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OVER-REACTED

A child was crying outside my room and the nurse was trying to pacify her. I could not make out what it was all about, but sometimes it is possible to gauge the emotion of someone who is crying by the tone and character of his or her cry without actually having to set eyes on the person. What I heard wasn’t just a cry of a sick child alone, it sounded quite sad and broken-hearted too.

The nurse brought her in. “Doctor, you better deal with her. She is frightened.” The patient was not more than ten years old. Her eyes were red and her face was covered with tears. Most doctors will agree that it is easier to manage a patient who is angry, fearful, demanding and unreasonable than one who is tearful. “Where are the parents?” I asked. “Part of the problem,” the nurse replied, “she came alone.” 

We are continuously being brain-washed to believe that it is compulsory to have kids. There was a long-running advertisement on TV that portrayed life as being incomplete, unfulfilled, miserable and otherwise not worth living without them. Well I don’t mind kids, in fact I actually fall for them now and then in a manner as crazy as that displayed by the couple on the screen, but I am under no illusion that I will kill myself if there are none around.

One reason among others is that I find wailing children hard to bear, be they ten days old or ten years old. Their cries pull at your heart strings. However, experience has shown that it is often a mistake to show sympathy or to trust crying children unreservedly. I know because I have been a child before and am a parent now. Anyway, I have to deal with the case in front of me.

“Won’t you be a good girl?” I appealed gently, “I am a friend that you can really trust and will take good care of you. Honest, I have helped many like you before, but first, promise me that you will stop crying.” 

I leaned towards her, patted her on the head, held her hand and passed her a Kleenex, a routine I employ for comforting teary members of the opposite sex. My voice was tender and my expression compassionate. I have performed this on numerous occasions. It usually works because I dramatise it rather well. The secret lies in its execution which I have perfected by imitation, having seen it enacted on screen so very often.

She clamed down. “Tell me what happened? Where are your parents?” I asked.

“I came without permission, I slipped out of the house to see you,” she answered.

Even though I am weary of crying children as mentioned earlier, I had to pay attention in this case; for a child who is running away from home to seek medical attention is a different proposition. Something could be seriously wrong.

With the article by Dr Douglas Kong in the SMA newsletter still fresh in my mind, I began careful inspection for signs of nonaccidental trauma, inadequate nutrition, poor hygiene, failure to thrive, deficient development milestones, inappropriate attire and poorly controlled behaviour etc. I found none.

Except for looking miserable and fidgety, she appeared well fed, well clothed, well groomed, well behaved and not sickly. I found no evidence of maltreatment or neglect externally. Having failed to make a spot diagnosis, I proceeded to take a history.

“What is wrong sweetheart?” I asked, continuing in the style calculated to make the opposite sex feel relaxed, at ease and unsuspecting.

“I can’t show you,” she said.

“Why?” I asked.

“Because there is nothing to show you now.”

“When can you show me?”

“At night only.”

“How come?”

“Because it happens only at night.”

“How often?”

“Most nights.”

“How do you feel when it happens?”

“Terrible, the affected area becomes hot, itchy, red and swollen.”

I find that in the practice of medicine it is often better not to over-react, which is also true in other situations in life. For example, I could not understand why some people and organisations are so upset over any and every allegation made by others about them, sometimes to the point of appearing to panic. After all, the truth will surface eventually, for 
“you can fool some of the people all the time and all the people some of the time; but you can’t fool all the people all the time.”

However, the direction in which this case was leading was rather uncomfortable, and I felt obliged to get to the bottom of it without wasting time. The question of sexual abuse had crossed my mind earlier but I had dismissed it. I had felt in the beginning, albeit intuitively, that this was not the problem. Could I be wrong?

“How are your parents?” I asked.

“I miss my mother. My father said she is working in another country.”

“Do you have any brothers?”

“No.”

“Any step brothers or half brothers?”

“No.”

“Do you have any tutors?”

“No.”

“Are there rooms in your house being rented out?“

“No.”

“Do you like your neighbours?”

“Yes.”

“Does your father go out often and leave you alone at night?”

“No.”

“Does your father give you plenty of hugs and kisses?”

“Yes. At night when it happens.”

“Why didn’t he accompany you here?”

“He says nobody can help me and it’s no use telling anyone.”

“What does he want you to do?”

“He said to get used to it and bear with it.”

It appeared that my worst fear was being realised and I paused because I didn’t know how to carry on. I lack the experience and expertise. I thought hard and was praying for some inspiration when the nurse interrupted, “Doctor, someone who claims to be her father just came in,” she said.

“Your father is here,” I told my little patient, “Maybe I should speak to him first, and don’t worry, I will explain to him why you are here without his permission, I am sure he will understand. Meanwhile you wait in the other room. There are some comic books there.”

The father came in. My first impression was that he was more exasperated than anything else and I could not detect any guilt in his demeanour. This wasn’t what I had expected, considering the picture of him that I had painted in my mind. I wondered whether he is a Dr Jekyll and Mr Hyde. “My neighbour told me she saw my daughter in your clinic,” he said.

“A nice girl. She needs help.”

“But you people can’t do a thing to help her,” he said, paying scant respect to the medical profession.

“A hasty and premature conclusion,” I protested. “There are lots of us around nowadays. Surely you can find one who can help. That person could even be me. And you need not worry, everything said and done within this four walls is confidential.”

”It is uncontrollable I tell you. I have tried all sorts of remedies but could not prevent it from happening. Do you think I want my daughter to suffer if I can help it?”

“How long has this been going on?”

“A few months, especially at night, irrepressible.”

“It’s unfortunate,” I said, trying to sound sympathetic, “But I have some suggestions. When this occurs why don’t you go out for a jog? You can also eat. Have you tried the satay around the corner? Very sedap. Or you can call a friend. Here, this is my telephone number, I can be your friend. I am a great gossip, I bet you’ll derive as much pleasure talking to me. Sometimes a cold shower will help too.”

“I don’t understand you.”

“A tactic based on the principle of distraction and diversion. A strategy used extensively in battles, politics, football, chess, courts of law etc. A lot of words but actually it’s mostly commonsense. It’s a good idea also to have a relative to stay with you.”

“Look here,” he said, “I don’t know what you are talking about. What sort of a doctor are you anyway? A fraud had been uncovered recently.”

I pointed to the certificate on the wall to reassure him.

He scrutinised it for a while then he took from his pocket various containers and placed it in front of me. They contained medicines. “Do you have anything new?” he said quite sarcastically. The medicines were first generation antihistamines, second generation histamines, steroids, sedatives and antipruritics. There were tablets, mixtures, creams and lotions in a variety of shapes, sizes,  smell and colours.

I was surprised and confused. “Who is taking these medicines?” I asked.

“Would it be for the family pet?” he sneered. “All these concoctions for my daughter, did 
they help?”

“I thought you’re the one who needs...”

“Yeah I’m the one who is needed to pay the bills.”

“So you have seen many doctors?”

“My daughter that is. All sorts. Numerous blood and skin tests too. Chronic urticaria they said. No apparent cause, perhaps psychological in origin and very difficult to treat. Can you do better?”

The clouds cleared from my mind. I was relieved. The most important thing in medicine is to clinch the diagnosis. Treatment, prognosis etc follow.

“You are quite right,” I told him. “I can’t do better.”

“Why then did you ask me to jog, eat satay and take a bath?”

“Never mind that,” I said. “Just kidding. Laughter is the best medicine.”

I brought the little girl from the next room and told her, “Your father is right but you need not cry or be frightened when you see a doctor.”

“Sir,” she said, “Although my daddy says it’s no use seeing doctors anymore, I feel real miserable when it happens. If one doctor cannot help, I thought maybe the next one can. I am frightened because my pocket money may not be enough to pay you.”

“My young friend, you need not worry,” I said. “You don’t have to pay me. I have good news for you too. Very soon you will be cured, automatically. I can see that coming. Meanwhile, Mopiko is as good as any other medicine.”