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Dr. Monaco
John Monaco, M.D.
In my job, I have the opportunity to view the parent-child relationship in many of its forms. Most often, I see it under stress, when a child has become sick and must be admitted to the hospital for treatment. It is at these moments that one appreciates this complex relationship at its most fundamental and honest. It sometimes becomes necessary for me to remind myself that parents will do anything they feel necessary to protect their child and get them well, even if their priorities sometimes appear misplaced.
Alexandra is a nine-year-old, beautiful little girl that I helped care for recently in our Pediatrics Intensive Care Unit (PICU). The night before being admitted to our unit, Allie, as they called her, had impulsively jumped on her bike, neglecting to wear the bike helmet she was typically compulsive about using. Somehow she fell off her bike hitting the back of her head on the curbside.
The details of her accident remain sketchy because no other child actually witnessed the fall, and she could not remember exactly what had happened to her, a fact which points up the severity of her injury. A "concussion" is described as any head injury in which mental status is in some way altered. This does not mean the child needs to be knocked out to suffer a concussion injury. Any degree of memory loss is ample evidence to determine that brain injury has occurred, thus meeting the definition of concussion... a fact well known to boxers and professional football players.
Allie was taken by her parents to a neighborhood urgent care center where she was not told that she had a concussion. In fact she was told that she should go home, take Tylenol for pain, and come back if her symptoms worsened. During the night, her symptoms did worsen, and they did so profoundly. She continued to have pain and dizziness and then, during the night, began vomiting repeatedly. Vomiting is a well known sign of brain injury.
The next morning, a Saturday, Allie's parents brought her to the Emergency Department at our hospital where she was examined and a CAT scan of the head was obtained. The scan showed a subdural hematoma, a collection of blood beneath the coverings of the brain. If large enough and left untreated, a subdural hematoma can result in severe disability or even death. In the best of circumstances, the hematoma can be drained by a neurosurgeon in the operating room in a timely fashion, and the patient will be absolutely fine.
Our neurosurgeon was called, and immediately took Allie to the operating room where he performed a craniotomy (incision in the skull), drained the hematoma, closed the skull and sutured her scalp. He sutured the scalp as close to Allie's hairline as he could. This technique results in the smallest scar and the best cosmetic appearance. In performing the surgery, it was necessary to shave off much of her beautiful, dark brown hair. She was admitted to our PICU post-operatively where she progressed quite quickly and had no complications.
After two nights in the PICU, Allie's pain was manageable, she was eating and drinking well, and had taken several walks to the bathroom without difficulty. In short, she met the criteria for being discharged from the hospital. Our neurosurgeon saw her early in the morning, and in the manner of many surgeons, discussed very little with the parents. I knew that he expected her to stay out of school for a week or so and not participate in any strenuous activities, like PE, for four to six weeks. I knew, also, that he expected me to discuss these issues with the family. I'm used to this!
I didn't mind, because this time it was good news! I knew how close Allie came to a bad outcome. I knew how fragile the central nervous system is, how a bigger hematoma would have resulted in irreversible brain injury and possibly death. I knew how lucky she was to have done so well, even given the delay in her diagnosis and treatment. I knew she was a fortunate young lady and her family should be thankful and humble.
"Do you think we should call a plastic surgeon?" was the first thing Allie's father said to me when I told them they had been cleared to go home. I must have looked at him with a mystified expression.
"The scar is so close to her hairline," he went on. "I'm not sure if it will show once her hair grows back."
I was a bit surprised. Didn't he realize how lucky she was? I tried to be polite. "At some point, you might want to have the scar looked at, but at this point it is far down the priority list." I was a bit paternalistic, I later realized. "Besides, no plastic surgeon would look at her so soon after a fairly significant head injury."
He was not satisfied with my answer, and seemed almost angry. "And what about her hair? How long will it take for her beautiful hair to grow back?"
He was definitely angry and I thought I detected a bit of a tear in his left eye. As a father of a beautiful, dark haired little girl myself, I suddenly understood his concern.
It would have been easy for me to accuse this daddy of being unappreciative or of having misplaced priorities. But, at that moment, I knew where he was coming from. His daughter, at least for now, was different. She had been damaged. Only two days ago, she was perfect. He wanted her perfect again.
For all I knew he felt guilty about her accident. I feel guilty about every negative thing that happens to my daughter, even if I rationally know that I had absolutely nothing to do with it. That's the way fathers of daughters are.
I gave him a prescription for a cream to help the scar heal nicely, and gave him the name of a plastic surgeon, but then reassured him that he probably wouldn't need his services. He smiled, but I know that he took my opinions under advisement. He would make the final decision. Fathers know what is best for their daughters.
John E. Monaco, M.D., is board certified in both Pediatrics and Pediatric Critical Care. He lives and works in Tampa, Florida. He welcomes your comments, suggestions, and thoughts on his observations.
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