The State Fair

“I got run over by a golf cart at the State Fair,” my five-year-old cheerfully says to the Emergency Department technician who is checking us in.

A utility cart knocked him down – he is a five-year-old running along the grass by the path, and some asshole wasn’t looking as he turned into my kid who was five feet away from me.  He cried, I picked him up, my husband and our friends and their kids and our other kids were all gathered.  “You were so calm,” the other mom said to me afterwards.  I was calm.  Crying and alertness and ability to move four limbs were all reassuring.  His head didn’t have bumps or scratches, he was making noise, scared, but appropriately upset.  I looked him over while holding him.  Four scrapes on the left hand fingers, right elbow.  “Does it hurt anywhere else?” I keep asking, all the while looking him over, pushing on his belly.  I know about distracting injuries.  When your arm is broken and the pain is so severe, everyone misses the far more serious injury of a lacerated liver.

“The guy didn’t even say ‘sorry,'” I later said to Paul.  “No, he did!  He did say ‘sorry,'” he assured me.  I didn’t hear ‘sorry.’  But I did hear the driver ask whether to “call it in,” which I was too busy looking over Paul to answer.  Umm, what do you think? You drove into a kid, the least that deserves is an incident report, no?  That’s what I might have said if I were responding.  “Did you yell at him? Was Amnon there?” a friend asked.  Nobody yelled at anyone.  Sound of Paul crying, me holding him in my arms asking if it hurts anywhere and looking at his bleeding hand.  Everyone else silent and looking at us.  

The first-aid people came.  “I can give you a band-aid,” the young woman offers.  I am silent for a second.  I was thinking this would be helpful.  I’m pressing his bleeding hand with the baby wipes our friend gave me.  Pressure to stop the bleeding.  I wait a beat.

“Do you have hydrogen peroxide?”

“No….it would sting.  Band-aid?” she offers.

“Umm, I need to take him to the bathroom and wash this off.  You can’t just put a band-aid on this.  Do you have antimicrobial cream?” Do you have anything? I want to ask but I’m thinking of what the closest bathroom is and how to carry Paul there while trying to free a hand to collect the two Band-aids she’s holding.

“We have a bathroom in the first-aid station,” her colleague, a middle aged man reports, as if this just occurred to them.  “Why don’t we give you a ride there.”

Paul and I get into their cart.  At the first aid station a man wearing a patrol officer uniform seems in charge of the place, which is a room with a few stretchers separated by curtains.   I walk past him to the bathroom and run water over Paul’s hand and elbow.  Paul cries with the water.  I carry him out.

The patrol officer pulls a chair in the middle in front of his desk. “Have a seat,” he says, and I put Paul down in the chair.  The young woman puts on gloves.  Did she wash her hands first? Not that I saw but it’s conceivable that she did.  Then she puts ointment and starts putting Band-aids over his wounds.  The officer asks me what happened and writes it down.

“At least he’s taking it well,” he says to me with a smile.  This infuriates me.  Yes, Paul is not crying.  But he didn’t cry when he got stitches in his nose after his ski cut him.  I look at Paul.

“I don’t know, he’s very pale,” I said pointedly.

“Oh yes, he’s looking green,” the officer agrees.

I pick Paul up and carry him to a stretcher.  I think he’s having a vaso-vagal episode – the type that sometimes causes people to pass out if they have blood drawn, or severe pain, like from being run over by a cart.  I ask if he feels nauseated.  He does.

“Do you have any juice?” I ask them.  

“No, we have water,” they offer.  I have water too.  Don’t they have any diabetic people who come with hypoglycemia? What is this place?

I blow on Paul’s face.  He’s sweating and looking pale, but conscious. I ask for a towel.  They offer me a paper towel and I wet it on his forehead.  I keep stroking his hair.  The young woman comes over to unpack the first-aid equipment.  She takes his blood pressure after several false starts.  I’m relaxed and so is Paul – he looks better lying down and I keep stroking his hair.  She tries to explain what she’s doing in a friendly way, but Paul knows about taking blood pressure, listening to heart and lungs.  His parents are doctors and he has toy doctor kits at home to play with.  His blood pressure and heart rate are fine.  The first-aid team leaves.

“It hurts too much,” Paul complains in a soft voice a little while later.

“Do you have any children’s ibuprofen or Tylenol?” I ask the officer.

“I have some adult Tylenol,” he offers.  “You can just break it in half.”

I sigh.  I don’t know the children’s dose of Tylenol.  But I have taken care of people whose livers have failed due to a Tylenol overdose.  People who have died or required a liver transplant as a result.  Tylenol has a very narrow toxic therapeutic ratio, meaning the dose at which it is toxic is very close to the dose at which it is therapeutic.  You can’t just give adult doses to children – their dose is by weight.  I tell him all of this.

“The bottle says you can take up to eight of these a day,” he tells me as he reads over the directions.  I sigh again.  It is hopeless, but I’m trying to convince him because who knows what he’ll tell the next kid that comes through.

“No, that’s the adult dose. The children’s doses are by weight.  It is important.”  I pull out my phone and look up the dose.  Half a pill would probably be the right dose.

“Do you want to take a pill for the pain?” I ask Paul.  He refuses.  No pills.  I’m relieved to set the issue aside.  I ask for ice for his hand, and they find a pack in the first-aid kit.  I wrap the packet in a towel and put it over his hand.  He tolerates it for a bit then as I keep stroking his hair he eventually falls asleep.  He sleeps for an hour or two until we decide it’s lunch time for the other kids.  I wake him up and carry him out.

“I’m sorry this happened to him,” says the middle aged first-aid man, and it’s the first time *I* hear someone say “sorry” and even though it’s not the driver, it is nice to hear it acknowledged.  I thank them for their help.

The next several hours we eat lunch, go on rides, see the fair.  It is a fun afternoon, but by the end we’re all ready to go home.  Everyone is tired and kids are melting down over their desire for their own $5 bucket of lemonade and yet another ride.  We cave on the lemonade on the way out.  They fall asleep in the car.  At home we have dinner.

“It hurts too much,” Paul complains after dinner.  I look at his left hand.  It is triple the size of his right.  Amnon and I look at each other.  We need to take him to the Emergency Room.

“It’ll be empty” Amnon says and he’s right.  Sunday evening at 7pm there’s hardly anyone there.  We get right in.  Paul cheerfully tells the staff about what happened and the security guard jovially tells him he looks “too good to be here.”  That makes me mad and silences Paul.  Really? You’re a doctor? You know about infection and hands? About how something seemingly small can bloom quickly? Really? I say nothing but looking at Paul, now quiet, and not sure how to respond makes me sad.  We are called in.

The nurse, then the nurse practitioner come in.  Paul and I tell them what happened.  They look at his hand.  The nurse practitioner tells me “you did exactly the right thing,” and I exhale as if a weight I didn’t realize I was carrying was just lifted.  He thinks it’s good that I washed it and put bandages over it to keep it clean.  I feel it’s terrible I didn’t whisk him to the ED in the first place to get the wounds properly cleaned.  They want to get an X-ray to rule out a fracture.  They don’t see signs of infection and would hold off on antibiotics for now.  “Do you have any other concerns?” he asks me.

“I’m worried about compartment syndrome,” I say.  Compartment syndrome is when there is so much swelling in the tissues that the increased pressure in the compartment cuts off circulation and needs to be addressed surgically or else you can lose the limb or worse.  “I don’t think he has it now,” I tell him, “it’s just that his hand got so swollen so quickly, what’s the risk of developing it?”  They already know I’m a doctor because at some point in the exchange I’ve said some medical term that precipitated the question of whether I’m a nurse, always a nurse for a woman, which I always answer by noting that I’m an adult only doctor and do not know anything about children.

Paul and I watch TV while we wait to be taken for the X-ray.  Someone else enters to complete the registration and charge my card the $100 copay.  I’m happy to pay $100 to get my kid quickly and expertly evaluated on a Sunday night, but my god, I think of the janitor who once asked me for advice for her kid because she couldn’t afford a doctor’s visit – what kind of injury would her kid need to sustain to end up in the ED?

The X-ray technician comes and escorts us to the machine.  Paul is a trooper.  He doesn’t cry the entire time we’re there.  I ask the X-ray technician whether Paul needs shielding over his chest (he has a lead apron over his waste down).  The technician looks at me:
“It’s very little radiation, if it were dangerous, I’d feel it because I’m here every day,” he reassures me.  I think of the restaurant owner in Montreal 15 years ago who similarly reassured us about the safety of the smoking section.  He’d been smoking for years, he said, and he was fine, as we could plainly see.

I look at the X-rays as they come on the screen. I’m far from expert in reading hand X-rays, but I don’t see any fractures, and from the way he looks at the film I can tell the technician doesn’t see any either.  I’m happy.  I didn’t think there would be a fracture because his hand looked so normal initially.  But seeing it like this – so swollen, it is reasonable to look for a fracture that we might have missed.  We’re looking for something to explain the swelling.

We go back to wait.  The nurse has brought ibuprofen (children’s dose) which Paul is not interested in drinking because it tastes yucky – he tried a lick.  

“It tastes good,” the nurse tries to tell him.  “Nobody likes how medicine tastes,” I say matter-of-factly, “but it will make the pain and swelling in your hand better.”  The negotiation doesn’t work and I ask her to fill the syringe with the medicine so I can squirt it in his mouth.  

We watch TV waiting for the doctor and nurse practitioner.  Paul picks football on TV and then educates me about the difference between tackling and pushing in football.  He expounds on how this must be the dentist’s office because the doctor’s office doesn’t have a TV, but the dentist has a TV and this has a TV so we  must be at the dentist.

The charge nurse comes in.  She asks if we’ve been happy with how we’ve been cared for.  If we’ve been kept informed, if his pain has been assessed.  I look up at the pain scale on the board and see a circle next to four (with neutral face) initially, then up to six (with a somewhat more displeased face).  They did offer us medicine.  I sheepishly tell her I didn’t get him to take it.  The kid hasn’t cried except for when I went near him with it.  She tries to convince him to take it, then after a while gives up.

“Any other questions?” she asks, and I actually do have a question but I don’t ask.  What I want to know is whether these charge nurse visits have succeeded in improving their department patient satisfaction scores.

After a while Paul starts complaining that “They’re not doing anything! They’re just sitting there! And they’re not even giving me a band-aid to put back on!”

Unlike Paul, I’m not impatient, but my hand is not hurting, either.  I know the ED doc looked at the X-ray and saw no fracture.  That probably took two minutes.  What I assume he’s waiting for is a call back from the hand surgeon on call, who is not the “head of hand surgery” but an orthopedics resident working 80+ hours a week.  I try to give Paul the medicine and he spits most of it out over his shirt.  After the crying over the medicine subsides, he is laughing.

“Tell the doctor I spit up all the medicine,” he says.  “And they’ll have to clean up the mess,” he adds satisfied.  I change his shirt, which, it’s true, is soaked with the orange-flavored suspension.  But hey, I tried.

I show Paul videos of him skiing on my phone, of his brothers skiing, of the three of them wishing various friends and family happy birthday and thanking for presents.

Then, eventually, the nurse practitioner comes in.  No fracture, he confirms.  The hand resident called back and said compartment syndrome would be unlikely given Paul’s age and mode of injury.  I am relieved but he keeps his eyes fixed on me.  His swelling is “impressive,” he says, and I am worried again.  He tells me to watch for pain unresponsive to ibuprofen, diminishing pulses, blue fingers, poor circulation – danger signs.   The ED doctor comes in a few minutes later to reiterate.  They’ll also give me prescription pain medicine in case he needs it.   The ED doctor pauses at the door and looks at me.  “You know, it is his hand.  So if you’re worried, we’re worried.  Just bring him back.”

They’ll clean the wounds and dress them, we should give him ibuprofen at regular intervals to get the swelling down, ice, rest it, keep it elevated – the RICE therapy to whose efficacy any athlete can attest.  Compression is tough because, well, his hand is so swollen and hurt, but they’ll bandage a bit loosely making sure not to cut off circulation.

Another technician comes in and starts washing the wounds.  Paul sits still in my lap, squeezes his eyes shut, and keeps his hand still.  She keeps scrubbing to get the dirt out, Paul sits still and sometimes squeezes his eyes so tight his little hands shake, but he doesn’t move and he doesn’t pull away, and he doesn’t cry. They wrap him up and give him a sling to keep the arm elevated.

Paul is proud and excited about the band aids and the sling.  We come home around 10pm, everyone else is sleeping except Amnon.  I give Paul dinner again then put him to bed.  He didn’t really get any medicine – I wonder if I’ll hear him if he cries at night.  Should I sleep downstairs next to his bed?

He wakes up the next morning and he is excited to show his brothers his bandages and sling.  He is excited to tell his friends about it.  We keep him home during the day with Amnon in case he gets worse.  We want to know that he has turned a corner, that the swelling is coming down, that things are improving. He picks out bandages and chewable tablets in the pharmacy, which do help his pain.  He agrees to some ice.  We send him to school on Tuesday with a sling and bandages.  He takes the ibuprofen before and after school.  We consider three doses a day but Amnon is worried about the doses too close together – “I don’t want him to get renal failure,” he says.

He comes back Tuesday with scrapes on his nose.

“Pauly, what happened?” I ask.

“I face-planted on the playground,” he answers cheerfully.

 

******

Update: Paul’s hand has fully recovered and after I sent this essay to the State Fair, they reimbursed us fully for the ED visit, which actually ended up costing $150.

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