TREATING IN THE FOURTH DIMENSION

At lunch the other day, a friend asked me about surgical indications.  The discussion turned to how treatment of kids differed from that in adults with similar problems.  I discussed the obvious things, like the relative size of the child, the anesthesia and other medical concerns, the relative strength of bones and soft tissues and the presence of growth plates.  But as I talked, it occurred to me that the biggest difference in operating on children vs. adults is the effects of time.

We teach our students to learn anatomy and surgery in all three dimensions.  It is not just the flat shape of a structure that is important, it is also its alignment in space and its relationship to the structures next to it on all sides.  But it seems to me that pediatric specialists bring a unique perspective to the operating table.  We also have to look at things in the fourth dimension – time.

All structures change with time.  Human anatomy and physiology is by no means immune to the effects of the passing years.  But once adulthood is reached, the changes in the body are less dramatic.  A thirty year old is almost the same anatomically as her forty year old self, barring disastrous pathology.  The opposite is true with children.  Small increments of even a few months during the growth spurt can change the length, the breadth and even the shape of an anatomic structure in a child.

Consequently, when we as pediatric providers make a decision on treatment, we are not only looking at the child in the clinic on that given day.  We are also calculating the passage of time, reading the tea leaves and consulting the crystal ball to determine what that child will be like – with and without treatment – in a month, in six months, in six years and in sixty years.  Our decision is not only based on the two dimensions of an x-ray or even the three dimensions of the alignment on the clinical examination.  That fourth dimension, the effect of time, is also of paramount importance.