Looking for Horses not Zebras

Thirty years ago this month, we made a life transition. I left my jobs at Johns Hopkins Hospital as a Pediatric Nurse Practitioner and Johns Hopkins University as an adjunct nursing instructor. My husband left his job in Delaware at the Nemours Children’s Hospital in Newark and we moved, “home” to Buffalo, New York. We had just bought our first house!

But, this post isn’t about that. It’s about something I learned while working at Johns Hopkins. During the time I worked in Baltimore, I had the privilege of working with some of the founding fathers of the modern-day field of Pediatrics. Henry Seidel, Frank Oski, Marvin Cornblatt, and Beryl Rosenstein were all attending physicians for our unit during my employment tenure. As I worked with them, these men made an impact on me and my nursing-medical philosophy.

As nurse practitioners on an in-patient unit, we had contact with the physicians daily. We rounded on our patients and discussed their cases with the physicians. They asked questions of us as we talked in the hospital hallways outside of the rooms. We decided as a team what was going on with the patients and what should be done.

While the unit I worked on was the newborn nursery, we also had to interact with and teach the moms on the postpartum unit. Let me be frank, many of the women had not received prenatal care. Yes, the nursery was for healthy, full-term babies but we took care of more than our share of problems. During the early 1990s, cocaine and heroin use was rampant. Many babies were born addicted to these drugs. It is an awful thing to witness because the babies are jittery and can cry uncontrollably with little to nothing working to soothe their overactive nervous system. They were in the newborn nursery but we had to keep a close eye on them, as did the nursing staff. We also had babies born with a host of other more common newborn maladies. Hyperbilirubinemia or jaundice, Erb’s palsy, Congenital Hip Dysplasia, cephalohematomas and more. Babies were born to diabetic mothers and needed close monitoring. There were babies who developed sepsis. And, there were babies born with congenital syphilis! This was something I thought I’d never see and definitely a zebra! Additionally, once in a while, but with regularity, there was an infant and/or mom that posed some other diagnostic dilemma for our team.

Before I go further, I need to include the medical residents as an integral part of our team. The residents learned from both the attending physicians and from our small group of experienced pediatric nurse practitioners. Our rounds included the attending (1), two residents assigned to the nursery for the month, and 3-4 of the nurse practitioners who were part of the medical staff for the nursery. We all learned together, and we all taught each other. It was one of the most rewarding and collegial work experiences I’ve ever had. Mutual respect ran through our daily work, including rounds on the patients.

One of the most important things I learned from my time as a Hopkins employee was that medically, one should look for horses first – not zebras. Of course, it is tempting to look for zebras – we all are interested in seeing them as well as being the person to identify one. And, of course, working in a large, tertiary-care, teaching hospital such as Johns Hopkins, we did have zebras. But, one should never look for the zebra first. The rule is to assume it’s a horse.

For those who are now completely lost about what I am referring to, I can assure you it’s not the actual animals. A horse, medically speaking is a common problem or diagnosis. While zebras, well, zebras are uncommon or unexpected medical diagnoses or problems.

Today, with the availability of information (some accurate and some not) it is easy for laypersons to look for zebras, rather than horses. There are societal pressures that contribute to this as well. Advertisements for relatively rare diseases like Huntington’s Chorea are on the television. The in-depth knowledge of medical doctors is questioned with regularity. And, then you have those that want to keep testing and testing until something odd is discovered. And, if it isn’t discovered, well, many assume it was because the findings were missed, not because it does not ring true as a diagnosis.

Why would anyone want a malady that is a zebra? Horses are much more well known and easier to care for. Zebras, well, not so much. So, in terms of medical diagnoses, one should always look for the horses first.

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