John E. Monaco, MD
It is a cliché, but in pediatrics we talk often of caring for two patients… the child and the parent. Generally, this is meant figuratively. The child is the one with the disease, but the parent is the one with the anxiety that must be dealt with and the questions that must be answered.
It is well accepted that treating parents can sometimes be more challenging than dealing with the medical illness of the child. Shop talk in pediatrics very often addresses the issue of difficult parents.
I had an experience the other day, however, which took this concept to a new level. A six year old girl had been admitted to our ward with pneumonia. She was quite ill, requiring aggressive respiratory treatments, oxygen and frequent interventions. Her relationship with her mother seemed somewhat, shall we say, strained. Basically they screamed at each other constantly. The nurses tried to deal with this as best they could and finally got to the point where the mother was asked to leave the room each time the child required a respiratory treatment.
On about the third day of her hospitalization when she was finally beginning to feel better, it was time for our little patient's respiratory treatment. The child seemed to be in a more pleasant mood than usual, so the mother decided to stay in the room this time. The child, unfortunately felt differently about the situation.
As the respiratory therapist began the treatment, this very strong wiry child arched up on her back and kicked her mother squarely in the sternum. The mother's wind was immediately knocked out of her (an experience high school athletes know well) and she began to panic when she could not catch her breath.
The respiratory therapist later told us that she heard a distinctive "crack" when the child's foot hit her mother's chest. In any event, it appeared to the staff that the child had done some real damage to her mother. For most of us, it was our first experience with child parent abuse!
Since I was in my office on the ward, the nurses immediately called me stating that a parent was having difficulty breathing. My first reaction was of course, "I don't do parents!", but the nurses were not interested in my excuses. They ordered me to the room immediately where I found a middle aged women, sitting in a chair in the corner, gasping for breath, clutching her chest, a panicked look on her face as she sucked oxygen through a mask attached to a tank the respiratory therapist had provided.
When I got to her, it seemed as if everyone else left immediately . So there I was, alone with this mother in obviously severe distress. A thousand thoughts began to run through my mind like… Is she having a heart attack?... Did she crack a rib?... Does she have a pneumothorax (a punctured lung with air leaking in the chest)?... Do I remember adult CPR?... Why did I come to work today? And then the most important… Where did everyone go?
Just as I thought this, this poor mother acquired a glazed look, became a bit ashen and then passed out in my arms. I was able to feel that she still had a pulse but was clearly not breathing effectively. I was still alone with her. The housekeeper happened to walk by at just that moment.
I screamed at her to call for help, and immediately two nurses showed up. I instructed her (a kind word for the screaming I was actually doing) to take the child from the bed immediately and simultaneously the other nurse and I lifted the mother and tossed her onto her daughter's hospital bed. We called a code as we feverishly attempted to establish an airway.
By the time the ER code team arrived she had begun to breath on her own but was in severe pain. She never lost her heart rate or became hypoxic (when there's not enough oxygen getting to tissue).
I would have sworn that she must have fractured a rib or two but x-rays did not bear this out. In the end, it appeared as if she had suffered a lung contusion as a result of the kick to her sternum. By evening she was alive and well, although in quite a bit of pain, sitting at her daughter's bedside… this time at a safe distance!
Never again will I utter the platitude, "The difficulty with pediatrics is having to care for two patients," without thinking of this case. I was, needless to say, ecstatic when they both healed and were discharged home in good spirits. Family therapy was recommended as one of the discharge instructions.
John E. Monaco, M.D., is board certified in both Pediatrics and Pediatric Critical Care. He lives and works in Tampa, Florida.
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