A tale of two children

Well, maybe this is a tale of two parents.It’s a school day. Shortly after breakfast, five-year-old Chloe Marshall (all names changed) tripped as she rushed to get ready for school. The thud of her chin hitting the tiled floor was so hard, her mother says, it shook the house. “We came because it wouldn’t stop bleeding,” she says, but as I carefully lift away the bandage, I see that the bleeding has stopped. There is an elliptical cut, about 55 millimetres long and five millimetres wide. It’s a gaping wound.Chloe’s mom is squinting, her shoulders stiff with apprehension. “Do you think we can glue it?”“If she were my child,” I say, “I’d stitch it. It’s on her face. Anywhere else, we could try glue or even Steri-Strips, but if you want the least visible scar, stitches are the best option.”It’s as if I’ve taken a pin and deflated Chloe’s mother. Her shoulders drop and her eyes glisten. “Is it going to hurt?”I speak to both mother and child, although I doubt Chloe hears me. She’s clutching an iPad, her eyes glued to a Disney movie. “A nurse is going to put freezing gel on your face,” I say. “In about half an hour, I’ll be able to fix it.”Before they leave the room, Chloe’s mother asks again. “Are you sure she’s not going to feel it?”“My face will be right over hers when I’m stitching it. She’s probably not going to like it, but she’s not going to feel any pain.”With Chloe’s gaze set on the screen, a nurse applies a topical anesthetic and secures it with a dressing. “It’ll take about 40 minutes,” the nurse says, “so don’t touch it.”NickWhile I’m waiting for Chloe’s anesthetic to take effect, I meet nine-year old Nick Patel and his mother. Nick woke around midnight with abdominal pain, but after a dose of Tylenol, he was able to get back to sleep. He’s otherwise healthy, has no medical history, and takes no medication. His mom tells me that he was fine at school the day before, but just before dinner, he seemed tired and said that he’d lost his appetite. When he woke this morning the abdominal pain had returned so they went to a walk-in clinic. There, a doctor assessed Nick, and then directed them to the ER for further investigation.Nick has a fever of 38 C, and when I examine him, the only pertinent finding is lower abdominal tenderness. “Maybe it’s just a stomach bug,” I say, “but he’s only sore over his appendix, which is suspicious.” I help Nick down from the table. “We’re going to get an ultrasound and we’re going to have to take some blood.”As Nick’s eyes widen with alarm, his mother pats him on the shoulder and turns to me. “That’s fine,” she says.“Just make sure he doesn’t eat or drink anything in the meantime.”ChloeI take the dressing off Chloe’s chin about 50 minutes after it was originally applied. I wipe the jelly freeze and note that a wide area around the cut has blanched. “It looks totally frozen,” I say, “almost up to her lower lip.”“OK,” Chloe’s mom says, “you have to give me the iPad now.”Chloe neither hears her mother nor does she notice that I’ve taken off the dressing. “Let her keep it,” I say. “She shouldn’t feel it, so if she’s distracted, it’ll make the procedure easier for both of us.”“Do you want her bunny wrapped?” the nurse says.I would usually say yes, but Chloe seems hypnotized by the movie. Restraining Chloe in a blanket wrap might unleash the fury of this tiny four-year-old. Chloe’s mother is hovering over her on the other side of the exam table. The procedure will be tricky enough with the iPad held over Chloe’s head. When I ask Chloe’s mom to step back, she doesn’t answer me but speaks to her daughter. “Mommy’s right here,” she says. “The doctor’s not going to hurt you.”The nurse picks up on the same word that I do. “Now why would mommy say such a thing,” the nurse says, her words intended for everyone in the room.Chloe’s mother turns slowly toward the nurse and holds a dirty glance for a few seconds. The nurse doesn’t notice. She’s helping Chloe hold the iPad far enough from her face so that I have room to work. As I grasp the needle and move it toward Chloe’s chin, her mother’s head leans in. Between the iPad and her head, much of my light is blocked. Just as I’m about to begin, her mother speaks. “Wait! Are you sure it’s frozen.”“It’s frozen,” the nurse says. “You don’t have to watch. You can turn your head away if you want.”“OK” she says, “maybe I will.”I pinch Chloe’s skin and pierce it with the needle. I pull the string through and tie the first knot as the wound begins to close. “First stitch through,” I say. “She didn’t feel a thing.”“Really?” Chloe’s mom is obscuring my light once again, as she stares at the stitch.“Great job, Chloe! You’re so brave!”Chloe’s gaze shifts away from her movie.“Who’s that?” the nurse says, pointing to the iPad.“That’s Elsa,” Chloe says.I grasp the needle and prepare for the second stitch. I pinch Chloe’s skin and as the needle goes through, Chloe’s mom speaks. “Does it hurt you? Chloe, do you feel it? Does it hurt?”Suddenly Chloe forgets about the movie and notices the black string that I’m pulling away from her face. “No!” Chloe yells. “No! I don’t want it!” She begins to cry and tries to get up but the nurse holds her head and calls for another nurse to help restrain her.As Chloe begins to cry, her mother’s forehead reddens. “Oh, I know,” her mother says. “I know it hurts so much!” I can feel her mother glaring at me, but I can’t return her glance. I’m too busy trying to tie the second stitch while the nurse struggles to hold Chloe so the thread doesn’t rip through her skin. Her mother continues as Chloe’s cry worsens. “Oh, I know, you’re so brave! I know, it hurts you so, so much!”I plead with Chloe to stay still as the nurse tries to shift her focus to the movie. It takes a few minutes but I’m able to tie the second stitch. With Chloe screaming now, I back away. “I won’t be able to do the third stitch unless she’s wrapped.”“Can’t you freeze it more?” her mother says.The nurse speaks before I can. “It’s completely frozen. She didn’t feel the first stitch at all. She’s just scared now.”Chloe’s mom shakes her head in disgust.Another nurse comes in to help. After several more minutes, Chloe is wrapped in a blanket, her arms secured tightly against her body. A nurse holds her head as she wails in protest.“Just one more,” I say. As I move close, Chloe’s mother does the same from the other side. The nurse’s forearm is flexed as she struggles to keep Chloe’s head still. I move quickly, and as I apply the final stitch, her mother announces the event. “I know it hurts so much, you’re so brave, I know it hurts so, so much!” I knot it quickly, three times, snip it, and say, “Done.”Chloe’s mother doesn’t thank me, nor does she thank the nurse who’s worked so hard to ensure the procedure’s success. Instead, she glares at me as I strip off my gloves and leave the room.“Do you want a dressing over it?” the nurse asks.“Sure,” I say. Chloe screams and fights off the nurse who is trying to secure gauze over the wound.I return to the room. “The stitches need to come out in six days,” I say. “Your family doctor or a walk-in clinic should be able to do it.” After today’s visit, there’s almost no chance that stitch removal will be a simple procedure.An hour laterThe nurse finds me an hour later. “Could you believe that mom?” she says.“Honestly,” I say. “I shouldn’t have said a word until the third stitch was through.”“Ya,” she says. “Why couldn’t you just shut up.”I laugh, shake my head and pull up Nick Patel’s results. His white count is high and his ultrasound shows acute appendicitis. Nick is sitting in a wheelchair, an I.V. line in his left arm. His mother is crouched down next to him. I join them and break the news.“No!” Nick says, turning to his mom, who has already prepared him. “Does this mean I have to have the operation?”“You’ll be OK,” she says, comforting him with a smile. I tell them that I’ll page the surgeon and remind them again: “Nothing to eat or drink.”“OK,” his mother says. “Thank you.”Dr. Raj Waghmare is an ER physician. He blogs at theoverheadpage.com. His stories come from more than 20 years of medical practice all over Ontario.

A tale of two children

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