Inspired after seeing my 5-year-old patient

Off I go to work a few shifts at a desperately understaffed rural hospital in a state far away.  The rental car GPS leads me to the ED address and it’s not there.  All that is there is what looks like a small supermarket with a funeral home next door.  I see a security guard in the parking lot.  He has a lump in his cheek and a badge that says “Sam.”  I pull into the supermarket parking lot to ask for directions.  “Sir, do you know how I get to Bumtruck Valley Hospital?”

In a slow, deep, and nearly indecipherable drawl he answers, “You found it, Cowboy.  Welcome to Bumtruck Valley Hospital.”

“That’s not a supermarket?” I ask.

“It’s not a market, and there’s nothin’ super about it, Shooter.  Funny how they put it right next to a funeral home, ain’t it?  Smart businessmen they are.  Kind of a conflict of interest though, I’d say. Ha, ha,” he gurgles.  “You workin’ here tonight?”

“Yes, sir.  I am,” I answer.

“How much they gonna pay ya?” he asks.

“Apparently not enough,” I conclude.

“I know that’s right,” laughs “Security” Sam.  “You won’t be back.”  I park in the dirt lot and go in for my shift.

There’s only one patient waiting: “5-year-old, headache, fever.”

I walk in the room to find a 5-year-old girl laying on the stretcher in a fetal position.  She is fantastically dressed with a beautiful, silk smocked dress, shiny gold-plated curls with a green bow to match her emerald eyes. A stark contrast is her mother who looks like she’s from a different gene pool altogether, sitting in the chair, dressed in pajamas.

I introduce myself and raise my hand to shake the mother’s hand and she does the “pant-leg hand-wipe” maneuver.  If you’ve never been a victim of this, it is when you go to shake someone’s hand, and rather than raising their hand to shake yours, they quickly send the hand down to their own pant-leg and proceed to very quickly wipe it on their leg, then quickly raise it up to shake yours.  All in a split-second you find yourself shaking the hand of someone who felt it necessary to wipe something off of their hand before shaking yours.  What it is that they attempted to wipe off, or whether they successfully did so or not, is yours to ponder for eternity.  It’s an etiquette faux pas of epic proportions.

“What brings you in here today, Suzie?” I ask, directing my question at the little girl herself, seeing what information she’ll give me before invoking Mom’s help.

“My head hurts,” she answers, laying there in a heap, looking sick.  “It hurts right here,” she says, pointing to the back of her head and neck.  “And I feel real hot,” she says, sinking back onto the hospital gurney.  Amazed at how well she’s answering my questions directly and to the point, I continue.  She proceeds to tell me that the symptoms started a few hours ago, her mom has not checked her temperature, and she’s had no other symptoms except for feeling a little achy.

Then, slowly rolling out of her mother’s mouth, in a deep drawl come the words, “Yuh, her neck is stiff, real stiff. She’s been actin’ like she’s dyin’.  You know, LETHARGIC. Dyin’!”  With that, she sticks her fingernail between her two front teeth, picks a piece of food out, holds her finger up to look at it, smells it, then puts it back in her mouth to perhaps… it?  Gross!

Suzy proceeds to tell me that she lives with her mom, takes no medications, has no significant medical problems, has never had surgery, and has no allergies. Her vital signs are normal, except for a borderline temperature of 100.1o F.  I proceed to examine her and everything is normal, except for when I test her for signs of meningitis.  Flexing her neck makes her say, “Ouch,” with just a hint of hip and knee flexion (equivocal Brudzinski sign).  She’s not showing definite signs of meningitis, but her exam isn’t totally normal either.

“What’s this?” I ask, pointing to a few fine red spots (petechial hemorrhages) on her cheeks below the eyes.  I examine the rest of her and they are only on her face.  “Mom, has she been coughing real hard, or throwing up?”

Her mom shrugs her shoulders, but Suzie answers limply, “I coughed once, but not hard.”

Suzie has a headache, fever (borderline) and a faintly stiff neck.  She has petechial hemorrhages on her face, without a definite cause.  My gut feeling is that she does not have meningitis, but thoughts of previous horrible and tragic cases of meningococcal meningitis race through my mind.  If she’s got a very early case, this is the time to catch it.  This could be a life saved.  Missing such a rare but devastating disease could be fatal.  She needs a lumbar puncture (“spinal tap”).

All of a sudden, Suzie sits up in bed and says, “I feel better” and gives a big smile.  Upon arrival she had been given Tylenol.  Maybe she’s not so sick, and maybe she doesn’t need a spinal tap, I think to myself.  We recheck her temperature, and despite her feeling better, it’s actually gone up to 103.3o F.  Susie jumps off the bed, does a twirl and breaks into dance with enough polish to put her headlining Dancing with the Stars.  Then, her spin seems to sputter out, drain of its energy and color and she slumps back to the stretcher.  “My head’s starting to hurt worse,” she says with a whimper.

“Suzie, can you hop back on the bed and lay down for me, please?”  She does so, and I gently lift up her head, flexing her neck forward.

“Ouch!” she cries, lifting up her leg, flexing her knee and hip: a positive Brudzinski sign  of meningitis.

This is worrisome, I think to myself.  Her temperature has gone up; she has a worsening headache, a stiff neck, and signs on exam consistent with meningitis.  We just need to do the lumbar puncture, I think to myself.  I’m wasting too much time.  I’m starting to get a very ominous feeling about this.  In cases like this, it’s critical that you have a parent that can have a thoughtful informed consent discussion about whether or not to do the procedure, including the risks and benefits.  I sit down with Suzie and her mom and give a detailed explanation of the risks and benefits of the procedure.  At the end of the discussion, the mother turns to Suzie and asks, “Hey baby, you want a spinal tap?”

I was taken aback.  Did this mother just ask her 5-year-old if she wants a spinal tap?  “Mom, wait.  No.  This is your decision.  Suzie is not old enough to make this decision for herself.  You need to decide,” I said appalled at the mother’s attempt to shift the responsibility of this decision onto her 5-year-old.

Again, the mom turns to 5-year-old Suzie and says, “Suzie, you want the needle in your back.  It’s a big needle.  It’s gonna hurt.  It’s gonna hurt real bad.  You want the spinal tap, Suzie?”

“Wait, Mom.  Wait.  You cannot leave this decision to your 5-year-old daughter,” I say, flabbergasted.  At this point I’m starting to get frustrated to say the least.  There’s no way a 5-year-old can be expected to properly give consent for a spinal tap.  “Mom, you have to make this decision for Suzie with my help.  Whether she gives us answer or not, the responsibility of this decision is yours.”  There are no signs that her mother is drunk, intoxicated or in any other way incompetent to make the decision, but she clearly is trying her best to avoid doing so.  I look over at Suzie, who a minute ago was smiling and dancing and she’s lying on her side again, in a fetal position, looking pale.  Again, I notice the faint red spots (petechiae) on her face.

“Baby, wake up!” her mom says as she shakes her shoulder.  Suzie sluggishly wakes up, and then closes her eyes. “Baby, you want the spinal tap?  You want the needle in your back!?  The doctor wants to stick a big needle in your back.  It’s gonna hurt!” her mother starts yelling at her.  Suzie starts crying.  “Baby?  You want the test?  You want the test?” says her mom again.

Though tears, eyes closed, in a fetal position, Suzie whimpers, “Yes, I want it.  I want the test.  I want it…”

What!? I think to myself.  Did a 5-year-old just willingly consent to a spinal tap, after her mother did everything she could do to make her terrified of it?  No way.

“So, baby, you do want it?” her mom prods.

“Yes,” sobs Suzie, “we need to listen to the doctor.  You should listen to the doctor, Mommy.  The doctor knows best.”

I’m stunned.  This 5-year-old girl just agreed to a spinal tap.  I can’t believe it.  This child somehow, apparently wise beyond her years (and wise beyond her mother’s years) was able to grasp the importance of going through a potentially painful test such as a lumber puncture, to rule out a serious illness.

“Mommy, you better wait outside the room while they do it, okay?” Suzie asks.  Her mother nods her head, and walks out of the room looking terrified.  Again, I’m stunned.  This kid not only isn’t scared to have this done, or afraid to have it done without her mother there, but seems to be protecting her mother from the trauma of seeing her, in pain.  Wow, I’m impressed and amazed.

We prep for the procedure, and like an old pro, Suzie follows every direction asked of her, withstands the pinch and burn of the numbing shot, the pressure of the needle going in her back and holds completely still the whole time.  She does so, better than 99 out of 100 adults I’ve seen.  The fluid comes out clear as water, and is sent to the lab.

A few minutes later the results came back: WBC 0, RBC 0.

100% normal.

The rest of her tests: Normal.  There is no evidence of serious infection, and no evidence of meningitis.  Suzie gets to go home.  Suzie is going to be just fine.

I go back to tell Mom, and more importantly Suzie (who seems to be the “acting parent” anyways) the good news.  “It’s just a virus; a flu-like illness.  In a couple days, she will be….I mean, you will be just fine, Suzie.  We’re going to send you home.  Mom, you can give her Tylenol every 4 to 6 hours to keep the fever down, if needed.”

Suzie sits up on the stretcher.  Her eyes perk up.  “I feel better now.  Can I have a popsicle?”

“Of course,” I say.  ”What flavor do you want, banana? I think that all we’ve got left.”

“No way, I want ‘red flavor’.  Don’t you know all kids hate yellow popsicles? Geez, doctor!  Are you really a doctor?” she shoots back, with a giggle.

“Let me see what I can do,” I personally run across the hallway to the break room to get her a popsicle. It kills me to do it, but I grab the last strawberry popsicle that I always secretly stash for myself for the end of a long night shift.  This kid deserves it.  This is an amazing little girl.  “Here you go, ‘red flavor’”.

“Thanks, doctor,” says Suzie.

I give her a smile and leave the room, to finish my charting and print out her discharge instructions.  I not worried about little Suzie, anymore.  Suzie is going to be just fine.  In fact, I’m quite convinced this kid’s going to be something special, perhaps the first female President of the United States, or a movie star, someday.  There is no doubt in my mind about that.  Her mother’s the one I’m worried about.  If fact, I’m not quite sure who’s the parent and who’s the child at this point.  “Suzie, what do you want to be when you grow up?” I ask.

“I already know what I’m going to be:  The President of the United States, or maybe a movie-star.  And if that doesn’t work out, my back up plan, is to be a doctor, just like you!” she says with a laugh.

“Wow, great answer!  I don’t doubt it for a second,” I answer.

“Doctor, I want to ask you one more question,” Suzie says, suddenly very serious.  “I’m worried about you.”

“Why is that, Suzie?” I ask.

“Do you have cancer?” asks Suzie.

“No,” I answer, puzzled.

“Are you sure the top of your head doesn’t have cancer, Dr. Bird, because something up there’s causing your hair to fall out!?” she says, with a laugh.

“Ha! That’s great!” I laugh.  ”You’re even smarter than I thought, Suzie.  Don’t worry. I’m going to be just fine.  I can’t say the same for the hair on top of my head, though.”

“Bye, bye!” she waves, looking dressed for Cinderella’s Ball, her long blond curls emitting beams of sunshine with each bounce. Suzie floats down the hallway as her mother follows behind with a Shrek-like shuffle, seeming to trip on the very floor itself with every step.  In the distance playing, is an old song from the Beatles.  Suzie picks up on the key and tempo right away, tap dancing down the hallway in sync with the melody.

Somehow she knows the words, singing them note for note: “Here comes the sun…do, do, do, do…  Here comes the sun.  And I say, it’s alright…”

Off Suzie goes, tap dancing her way right out the Bumtruck Valley Hospital double doors, and off I go to finish my shift, unexpectedly and refreshingly, inspired.

“BirdStrike” is an emergency physician who blogs at Dr. Whitecoat.

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