What is it that leads someone to abuse and torture the frailest of us all, those most in need of our protection, whether it is a child, the elderly, or the infirmed? What is the root problem? Is it simply anger management, is it being able to dominate someone or something when you have no control over your own world, or is it simply being sadistic? While physical abuse is certainly active in nature with mom or dad beating the child, even more pervasive is passive child abuse; this is even more frustrating since it is completely sanctioned.
I would include the parent that rarely bathes their child, leaving him or her caked in dirt, head filled with lice and fungus, essentially setting the stage for a lifetime of self-neglect and lack of self-respect. I would include the parent whose clothes are so filled with cigarette smoke that even breathing for the physician is a chore, let alone the effects the residual smoke has on the small delicate eardrums, lung cells, eyes, and health of their child. I would include the separated parents that come to the ER fighting each other, spending more time assigning blame than caring for their child. I would include the parents who have money for cigarettes and alcohol but not for Tylenol, toothbrushes, bars of soap, shampoo, booster seats, diaper rash ointment, and bus or cab fare to their pediatrician’s office.
While most in the healthcare industry like to call this neglect, or situational stressors, or whatever politically correct nomenclature comes to mind, I would prefer to call it what it really is: abuse. Any time you are put in charge of the welfare of another, especially your own child, and you do not maximize all the resources available to you to ensure that your small bundle of life is safe, clean, fed, and educated, then you are abusing that gift you have been given. It is an abuse of God’s gift of life. As a parent the child owes us nothing. We owe them everything. We can only hope that by committing all our effort, love, energy, and resources to their well-being, we will raise a child who will grow to honor us—principally by doing the same for their own children. It is in all sense a self-fulfilling prophecy.
There is a bizarre illness called Munchausen’s disease by proxy. I have seen this problem on numerous occasions. It is a confusing psychological condition in which the parent, typically the mother in more than 90 percent of the cases, actually fakes illness or symptoms in their own child. One school of thought claims that it is an attention-getting mechanism on the part of the parent. What is terrifying is that the case fatality ratio is greater than many forms of childhood cancer. That means that a child of a parent suffering from this condition has a better chance of dying under their care than if they contracted certain types of lymphoma or other cancers. Can you imagine any physician or healthcare provider ignoring this prospect?
Many years ago I cared for a little five-year-old boy; his mother brought the child to the ER frantic that he had a fever of 105 and suffered a febrile seizure just thirty minutes prior to their arrival. The child in question was sitting on the bed, laughing, playing with a rubber glove with no signs of any illness, and with no fever. I listened to his mother’s story with a great degree of skepticism, at first figuring that she had been confused. Perhaps, I rationalized, mom thought the child felt warm, and then he had some activity that may have looked like a seizure. It sounded feasible; that is until I requested and reviewed all the old records from our hospital and the nearby pediatric referral hospital. What I found was both chilling and distressing.
By age five this small boy had had multiple spinal taps, numerous CT scans, EEGs, MRIs, blood draws, and IV lines too numerous to count. The results were that no one had ever found a single, real concrete illness—each diagnosis started with “probable” or “possible” or “can’t rule out”. That’s medical jargon for ‘beats the hell out of me what’s going on; let’s dish it off to another consultant’. Yet the tests went on and on, the chart getting thicker, taking on an authority all of its own, as if to say, “He must be sick . . . look at the size of the chart.” In fact, in five years this child had not gone more than a week without showing up in some ER, Med-check, or physician’s office, undergoing hundreds of inpatient and outpatient tests all with the goal of ‘making the correct diagnosis’. That’s when I said—and admittedly with trepidation—“Enough.” I walked into the room, looked right at the mom, and told her I thought she was lying . . . not mistaken . . . but outright lying. Needless to say she was incensed, yelled about suing me and taking my license and so on, and proceeded to leave until security stopped her at the door. Of course, I had alerted the officers in advance. I notified the mother that I was calling child welfare and taking immediate custody of her child on charges of abuse by Munchausen’s disease by proxy. The child was placed in foster care for six months, during which he never so much as had a runny nose, cough, or fever, let alone a seizure. Mom was forced by the courts to get psychological counseling and, as is the case with nearly all Munchausen’s patients, once confronted with the facts, the abuse stopped and they were reunited in a healthy mother-and-child atmosphere.
Upon review of this case, what was most disturbing was how often the prospect of Munchausen’s disease was mentioned in consult notes. Every doctor wanted every other doctor to take the reins, stick their neck out, but not them. In every sense, we as physicians were as guilty of abuse as his mother. Nobody ever forced our hands to insert needles, administer medications, order tests, and contribute to the problem. We were given the gun, the mechanism of abuse, and instead of putting a lock on it, we pulled the trigger for five years over and over again.
Over the years I have been invited to give a fair number of lectures to educators on identifying abuse and teaching basic childhood safety. So often I am met with questions that focus more attention on the legalities of getting it wrong than getting it right. It seems no one wants to get involved anymore. What is it that has led us to turn our backs so many times to injustice?
I always reaffirm to these educators that I have been wrong on occasion, but more important, the parents of these children are typically more grateful for my concern than they are about being falsely questioned about abuse. In fifteen years I can count on two hands how many times a teacher has brought an abused child to the ER. It is action that happens far too infrequently. In perhaps half of these situations, the child has not been abused. Usually, it is the misidentification of Mongolian spots on the rump of a child (a large bluish pigmented patch that looks like a huge bruise). In each case the parents laughed it off and told the teacher it was no big deal. In most of the other cases, the abuse that initiated the investigation paled in comparison to what lay below the surface.
Most recently a teacher brought a child to the ER because she noticed a small bruise on the young boy’s forehead that was partly covered with makeup in a pathetic attempt to hide it. When I exposed the child fully, wiped off all the makeup, the child had literally a hundred marks ranging from belt loops, handprints, bites, and bruises in various stages of healing. This teacher saved this child’s life. Nothing in her career will have a greater impact than the simple act of her getting involved that day, not closing her eyes, and standing up and demanding an explanation.
We not only owe it to the weak and the disenfranchised to get involved, but we owe it to our own children. We owe our involvement to the Damiens of the world who were slammed to the ground for crying and to the six million Jews who died while millions more turned their backs because they did not, for whatever reason, want to get involved. There is an ancient Talmudic saying: “To have saved a life is to have saved the whole world.” We owe it to God and the world to keep our eyes open, to make a stand for those who can’t stand up for themselves, to take a moment, however brief, and to look under the makeup.
Chapter Thirteen
One Man’s Hero, Another Man’s Bum
As I’ve often said, I am a son of a bitch at times. I can’t help it. Well, maybe I could if I really tried. It’s just that I get tired of trying to be everything to everybody. I think it would be easier if I ran a bait shop or worked in a bookstore. Let’s
face it, most people who come to the bait shop aren’t ill, tired of waiting, or in a bad mood. They’re just going fishing.
When my neighbor Dave invited me to go to the Cayman Islands with him for five days of scuba diving and relaxation at his condo, I couldn’t decline. My wife, understanding my need to clear my head, thought it would be great for me to get away. I had entered one of those down periods where I needed to be rebooted. But I warned Dave, “One of the problems traveling with an ER doctor is that something always happens. I’ll most certainly have to perform some type of medical intervention, or someone strikes up a conversation and I’ll end up giving advice on prostate testing or menstrual irregularities.” In fact we bet $50 on it, but I had to promise not to seek it out—it just had to happen. Well, it did and with a vengeance.
We had just arrived at the Detroit Airport and disembarked to catch our plane to the Caribbean. The minute I stepped out of the walkway, I noticed a mild commotion against the far wall. I could make out the typical orange color of emergency equipment and oxygen tanks alongside one of those small airport golf carts. A security guard was fumbling with the O2 canister; a few people were kneeling. An African-American family milled around the perimeter talking to airport personnel. No one seemed too concerned at the time. Dave nudged me away from viewing the scene, saying, “Let’s go get a drink, we’ve got time.”
“Sure,” I said, and we walked a little farther into the concourse, my head still slightly tilted in the direction of the crowd. “Doesn’t look too bad anyway, someone probably just fell or fainted?” I took a few more steps but then slowed down.
Dave shrugged his shoulders and glanced at me. “You want to go check it out?” I paused for a second, rocked in my stance, trying to pull myself toward the airport bar. The Heineken sign beckoned.
“Yeeaaahhh, I should just take a peek, make sure nothing really bad is going on.” We slowly ambled over to the gathering in no particular hurry.
By that time someone had put an oxygen mask, though not attached to the tank, onto the young man lying on the floor. His eyes were open and he was breathing. He was a big African-American teenager, probably 260 pounds, six feet tall. He was dressed in big baggy pants and a Pistons team jacket, and he was lying sprawled out in a pile of winter apparel.
Quietly, I approached the guard, or ticket agent, I can’t recall. “I’m Dr. Profeta, an ER doc. Anything I can do, or do you need some help?”
I’ve learned over the years that if you charge in with a puffed-out chest like Underdog, you come across as a prick, especially to those who have already stopped to render assistance. Good Samaritans, for the most part, do a great job in often demanding situations. They are honorable people using the skills they have to make a difference. They are just trying to help, and that takes courage in every sense of the word. To most ER docs, stopping to help is a rewarding, simple chore, like doing the laundry. Besides, there is nothing like folding warm towels.
After a very brief survey and introduction all around, I came to the quick realization that this kid was f%#$d. Sweat was pouring off this man-child; his heart rate was like forty. He barely had a pulse, and to top it off, on the side of his scalp was a huge elliptical scar still scabbed over from where he had had a bullet removed from his brain a few weeks earlier. But that was nothing compared to his breathing which sounded like he was sucking air though a coffee stirrer. That was when I noticed that someone had cut a breathing hole in this kid’s neck during his hospital stay. He must have been on life support for a while and had to have a tracheotomy that recently had been sewn. His grandparents were fairly uninformed, only aware that he had just been discharged from a rehab center, and had become short of breath in the airport.
So now all I could think was, “Is this kid is going to die?” He most certainly had scar tissue narrowing his airway from his neck surgery. There was no way I was going to be able to force enough air into his lungs via mouth to mouth, and I was not about to thrust a knife blade through this kid’s throat in the middle of the Detroit Airport. Though honestly, I thought it would have been pretty cool to do and I would have done it if necessary. I even tried to force the neck incision open with my bare hands and tried to get my finger into his airway, but the skin wouldn’t budge. Thank God that the paramedics arrived.
I immediately moved to the side, informing them I was an ER doctor, and I filled them in on the situation. I offered my expertise and told them I would be willing to talk to their online medical command physician. That was my way of making the medics aware that I really knew what I was talking about. It let them know that I understood that they were in charge, and that I have all the respect in the world for them as healthcare providers. After all, I was on my way to the airport bar; this was their job. Subsequent after sizing me up, they were more than happy to let me take control of this complex case. That is the sign of a great medical team: no egos, just patient care, and doing what is right.
When medical students are co-managing a very sick patient with me at the bedside, I can often see how nervous and apprehensive they become, especially around someone who is unstable. I repeat a standard phrase to them that always seems to remove some of the tension: “Don’t be afraid or nervous until I am. But when I am, be damn afraid.” This was one of those cases where I had to admit that I was damn afraid, although I didn’t say anything.
The medics were trying to bag ventilate this kid, but we could barely squeeze air into his lungs. His teeth were clenched tightly together and we could not pry open his mouth. By that time, the young man was covered in vomit, and getting an IV line in his arms, hands, or external jugular veins in his neck was impossible due to his obesity and lack of visible veins from his recent hospitalization. His pulse rate was slowing, and it was obvious he was going to go into full cardiac arrest soon.
“Give me a big IV needle; what sedative or paralysis drugs do you guys carry?” I asked urgently. My commanding voice was strained even to me.
“Valium. That’s all we have for sedation . . . oh, and some morphine.” I grabbed the needle and felt hard for the carotid artery. I remember silently asking God for help to get a line into this kid. I felt the pulse angled to the side and drove the needle deep into his neck, hoping to hit the external jugular vein. Dark, rich, and heavenly venous blood percolated up through the top of the catheter. Now I know how Moses felt when he hit that rock. The medic immediately slammed in a boatload of Valium and morphine. This loosened the kid’s mandible and lungs, briefly making it a little easier to bag ventilate him. I grabbed an intubation blade (sort of like a large spatula with a light), lay back on the floor, and pulled this giant onto my chest. Using the blade while the medic carefully got the vocal cords in view, I pushed aside a mass of huge tongue, scar tissue, and vomit seasoned with ‘Beef-A-Roni’ to snake a small tube directly into his lungs, one that I would normally have used on a child. Instantly the tube fogged with heavenly condensation as trapped air from his over-inflated chest escaped from his stressed lungs. His heart rate quickly improved, his blood pressure returned, and he survived, much to everyone’s relief.
After we got him on a gurney, we all remained quiet for a second; I followed the medics out into the ambulance where we secured all the lines, spoke with the receiving hospital, and wrote up the run sheet. I talked with the medics, and we all agreed that this was the single hardest airway lifesaving rescue we had ever taken part in. We exchanged pats on the back, and some brief guy hugs, and parted ways, all of us feeling like heroes. That is, until Dave and I hit the Cayman Islands with me $50 richer.
We had about ten minutes to get to our plane. But Northwest Airlines had called the pilot to hold departure for us heroes. They gave us some drink coupons, and two hours and forty minutes later, I was standing on a beach in the Cayman Islands: the power of travel. Needless to say, the adrenalin surge I was experiencing on the plane was excessive. I knocked down a couple of Tanqueray and tonics with extra lime, listened to music, and rehashed the near catastrophe over
and over with Dave, who just shook his head for two hours and sarcastically laughed, “Only you, Profeta. This could happen only to you.”
Dave has no medical background and is about 15 years older than I and a new grandpa. He sells novelty lighters, convenient store items, gag gifts; actually, some of it is pretty cool stuff. My kids love going to his office. They come home with naked cherub key chains that pee—all of those crazy items you see at the gas station. It’s good to have a friend like Dave, who sells pooping pig key chains; it keeps things in perspective.
We made it to the condo, where Dave plopped down on the couch. “You need to go for a walk and cool down; you’re wired for sound,” he told me.
It didn’t take much for me to realize that I was experiencing a touch of posttraumatic epinephrine overdrive. This comes when the last drop of adrenaline has been forced into your bloodstream by those damn adrenal glands, which are the lifeblood of ER doctors, battlefield soldiers, and Robin Williams doing standup comedy.
“I’m gone, enough said,” I replied as I donned a swimsuit, grabbed a towel and a bottle of water, and headed down the pearly white sands of Seven Mile Beach. Riding high, I was unaware that my world would soon be turned upside down by, of all things, a cheap plastic chair.
I walked about a quarter of a mile down the beach, which was surprisingly deserted. It was, after all, the middle of the week during the off-season. I meandered past a couple of luxury hotels and other condo complexes. I strolled beneath the palms, letting the sound of the waves and the salt air wash away visions of vomit, bullet wounds, and near death from my strained psyche.
I came upon a cluster of about forty beach chairs strewn around in front of an older complex, all for the most part tossed haphazardly. I sat on one of these cheap dime-store chairs, gently sinking my toes into the soft powdery sand. I closed my eyes, relishing the pure unspoiled splendor of the moment. And for me, at that instant in time, I had found it . . . my Shangri-la, my center. That is, until this rotten, pissant, skinny, little son of a bitch burst into my world.
The Patient in Room Nine Says He's God Page 8