 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 amazing? You can just see how comfortable and 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 for her quality of life. But whenever I see a little kid with a disease, you have to wonder, what does it look like going forward for her?

Batthish: Well, we are very fortunate that we have a lot of therapy available to us for children like Mona. With early onset treatment, they generally do really well. Someone like Mona, who has already shown such improvement so early, I’m really hopeful that we will be able to maintain her state of remission and eventually even wean her off therapy.

Deshauer: Fantastic. Hopefully just be able to have a normal childhood and…

Batthish: Absolutely. She should be able to do whatever she wants. Any sport or any activity in the future will be available to her.

Deshauer: That’s fantastic.

Batthish: Thank you so much Deshauer for a lovely morning. I really appreciate having you in clinic today. I did hear though, that there may be a consult on the ward for a possible MIS-C [multisystem inflammatory syndrome in children] case. When you’re done, why don’t you meet up with Dr. [inaudible] to review it.

Deshauer: Absolutely. No problem. I’ll just finish my notes, and then I’ll head upstairs. I love how the hospital is full of so much color. It’s so cheerful. It’s honestly, I wish we did this in adult hospitals. Also, check out these cute buggies to push kids around. There is even a little parking lot to leave them in.

This is the hospital map and you can see it’s divided into four colors, which is really nice for kids. It’s actually really helpful when you get lost. This is the red section, as you can see. Now, I’m going to try to find the ward this patient is on.

I haven’t read this patient’s chart yet. But what I know so far is that she is a 10-year-old girl who was previously completely healthy and comes in today with 4 days of fever, sounds like abdominal pain, diarrhea, a rash and has had kind of red eyes. The question to us today is could this be multi-system inflammatory syndrome in children, which is a serious condition that’s linked to COVID-19.

MIS-C can happen to kids about 4 weeks after a COVID infection, and they usually develop a fever, rash, and swelling. We’re still learning a lot about the condition. But so far we know that early diagnosis and treatment is important to prevent complications. I walk into the room and see a young girl lying in bed with her mom stroking her hair. Her mom explains that they have been so careful to avoid any COVID exposures.

She does attend school, but there haven’t been any recent cases in her class. The girl isn’t interested in talking, but she does allow me to examine her. Both eyes are red. Her stomach is mildly tender, and her hands do look puffy and red.

Her lab work shows high levels of inflammation and special tests for her heart called the troponin and pro-BNP show that her heart is under extra stress. Some of her infectious workup is still pending and not back yet, but so far this is looking pretty consistent with MIS-C.

One thing that’s really different in pediatrics is that you’re not just treating the patient, but you’re often talking with parents and counselling them. So it feels like there is kind of multiple patients in the room to look after in a way. At this point, we need to get a little bit more information, get some blood work to look for antibodies to show if there was a COVID exposure, and an ultrasound of the heart. Because the blood work showed that the heart is under a lot of strain right now, and we want to actually see how it’s pumping, if there is any other issues.

The final step is actually treating her so that she could feel better again. We need to treat the immune system that’s so revved up right now by giving a medication called IVIG [intravenous immunoglobulin] and steroids. Both of those should work pretty quickly and get her feeling better soon.

I just feel badly because it seems like these parents are blaming themselves. I mean, they have been super careful. There is no known COVID exposure, but often that’s what happens. We are in a global pandemic, so it’s impossible to avoid it completely.

I’m absolutely loving this rotation, seriously a highlight in my training. This medical team is so passionate. They really go above and beyond to advocate for all of their patients. It’s just so much fun to play with kids and empathize with parents. I mean, there have definitely been some days that I’ve come home, especially after seeing some really sad cases or sick kids, that sort of weighs on your heart and that’s tough.

But then there are other days that I come home and I wonder why don’t I go into pediatrics because I’m loving this so much. Then I remember this is the way I felt after pretty much every rotation in medical school, because there is something amazing to discover in every medical specialty. I want to say a huge thank you to the entire pediatric rheumatology team and, of course, to Mona for making this video possible. If you want to see more videos like this, then be sure to subscribe and that way, I’ll see you in the next video. Bye for now.

Siobhan Deshauer, MD, is an internal medicine resident in Toronto. Before medicine, she was a violinist, which is why her YouTube channel is called Violin MD.