A patient encounter that almost pushes this doctor over the edge


It’s the beginning of October, it’s Sunday, and it’s been an uneventful shift thus far. However, in exactly seventy minutes, a patient that I’ve just seen — one that I think has nothing more than an upset stomach — will collapse and begin a fight for her life.

I’m at the nursing station scribbling on a chart when a lanky man leans over me, a toddler in his arms. He’s looking at the nurse, but really he’s talking to me. He asks why his son has to wait, insisting that his child be seen first “because he’s a baby.” I look at the child — curious, happy, inquisitive — and a second later, I’m called to see a teenager who’s downed a bottle of Tylenol.

Twenty minutes later, the father hasn’t moved. I direct them into a room. Sam Sampson is almost two. His father tells me that he’s had a cold — runny nose, congestion, cough — for a few days. An initial fever has passed. He’s drinking well, but hasn’t been eating much. He just wants his bottle, which he’s sucking on right now, as he sits on the examining table and studies me.

Sam’s dad talks fast, his frustrated hands jittering as he speaks. The cough and fever, he could live with. But now, he won’t walk. “He just lifts his left leg when we try to stand him, and then he sits back down and shuffles along the floor, or crawls.”

Sam coughs while his father is talking. It sounds innocent, as he babbles, mucous dripping from his crusty nose. He’s a healthy kid; there’s nothing significant in his medical history. He’s been perfect. Until now.

Sam’s vital signs are fine, and he is in no distress. His skin is moist, and flushed. I look in his ears, then his throat. They’re clear. I listen to his heart, examine him for rashes, then listen to his lungs. I press into his abdomen, and he neither cries, nor flinches.

I examine his arms, then his legs, concentrating on the one he won’t move. I palpate his pelvis, then his hip, moving slowly to his toes. He’s curious throughout, grabbing at my face, my stethoscope. I move his joints. Finally, I lift him until his legs hover above the exam table. As I lower him, he raises his left leg and then sits down. As his father said, he doesn’t let the leg touch the ground.

I ask a few more questions. There have been no crying fits to suggest pain, just crankiness. And there’s been no injury; at least none that he knows of.

I explain that this is not uncommon — that this happens sometimes — children refuse to walk, or have mysterious musculoskeletal symptoms associated with viral illnesses. Sometimes these things happen in the absence of illness. I review my exam with him: There’s no tenderness on palpation, so there is likely no bony injury. Occasionally kids get fluid around a joint that can be found by blood work and ultrasound, but his hip, knee, and ankle move well, so this too, is unlikely. And he pulls up his leg quickly and easily – so the joints are working, and so are his muscles.

“So why isn’t he walking?”

“I’m not exactly sure,” I say, “but, I think the best thing to do at this point is set him up with a follow-up appointment Tuesday morning. You can give him ibuprofen until then. It should improve, and if not, we can consider further investigation if warranted. If things worsen, or new symptoms arise, we’re always here.”

“I want an x-ray,” he says. He points to his cell phone. “My wife thinks he needs one too.”

“I don’t think the x-ray is going to show anything.”

“How do you know unless you do it?” He is uncomfortably close to me, and I want to reach out and push him back a step. “My son was perfect, and now he won’t walk.”

“And what if the x-ray’s normal. Then what.”

“I don’t care,” he says. “He needs one.”

I’m not going to win this battle, so I scribble the order, and hand him his requisition.

Ten minutes later, they’re back, and I’ve already seen the normal x-ray. I explain the plan again, but he interrupts: “no way, you haven’t given me an answer yet.”

“What exactly is it that you want?”

“Tell me why he won’t walk.”

“I went over this already.”

He puts his hand on the examining table, as if he’s claimed it. “I’m not leaving,” he says. “Bring me the pediatrician. Do the ultrasound, and the blood work. ” I offer him follow-up first thing tomorrow. This isn’t good enough.

“OK.” I give in. “Just wait outside. I’ll talk to the pediatrician and see if he isn’t busy. But he’s here for emergencies,” I explain. “And this isn’t an emergency.”

He disagrees. Again, I ask him to have a seat in the hall, as I return to the nursing station to make the call. My assistant goes to the room to explain what I’m doing; that I’m paging the pediatrician and that I’ll discuss it with him. When I hang up, she returns and tells me that he refuses to leave the examining room.

“Why?” I ask her.

“He says his baby needs the room more than someone with a sore finger.”

I approach him. “Just have a seat in the hall for the time being, so I can see the next patient.”

“You say this isn’t an emergency,” he says. “Because it’s not your child.”

And instantly, I’m angry. He’s right, it’s not my child. I can still see the scared eyes of a skinny blonde boy, fourteen years ago, his skin so pale it was barely human. He was bleeding profusely — as my fists squeezed bags of blood and platelets into his veins. “You’ll be OK,” I told him, as my heart raced and I begged to a higher force: Please don’t die. He wasn’t my child either. That toddler, chasing me around the ER, asking if she could go home — as I practiced in my mind how I would tell her mother she has cancer — also not my child. And the teenager I used to see every week — the one who taught me about horse racing and video games — the one who cried with embarrassment when he was so sick he soiled himself in front of me. Not my child. It was 5 a.m. in a Reykjavik hotel room when my colleague called me, tears in his throat, to tell me that his cancer had finally gotten him. Wasn’t his child either.

I want to walk over to him. I want to ask him what exactly he’s implying. His comment is insulting, shameful, and disgusting. What I want to say to him won’t get me anywhere, other than a meeting with a disciplinary committee.

I tell the pediatrician the story. He’s busy, but understands my situation. He arrives three hours later, examines Sam, and tells him exactly what I’d said earlier. But now, complaining of the three-hour wait, Sam’s father expects blood work. Sam screams as two nurses hold him down and prick his veins. Two hours later, the blood work returns, and it adds nothing to the clinical picture.

My colleague can’t help himself, as he gives Sam’s father the follow-up appointment. “So,” he says. “I guess we’re right back where we were about six hours ago.” The father takes the appointment, packs up his sleeping son and leaves.

Two days later, after a normal ultrasound of his joints, Sam begins to weight bear during his follow-up appointment.

Raj Waghmare is an emergency physician who blogs at the Overhead Page.

Image credit: Shutterstock.com


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