Case 11: Not My Child

[Triage Note: Cold for a few days, today not bearing weight on left leg. Usually healthy. No injury. Cannot elicit tenderness]

It’s the beginning of October, it’s Sunday, and it’s been fairly uneventful so 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 overhead to see a teenager who’s intoxicated and has 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 – the usual – runny nose, congestion, cough – for a few days. He had a low grade fever the first day, but that’s 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 a couple times 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 ask Mr. Sampson to put Sam on his lap so I can 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, and again, he doesn’t protest. 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 an x-ray 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, and what’s worse, I know the x-ray won’t solve anything. Still, 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 explained this already. I don’t have an exact answer.”

He puts his hand on the examining table, as if he’s claimed it. “I’m not leaving,” he says. “Bring me the Paediatrician. Do the ultrasound, and the bloodwork. I’m not leaving.” I explain that if he’s uncomfortable waiting until Tuesday, I can have him see the Paediatrician in follow-up first thing tomorrow morning. This isn’t good enough he says. He has a small container with pasta and begins shoving spoonfuls into Sam’s unsuspecting  mouth. As his son bats away the spoon, he forces harder, until Sam coughs, gags, and vomits. “See,” he says, “my son won’t even eat.”

“Stop,” I say, for the child’s sake. “Okay. Just wait outside. I’ll talk to the Paediatrician and see if he isn’t busy. But he’s here for emergencies,” I explain. “And this isn’t an emergency.”

He disagrees. 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 Paediatrician 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 okay,” 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 E.R, 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 five 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 hit the pause button and 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 Paediatrician 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.

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  1. Hi Raj,
    This one bothered me. There can be a fine line between advocating for a family member, and just being a jerk. When did doctors stop being the guardians of our health care, a trusted medical professional? “Well I Googled my symptoms and I am pretty sure I have COPD”. No random guy at my triage desk…. you have a cold…and a computer. Patient satisfaction scores, the customer is alway right… I guess what I am really saying is, can you change the ending for me? Dad is on his rant, a crazy nurse rips back the curtains, suckered punches the dad yelling something like “This is for Healthcare “, and everyone applauds and cheers ? (and no one gets fired?).

  2. Hi Sarah,
    This isn’t just about doctors. As I was telling my son’s teacher this morning – if they’re rude to us, then they’re going to be worse with the nurses. Think about it – this guy REFUSED to leave the E.R., even refused to leave the examining room. This is threatening behaviour. If he didn’t have a baby with him, security would have escorted him out. Thankfully, patients like this are few and far between. Parents are usually great, and usually want to spare their children from unnecessary testing if it’s not warranted/indicated. Thanks for your comment (and no, I don’t think I can change the ending 🙂

  3. Why give in to dads requests for unnecessary investigations? If a publicly funded health care system even more important not to give in to patient demands like this. Sometimes the best thing is to do nothing.

  4. Brilliant. Your patience and responses to a difficult father are admirable. The “not my child” paragraph was riveting…will remember this every time I’m frustrated with a physician who won’t follow my advice.

  5. Raj,
    You exhibited an abundance of patience when confronted by an overly concerned and demanding parent. It made me think that a public health care system ought to make some allowance for a human’s penchant for acting like an idiot when under stress or concern.

    BUT… there clearly is a point where indulging such demands, imposes a cost on the time of hospital personnel, the health of other ER patients, the public health system’s ability to operate efficiently.

    When issuing the order and the read of an x-ray did not moderate the Dad’s behavior, it seemed entirely fitting that delays in seeing the pediatrician and further delays in awaiting the blood work should impose a cost on the Dad (and unfortunately on his son).

    It was useful that you attempted to educate the Dad that the pediatrician was treating emergencies and it may take some time to see his son, because his son was not in emergency status. It may not have helped at all on this particular day, but it may have planted a seed.

  6. Unfortunately I have had to many times when Drs have told me that it was just a cold or whatever and because of his wanting to just move on my son almost died… So people please remember that all Drs don’t have the good of the patient in mind but rather are more concerned with how many they can see in a day.. The more they see the more they make…..Please don’t misread what I have said… I said “not all Drs.”.. There are some great Drs out there but you have to look long and hard to find them…

  7. Oh my you and your other doctor buddy just can’t help but be smug that you were “right” now can you? That father did the right thing. My own 2 year old son was continuosly misdiagnosed and ignored by doctors who thought they knew all. He had a cardiac arrest and is alive today only because I made a big scene when I took him to the ER where I was told I was wasting their valuable time. Then the brilliant MDs had the nerve to tell me my son was probably brain dead and to prepare myself and start thinking about organ donation. I told them I would sue if tbey didn’t treat my child. Then they life flighted him out to another hospital. Guess what! His brain is perfectly fine! So keep patting yourselves on the back and insulting a worried father. You sicken me.

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