Chapter 56: Sometimes the Obvious Has to Be Stated

November 5, 1985, McKinley, Ohio

"We usually do afternoon rounds starting about 1:00pm," Doctor O'Neill said. "They're not as formal as Grand Rounds in the morning when all the Residents and med students follow the Attending and see all the patients."

"How many doctors are here at any given time?" I asked.

"Three during the day — an Attending and two Residents. At night, usually just a Resident with an Attending on call. And there is a complement of either four or five nurses at all times."

"For how many patients?"

"Our capacity is twenty-four; right now, we have nineteen."

We walked into a room which housed two male patients, with a curtain pulled to separate them.

"Hi, Teddy," Doctor O'Neill said. "How are you doing this afternoon?"

"It still sucks to be in the hospital!" the approximately ten-year-old boy complained.

"I'm sure it does! If you continue to heal properly, you'll be out of here on Thursday. Lindsey, the case, please?"

"Teddy Jackson, eleven; suffered a three-centimetre laceration of his liver on Saturday afternoon as a result of a football tackle with the tackling player's helmet striking his right posterior chest wall. Vomiting, pain, and elevated respiration caused the team trainer to call for an ambulance. He was treated with IV Ringer's, and after examination and a surgical consult, the decision was made to admit him for observation. He was hemodynamically stable, so surgery was ruled out. Treated with Demerol for pain. Hemoglobin was low but has recovered to 16.6. Liver enzymes were elevated, but have returned to normal. He will be ready for discharge on Thursday morning."

"Very good. Frank, what was the differential diagnosis when he was brought to the ER?"

"Rib fracture, abdominal wall contusion, pneumothorax, diaphragm rupture or hematoma, or rupture of the stomach or other gastrointestinal organs. The laceration was detected by radiology after elevated liver enzymes were detected."

"Correct. Anything to note from the chart?"

"No. All his vitals and labs are all in the normal range."

"Good. Teddy, Just hang in there for another day and a half."

"And I can play football?"

"Not right away. We'll discuss that with your mom and dad on Thursday morning. I'm going to check on your roommate now."

Teddy frowned and I could tell he wasn't happy with the football answer. Doctor O'Neill, Frank, Lindsey, and I moved to the other side of the curtain where a boy of about six was sleeping.

"Frank," Doctor O'Neill said quietly, "the case, please."

"William Aikens, six; admitted for observation after concussion which occurred following a helmetless bicycle accident last Friday. Dizziness, nausea, and blurred vision immediately after the incident, which caused his parents to bring him to the hospital. Neuro consult revealed no hematoma. The conditions have resolved, all cognitive functions appear normal, and he's ready for discharge."

"Good. Do the paperwork, bring it to me, and we'll call his parents to come to get him."

We left the room, which gave me a chance to ask a question.

"How long will it take for Teddy's liver laceration to heal?" I asked.

"Lindsey?" Doctor O'Neill prompted.

"He won't be able to exercise for another three to four weeks, and most likely, he won't be able to resume playing football for four to six months."

"Does he know?" I asked.

"No," Doctor O'Neill replied.

"He's going to be VERY unhappy," I observed.

"You think?" Doctor O'Neill asked. "We've discussed it with his parents, and they suggested we wait until right before we discharge him because they suspect he's going to throw a fit, and they'd rather we didn't suffer his wrath for an extended period."

We went into another room, this time occupied by two girls who were about ten and who were chatting.

"Mind if we interrupt for a moment, girls?" Doctor O'Neill asked.

"Hi, Doctor O'Neill!" a cute blonde girl exclaimed.

"Ready to go home today, Melissa?"

"Yes!"

"Lindsey, the case please?"

"Melissa Beckworth, ten; presented to the ER with intense abdominal pain, nausea, and diarrhea. After discussions with her parents, food poisoning was suspected and confirmed by the lab. She was treated with IV Ringer's and antibiotics and was admitted for overnight observation. Her condition has improved, all vitals and labs are normal, and she's ready for discharge."

"Yay!" Melissa exclaimed.

"As soon as your parents arrive, we'll do the paperwork," Doctor O'Neill said.

"Cool!"

"Frank, Peggy's case, please."

"May I say 'ditto', except she's eight?"

Doctor O'Neill laughed, "That's not exactly the procedure, but given they're sisters who came in at the same time with the same symptoms, I suppose that's OK."

"Yay!" Peggy exclaimed.

"I'll see you both in a bit," Doctor O'Neill said.

We left the room.

"Their parents weren't sick?" I asked.

"No. The parents had shrimp; the girls had chicken. We called the health department to check the restaurant. The next case is a battered child, so prepare yourself before we go into the room. We'll just review the chart, then step into the hall to discuss the case."

We went into the room, and Doctor O'Neill greeted the little girl, who was about five, and who had bruises on her face and bandages covering what I was sure were lacerations that had been sutured. She also had a cast on her left arm and an IV in her right arm. My immediate, visceral reaction was that anyone who would hurt a child deserved the ultimate punishment, and I was sure my blood pressure went up fifty points. I took a deep breath and let it out, trying to relax. Lindsey got the chart, and we went back into the hallway.

"You OK, Mike?" Doctor O'Neill asked.

"Anyone who would hurt a kid..."

"We're all in agreement on that. Her father was arrested the day after her mother brought her in. Lindsey?"

"Brenda Liston, five. Admitted six days ago with multiple contusions, lacerations, a broken wrist, and a severe concussion. Post-admission examination showed previously broken ribs and a previously broken arm, which had not been properly set. Her vitals are all within the normal range, and kidney function has returned to normal, with no blood in her urine. She's mildly sedated. X-rays this morning showed her arm is knitting properly. Monitor until she's able to be released to Family Services."

"Frank, conditions for discharge?"

"Once we've removed the sutures from her face, which should be Thursday or Friday, following a consult with the plastic surgeon."

"She's been abused long-term?" I asked.

"Yes. Her mother is in Internal Medicine as payback for bringing Brenda to the ER."

"Lord have mercy," I replied softly, shaking my head.

I wondered how someone could do something like that to their own child, but then I thought back to Becky and her sister and what her parents had done to them. Becky had escaped the actual physical abuse, but I was sure the mental and emotional scars would last for the rest of her life. I was just happy she had been able to get counseling and have a somewhat normal life.

"Her dad had an ER visit as well," Frank said. "It seems he fell down a flight of stairs while he was being arrested."

Or, more likely, given Frank's tone of voice, was pushed by a cop. I didn't like the idea of police brutality, but I could certainly see how a police officer might respond in that fashion. And, of course, given how my mind worked, an image of Emmy with handcuffs and a nightstick appeared in my head. I fought mightily not to laugh, as it would have been inappropriate, but I was sure Clarissa would find it amusing.

"How common is this?" I asked.

"Battered kids? All too common," Doctor O'Neill said. "We admit one or two cases a month, and the ER sees kids who appear to be abused at least once a week. And there are cases of battered women and rape as well. We have a permanent social worker assigned to the hospital as of a few weeks ago. She handles cases of domestic violence, rape, or anything else that needs attention from Family Services."

Of course, MY past experiences with Family Services hadn't been positive, and they'd actually done far more harm than good in my life. That said, I knew that as a doctor, especially in the ER, I would have to find a way to work with them that protected BOTH the kids who were being harmed and the parents who were being falsely accused. Figuring out which were which would be a difficult prospect, but given what had happened with Liz, I knew I would need to try.

"Does anyone come to see her?" I asked.

"No," Doctor O'Neill replied.

"Speaking with zero experience, I think it might help her if someone came to see her — a friend, a teacher, someone."

"You're probably right, but that's up to Family Services, not us. She's a ward of the state until her mom can care for her again."

Which meant foster care, and Liz's experience had been anything but positive. That got me to wondering about how families became foster families, and what the criteria were for placing a kid in a specific home. I also wondered if somehow our church might get involved, maybe even in conjunction with Saint Augustine Catholic Church. I'd met Father Clifton, the priest who had replaced Father Jacobs, once, but I knew Father Nicholas had continued his monthly lunches. It wasn't something I had time for, any more than I had time for campus ministry or prison ministry, but it was certainly something to discuss with Father Nicholas.

"No grandparents?" I asked.

"I don't know, actually," Doctor O'Neill replied. "I know this might sound a bit crass, but our job is healing of bodies; it's up to the psychologists and social workers to heal the mind and spirit. Let's move on to the next patient."

I wasn't sure she was right. While I did understand the situation in the ER where the goals were different, once a patient was admitted, it seemed not just crass, but wrong, to ignore the emotional and spiritual needs of the patient. That was something which we'd discussed, briefly, in our Practice of Medicine course, but we hadn't really delved into the topic, and given my chosen specialty, I'd have limited opportunities to do much more than 'treat them and street them', as the ER doctors described their roles.

We saw five more patients before Doctor O'Neill assigned tasks to Frank and Lindsey and then introduced me to Julia Miles, a nurse I guessed was about my mom's age.

"As I said, things are relatively calm and routine on the pediatrics service," Doctor O'Neill said. "I have charts to review, so I'll be in the lounge if you need me for anything."

"Thanks, Doctor O'Neill."

"First Year, and you're sure you want emergency medicine?" Nurse Julia asked after Doctor O'Neill walked away.

I nodded, "Yes. That's what I've wanted since fourth grade."

"Emergency? Medical Center?"

"Those ERs didn't look anything like the one in this hospital! It was actually because of a First Aid incident where I was the only kid who didn't either run screaming or think it was 'cool' that a girl was bleeding badly from a severe laceration."

"What happened?"

"A playground accident," I replied. "There was a jagged piece of metal on a merry-go-round. She fell, and it sliced her arm open. She was bleeding badly, so I took off my shirt and used it to put pressure on the laceration until the school nurse arrived. I helped her until the ambulance showed up."

"And that one incident did it?"

"Yes. From that moment on, I knew I wanted to be a doctor in the emergency room."

"Well, we're pretty boring here in pediatrics compared to the ER, but that also means we can take time to teach in ways they can't. I know you can't touch patients as a First Year, but I'll show you how to change dressings, inject medication into an IV, draw blood, and so on. All things you'll need to know how to do, even if you won't do them very often as a doctor. May I ask about the robes?"

"I'm a deacon at Saint Michael the Archangel Orthodox Church, and our bishop requires us to wear our cassocks anytime we're in public, though I have permission to wear scrubs or other appropriate medical attire when required."

"My husband's mother is Greek Orthodox, but I don't recall her priest wearing anything other than the usual shirt and collar that our priests wear in public."

"You're Roman Catholic?"

"Yes. My family attends Saint Augustine."

"I had Father Jacobs for Latin and for world religions when I was at Taft. I was sorry to see him leave."

"We were as well. Shall we start with checking the dressings on little Brenda?"

"Some days..." I sighed.

"You aren't the only one to feel that way, Mike. She's a lovely little girl, though deeply emotionally troubled."

"The little sister of a friend of mine was abused by her father," I said. "He's basically serving life in prison."

"Good," she replied flatly.

I followed her to Brenda's room and stood on the opposite side of the bed from Nurse Julia so I could see everything she did.

"First, we're going to carefully remove the dressings from her face," she said as she began with the one on Brenda's cheek. The bruising I'd seen was only the tip of the iceberg, as removal of the dressing revealed ugly purple/green markings, in addition to about a dozen sutures along Brenda's cheekbone.

"Lord have mercy," I said quietly.

"I daresay He wasn't watching over this little one when it mattered," Julia said quietly.

"Sadly, evil is a product of the Free Will which God gave us, and her father chose to misuse it in one of the most horrible ways possible. Hopefully, once she's physically healed, she and her mom can start a new life."

"Equally sadly, the outcomes in those kinds of situations are pretty much uniformly bad. There aren't enough resources, and being a single mother is difficult even in the best of circumstances."

I knew that from Nancy's experience, though she and her mom had done OK, all things considered. Nurse Julia continued removing dressings until Brenda's face was completely exposed. Brenda stirred, but she didn't wake up.

"We look for redness, heat, swelling, or pus, all of which are signs of infection. Brenda is receiving IV antibiotics to reduce the risk of infection. I don't see any signs, so I'm going to put on a new sterile dressing."

"How long do the bandages stay on?"

"It all depends on the wounds and the patient. In Brenda's case, we're worried about her scratching or picking at her sutures."

Once she finished changing the dressings, she took Brenda's temperature, then checked her pulse, breathing, and blood pressure. Brenda opened her eyes.

"Hi," Nurse Julia said. "I just finished changing your bandages. This is Mike; he's learning how to be a doctor."

"Hi," Brenda said quietly.

"Hi, Brenda," I replied.

"Can I see my mommy?" she asked.

I looked over to Nurse Julia.

"Not right now, honey. The doctors are taking care of her."

"I want my mommy," she whined, then started sobbing.

"I know, Brenda, but she can't come to see you right now."

I felt helpless because there was literally nothing I could do. Or was there? Even sitting with Brenda for a few minutes, and holding her hand or reading a book to her might help. But I didn't know if that was possible, and I didn't want to ask while we were in the room.

"I'll come check on you again soon," Nurse Julia said, then motioned me to follow her out.

"You OK?" she asked once we were in the hallway. "You looked as if you were going to cry."

"I just feel so badly for her," I replied. "Is her mom that seriously injured?"

"Broken nose, broken orbital bone, and broken jaw, just to start."

"Lord have mercy."

"Her husband tried to kill her for bringing Brenda to the ER."

"I don't even know if this is possible, but could I sit with her, even for a few minutes? Maybe read her a book?"

"As much as I agree with you," Nurse Julia replied gently, "that's not your role. If you want to be a nurse or a social worker, medical school is not the place for you. I can see you're hurting, and I understand, but your job is healing the patient's body. That's what you're training to do. I know it's difficult, but it's a lesson to learn right now."

"I just feel as if there's more that can be done."

"There is, obviously. And most young doctors, the good ones anyway, struggle exactly the way you are struggling right now. The ones who don't are usually surgeons, if they can make it through that program. Your religious calling is about service, the same as Catholic deacons, right?"

I nodded, "Yes, that's true."

"You're going to have a constant tension between your two callings, and you're going to have to find a way to resolve that, or you're going to struggle for your entire career. You should absolutely speak to your priest and your advisor at the medical school about this."

"I'm sorry," I replied.

"For what? Being human? Caring? There's nothing wrong with those feelings; in fact, they're important. An empathetic doctor is a good doctor. But, he IS a doctor, and needs to fulfill his role in the process of healing."

"We're called to heal both souls and bodies," I replied.

"And the way YOU do that as a doctor is to heal bodies, Mike. I struggled the way you are when I first started. You have to get past it, or it will eat you alive."

She made some notes on the chart, then asked, "Shall we go see our next patient?"