				Using the search form

To view this article in PDF form, click here.

Juxtaposition

Brian T. Maurer, PA-C

Brian Maurer practices pediatrics at Enfield Pediatric Associates, Enfield, Connecticut. He is the author of Patients Are a Virtue and is a member of the JAAPA editorial board. For more on the author, please visit www.lulu.com/briantmaurer.

It has been a long, exhausting weekend at the hospital. Monday morning arrives too soon. Standing in my office, I let my tired eyes drift down the long list of patients. Most of my morning consists of routine physical examinations and straightforward problems—coughs, earaches, sore throats—bread and butter pediatrics. Then I read the name that brings me up short.

This boy, just 3 months shy of his third birthday, is scheduled for follow-up today for a fractured clavicle. He sustained the break 3 weeks ago, along with a facial laceration. These two significant injuries occurred on opposite sides of his body: the fractured collarbone on the right and the facial laceration on the left cheek. I had had a great deal of difficulty understanding how these injuries occurred simultaneously—unless foul play was involved.

The mother claimed that she did not witness the event herself; she was in the bathroom at the time. Siblings in the household reported hearing one or two loud cracks followed by shouts and screams. When the child appeared sobbing in the bathroom, the mother saw fresh blood pouring from the cut. It was only later in the emergency room that an astute clinician noticed that the boy was favoring his right arm. An x-ray showed a clean break of the clavicle.

I had interviewed the boy and his five siblings the following day in the office. By that time the father had been arrested for suspected child abuse. The mother defended him to the hilt. She was certain that he could have never done such a thing. I reported my findings and concerns to the Department of Children and Families (DCF). They decided to remove the children from the home pending an investigation.

That was 3 weeks ago. I had heard nothing in the interim. Now today, this boy’s name appears on my schedule. A note says that he is to be accompanied by both his mother and a DCF worker. This Monday morning will not be routine after all.

As I work my way through a myriad of patients, I can only think of one. When the time comes, I pick the chart from the plastic bin mounted on the wall outside my office and step into the exam room where the boy, his mother, and another woman wait in silence.

I try to be as cordial as possible, given the scenario at hand. I concentrate on the child’s injuries, asking questions to discern his level of pain. The DCF worker reports that the foster mother says the boy has been sleeping well at night. He’s been active and has a good appetite. The facial laceration has healed with a scar; I palpate fibrous subcutaneous tissue below it. A callus has formed at the fracture site, still somewhat tender to touch. The mother sits on the table next to her son and says nothing.

I retreat to the counter top and begin to talk, explaining my findings, gently leading into further recommendations: a follow up x-ray to document the healing, and—

A knock on the door silences my words. Momentarily, I excuse myself. Our receptionist beckons me into the hallway. “It’s your wife on the phone,” she whispers.

I pull the door closed behind me and head to my office. My wife hardly ever calls me at work unless it’s a true emergency. I pick up the phone and punch the blinking red light. “Yes?” I say.

“Avery’s wife called a few minutes ago to say that he passed away this morning.”

I swallow hard, try to respond, but find that I can produce no discernible words. I push my glasses up from under my eyes and reach for a tissue from the box on my desk.

It wasn’t as though I hadn’t seen it coming. My friend Avery had been sick for the past 11 months. Primary lung cancer had metastasized to his brain and spine. I watched him struggle for breath in the ICU this past weekend. Knowing the end was near did not make the final news any easier to take.

“Are you OK?” my wife asks.

“Yes. Thanks for calling.”

I hang up the phone and stand at my desk, broken and numb. I reach for my pocket handkerchief and clean the lenses of my glasses. In the room adjacent to my office, my patient waits with his mother and the DCF worker for my return.

The wall that separates us is 4.5 inches thick. If you put your ear against it, you could hear muffled strains of conversation. Although not soundproof, this wall separates and defines two worlds: the pain of a child’s family and the grief of a clinician.

Yet these two different worlds are similar in many respects, I think, as I readjust my glasses and put my hand on the exam room doorknob. For the moment, both are charged with human emotion and heartbreak. JAAPA