Chapter 49: "One to go, and then it gets real!"

March 24, 1987, McKinley, Ohio

"What's on tap today?" I asked when I entered Trina's office on Tuesday afternoon.

"No appointments and you just missed the toddler with a jelly bean up their nose!"

I laughed, "How did that go?"

"Once we got him calmed down, I managed to get it with forceps. Fortunately, Mom didn't try to get it out because that usually forces it deeper, which would normally require an ER visit."

"Is that common? I mean, the jelly bean up the nose?"

"That or something else. Toddlers are proficient at finding things to stick in their mouths, noses, or ears, usually with entertaining results, but sometimes requiring medical attention."

"Entertaining?"

"Making mud pies, for example. And deciding to sample them."

"Gross!" I chuckled.

"Yeah, well, you aren't a toddler! The usual concern there is a bout of nausea, though if they ingest stones, that can require intervention. And, of course, toxic plants are a problem, in addition to things like pesticides, cleaning products, and medications. On those last ones — if you have a toddler or young child with sudden-onset symptoms or symptoms which do not make sense, that's one of the first questions you ask their parent or caregiver."

"Don't make sense?"

"It's a gut feeling, really, when you can't think of something that might create the group of sudden-onset symptoms. It's always a good first question to ask if a patient presents with symptoms beyond an obvious physical injury or what parents would call the 'common cold', which is usually a strain of rhinoviruses."

"It sounds like a good first question, period," I replied. "Certainly in an ER situation, and probably here."

"You're not wrong, but there's no need to cause a parent unnecessary worry. That said, if you have ANY suspicions, you ask."

I nodded, "OK. I saw a few people in the waiting room, so I expect we'll see someone once they finish filling out the intake form."

Almost as if on cue, Nurse Nadia came to the door of the small office.

"It's your day for kids," she said. "Four-year-old with very badly scraped knees with some asphalt bits embedded. Exam 4."

"Thanks, Nadia," Trina said. "Mike, take the lead, please."

We followed the usual entry protocol and found a pretty young woman with a very unhappy four-year-old boy.

"Hi, Ms. Richards," I said. "I'm Mike, a medical student. This is Nurse-Practitioner Trina Carlslyle. She'll be the one performing any necessary first aid, and I'll be observing and asking questions."

"OK. What's with the robes?"

"I'm a deacon in the local Russian Orthodox Church, in addition to being a medical student. If it makes you uncomfortable, I'll change."

"No, it's OK. I was just curious."

"So, what seems to be the problem with Sam?"

"It was a nice day, and he was playing with his mini-basketball hoop in the driveway and fell."

"I see the obvious injuries to his knees. Are there any other injuries?"

"Just his hands, but those weren't too bad, and I cleaned them with soapy water, but I saw bits of asphalt in his knees and didn't want to mess with those.'

"OK. Trina will examine him while I ask you some general questions, some of which might have already been answered on the intake form. Has Sam had all of his regular vaccinations and other shots?"

"Yes. All the normal ones, plus the boosters. Doctor Verner is adamant about those."

"Good. Has he been sick lately?"

"No. You can see he's built like a tank, and I don't think there's a self-respecting virus that would dare come after him for fear of its life!"

I laughed and smiled, "He does appear to be a big kid."

"His dad is six-two, and his grandfather is six-three. Both of them played college football. I'm pretty sure Sam is on that same trajectory!"

"Any allergies?"

"Only to being inside!"

"That's a good one to have!"

"Sam, does anything hurt other than your knees?" I asked.

"No," he said. "Can I keep playing?"

"I think so," Trina said to him.

I asked a number of other usual questions, but it was obvious that minus the badly scraped knees, Sam was probably the healthiest one in the room! Trina completed her exam and asked me to get two bottles of saline for her from the supply room. I fetched them and then she proceeded to use the saline to rinse the wounds, then used tweezers to pick out flecks of asphalt. Sam winced but didn't cry, though his mood was still dark, with a big frown and a death stare directed at Trina.

"I'm going to apply a topical antibiotic," Trina said. "Just keep the scrapes covered with gauze, change it regularly, and have him wear jeans for a few days to protect his knees. They should heal within a week and please try to keep him from picking at the scabs."

"Thank you."

"If you see any signs of infection, which means red, puffy, or oozing anything other than a bit of blood or clear liquid, bring him back right away, please. You can also see your family doctor, if you prefer."

"His office is closed on Tuesdays; otherwise, I would have taken Sam there."

"That's why we're here!" Trina declared. "Mike will walk you out."

I did that, then returned to Trina's office.

"A real champ, that one," she said.

I nodded, "He's the 'rub a bit of dirt on it' type. He was annoyed with us, I think, more than he was hurt."

"He was giving me a death stare when I cleaned his wounds."

"I noticed!" I chuckled. "I believe we were interfering with his play time, and he was singularly unhappy about that."

Trina nodded, "Our Junior John Madden will be back outside as soon as his mom is comfortable."

"I think he'll demand to go outside long before his mom is comfortable!"

"True."

Trina updated the chart, signed it, and put it in the rack with several others. Nurse Nadia came to the door.

"Trina, there's a very young woman here asking about birth control."

"How old?"

"She claims to be sixteen, but she looks like she's thirteen or maybe fourteen."

"OK. Bring her back, and we'll speak with her."

"I'll put her in Exam 1."

"So what do we do?" I asked.

"If she's that young, we can't prescribe birth control pills without parental authorization, and even then, we'd have to determine that it's for regulation of the girl's period, not about preventing conception. Fifteen, and we can do it. Fourteen is a serious judgment call, and our policy is to do it if we're convinced that the girl's partner is close in age and she's not being coërced. Basically, we have to ask more questions than we would for a fifteen-year-old who comes in and says, 'I want the Pill so I can fuck! And I want it NOW!'"

I chuckled, "Basically, our seventeen-year-old from last week, right?"

"Yes. I'll need to take the lead on this one, and if she's at all reluctant to speak, I'll ask you to leave and have Nadia come in with me, OK?"

"Absolutely."

We went to the exam room, and my first thought was that Nadia had overestimated the girl's age by a couple of years, but then I remembered how small Lara was and how she hadn't been as developed at sixteen as Tasha had been at fourteen, and was still very small, even though she was nearly twenty. When I'd first been with her, had she shaved her pubic hair, she could probably have passed for twelve, and that's about how old this girl appeared.

"Hi, Julie," Trina said. "I'm Trina, a nurse, and this is Mike, a medical student. Would you tell me why you're here?"

Julie's eyes darted nervously to me, then away again, and I immediately got the picture.

"I'll ask Nadia to assist," I said.

"Thanks, Mike," Trina replied.

I left the room and found Nadia in the supply room.

"She was very uncomfortable with me in the room," I said.

"That's no surprise, and it's not about you, specifically, but about the Y chromosome."

"I understand. I'm not offended. Trina would like you to assist."

"OK. Would you mind stocking the rest of the supplies? All the shelves are labeled, as are the cabinets. There's nothing that needs to go into the locked med cabinet."

"I'll take care of it."

I opened boxes using the box cutter on the table and stacked all manner of consumables on the shelves and in the cabinets. I finished that task, broke down the boxes, put them with the other recycling, then went back to Trina's office to wait. She came in about twenty minutes later and picked up the phone.

"Child Protective Services," she said, pressing buttons on the phone.

"Why?"

"One sec."

Someone answered on the other end.

"Yes, This is Katrina Carlslyle at the McKinley Free Clinic. I have a child-safety emergency which requires an immediate response ... No, I don't believe there's a risk she'll leave ... yes, we have her name and address ... yes, sexual abuse ... thank you."

She hung up.

"She's sexually active, and based on my exam, she's twelve or thirteen. She has almost no pubic hair, and the rest of her development, especially her breasts, matches what I'd expect from a girl who just entered puberty."

"I know a girl who wasn't much more developed at sixteen, though she did have pubic hair."

"From close, personal examination?" Trina asked with an arched eyebrow and a slight smile.

I nodded, "Yes."

"It can be tricky, but with no body hair to speak of, her breast development, and other indicators, she's at best a II on the Tanner scale. That's not age-determinative, but with everything else she said, it confirms all our suspicions. How did you know your girl was of age?"

"She was enrolled at Taft full-time, so I assumed she was eighteen. I found out later that she was sixteen and an emancipated minor."

"And right there is the problem with making assumptions. In this case, she gave evasive answers that might have confirmed her age, so that, plus having no ID, not even the normal school IDs they issue at Hayes County High, made me suspicious. She refused to identify her partner, except to say he was an 'older guy', which we took to mean an adult over eighteen. That's what led to the phone call I just made to Child Protective Services. If her partner was her age, or perhaps a year older, I'd have counseled her and probably sent her on her way with condoms, which I can hand out to anyone, so long as I don't think they're being abused."

"So what happens now?" I asked, knowing from my experience with Paul and Liz what was likely.

"A social worker from Child Protective Services will be here in about ten minutes — they just need to come from the Courthouse. She'll speak with Julie and make a determination of what to do. I'm going to guess she'll take her into what amounts to protective custody, notify the parents, and do their best to find out who the man is who is abusing her."

"Where do you draw the line?" I asked.

"Obviously, at sixteen, it's not anyone's business unless it's abusive. At fifteen, I'd probably make the call if the guy was out of college. At fourteen, if he was out of High School. Similar to what we discussed before. But in the end, it would depend a lot on the girl and what she said."

Which meant my call to the Sheriff about my sister and Paul was in line with Trina's thinking, though I still wondered if it had been the right thing to do.

"How did you convince her to stay?"

"Nadia is taking her through the checklist because we're concerned she might not have understood all the questions relating to sex."

"At twelve, I certainly wouldn't have," I replied. "I had health class at thirteen, and before that, I knew boys and girls were different and that making babies involved my penis going inside the girl, but the details were a bit sketchy. It wasn't that my parents tried to hide it; it was just that the details were somewhat perfunctory, which I think is fairly common, especially for prepubescent kids. At least according to my coursework."

"I'd say that's pretty accurate and fairly typical. I'd like to see sex education in sixth grade to make sure we catch all the kids before puberty, but given there are people who want to eliminate it even in eighth grade, I doubt we're going to see any improvements in that area."

The phone rang and Trina answered, then put the phone back in the cradle and went to the reception desk to meet the social worker, whom she escorted into the exam room. I assumed I had some time to wait, so I picked up a copy of a nursing journal and began paging through it, looking for an interesting article to read. I found one on treating sports injuries and settled back to read. I was just about finished when Trina returned.

"There's a very unhappy little girl in there," she said, "but I'm positive I did the right thing. She'll be taken into emergency protective care, and her parents will be notified and interviewed. If they didn't know about it, she'll likely be returned to them. If they did, they'll likely be prosecuted. She admitted she'd had her twelfth birthday three weeks ago, which was when she first had what she calls voluntary sex with her 'older boyfriend'. She still won't identify him or give his age."

"What happens then?"

"If she won't talk, and her parents have no knowledge, she'll be returned to them, but have to meet with a social worker on a weekly basis, with the obvious goal of ending the relationship and determining the identity of the 'older boyfriend'. Someone will speak with Julie's friends and teachers to find out if she's been hanging out with anyone from an inappropriate age group."

"That's only a problem if there's sex, right?"

"Yes. I wasn't implying generally inappropriate, just an improper relationship."

"OK. Do the police get involved?"

"That's up to Child Protective Services. In this case, they might use female detectives to speak to Julie's friends. But I honestly don't know for sure. Now, if they do identify the boyfriend, and he's over eighteen, they'll throw the book at him. If he's under eighteen, well, there are all kinds of factors they consider."

"Did she come here for birth control pills on her own?" I asked.

"It would appear so, but she might also be trying to protect her boyfriend."

"Do you think she understood what she was doing? I'm not asking consent, but even the concept?"

"I'd say her understanding of sex was that for a normal twelve-year-old before it happened. So I think the answer to your question is she understood in only the vaguest of terms."

"How often does this happen?"

"Rarely. I think I've only ever seen one other twelve-year-old come in without their parents. That was about five years ago, and she was worried that she could get pregnant by performing oral sex on her boyfriend, who was just a year older."

"Wow."

"Yeah. That was a toss-up here, and after quite a bit of debate, we had a short sex education talk and encouraged her not to go any further until she was a few years older. She actually returned about four years later for birth control pills and had not had intercourse."

"Most teenage guys would be ecstatic to get a blowjob from a willing teenage girl, so I can see that!"

"Men are pigs," Trina declared mirthfully. "But I do agree with you on that."

"You're number 9,377 to call me a pig," I chuckled. "It started with my mom when I decided to counter her teasing with teasing of my own."

"Exaggeration aside, when was that?"

"When I was eighteen. Clarissa used to call me a pig when we were at Taft, but less so now. On the other hand, she did call me one just over a week ago when I suggested she could be my lab partner for our module on reproductive systems."

"Smooth move asking the lesbian to have sex with you, not to mention you being married!"

I chuckled, "That was a running joke between Clarissa and me. I was the very first person she came out to and consoled her when she broke up with her first girlfriend. And I see that look; I only hugged her!"

Trina laughed, "Well, being a self-admitted pig and all..."

"Yes, yes," I chuckled. "As Clarissa said, it would be my funeral, and she's right. That's one thing my wife would not tolerate in any way, shape, or form. No forgiveness, just a slow, painful death."

"I can see that," Trina said. "I told my husband he was free to have a girlfriend if he didn't mind me surgically removing his penis and testicles."

"You aren't licensed to use a scalpel."

"Scissors or a hacksaw would do in a pinch."

"Ouch! Of course, a friend's girlfriend threatened to put it through a food processor."

"That would prevent reattachment surgery, for sure," Trina said.

I heard a minor commotion in the hallway and was sure it was Julie being taken unwillingly by the social worker, and Nurse Nadia confirmed that when she came to the door.

"She became very combative after you left," Nurse Nadia said. "I'd bet she's sure her parents know who the person is, and she's very upset that she came here."

"At twelve, she's not really capable of good judgment with regard to sex," Trina said. "As I was saying to Mike, if her boyfriend was thirteen or fourteen, we'd likely have counseled her to stop having sex and possibly given her condoms. But not in this case."

"I agree."

She left, and Trina pulled down a stack of papers.

"This paperwork is a nightmare," she said. "Any time we refer a minor to Family Services, we have to do a ton of extra paperwork."

"The bureaucracy runs on paperwork, or so they told us in our Practice of Medicine classes."

"They weren't lying. You'll see it when you treat your first rape victim in the ER, or someone dies in the ER as a result of a criminal act. The cops will be all over you, and the amount of paperwork can be blinding."

"I had a brief taste of that during my ER Preceptorship, but I simply said I was a med student and legally couldn't comment on anything medical, then walked away. The doctors, on the other hand, had to talk to the cops."

"First and last time for THAT for you," she said, shaking her head. "Once you pass your MLE, you're a medical practitioner, even if you're still a student."'

"I'll be a student for the next six to eight years," I replied.

"True, though I meant in medical school, as opposed to Residency."