Stories accumulated by an Emergency Physician about patients seen in a busy Emergency Department. These are case reports of real situations seen in the practice of a 20-year-veteran physician of the Emergency Department. The following is an except: Another child who stands out, for different reasons, was a three year old with a scalp laceration who I will call Max. Max was there with his mother who seemed even more unhappy than the average parent to be at the ER. Max had, of course, hit his head on the coffee table, the bane of a three-year-old's existence. I truly believe that if everyone got rid of their coffee tables it would reduce the ER census by 10%. He had a very small, approximately 1 centimeter laceration, but it needed stitches. At this age, I would estimate that 90% of the time I can reason with the child, have a long discussion about imaginary things and fairy tales that I make up, and we get them through it. If the child is below 18 months in age, it is just a "get it over with procedure", there is no way they can understand it, but by two to three I pride myself on making it a good experience for them. Right away, I realized that may not be the case with young Max. He was screaming with any attempt to look at the laceration, even though I didn't even touch him. By the time he had seen three of us in scrubs (the triage nurse, the nurse, and me), he would scream even if he saw someone in the hallway in scrubs. We decided it would be in his best interest to restrain him in a sheet which we gently wrap around the child; it is less traumatizing than the old boards with Velcro straps we used to use. His mother agreed. We gave him a small dose of sedative medicine as he was so remarkably agitated, part of which he spit back at the nurse. He ripped off his topical medication and screamed bloody murder even when the nurse had tried to apply it. After he was held down gently, I began to numb the wound with injectable lidocaine. If a child is screaming even when we aren't doing anything yet, even though they've received the topical numbing which works very well, I can't gauge their pain response during the procedure. So I just have to go ahead and put injectable numbing medicine into the laceration to be sure I'm not hurting them while stitching. "JESUS FUCKING CHRIST!" I thought he said as I carefully injected his laceration. I shook my head slightly, and thought to myself, I'm sure I misunderstood what he just said. Sometimes when kids are crying you can almost hear words in the cry. I started washing the wound. "FUCK! FUCK!' he yelled. Everyone in the department was now quite silent, as they could hear this. As we continued, we were treated to every bad word in the English language. From a three year old? Could this be right? I glanced quickly at the mother as I worked, she had her hands on his legs, helping hold Max, and her head was down. She was doing deep breathing exercises, the kind you do during labor. As we wrapped up, I pretended I hadn't heard anything and started giving her wound-care instructions as the technician cleaned the wound and lifted Max up out of the sheet. "I want to tell you, I really apologize for the language. He has four older brothers, the oldest is 17, and he has really learned all of the words and when to use it." This made it quite understandable to all of us, and we all got a laugh out of it. When I think about it, he was just saying what every toddler who is sutured would like to tell us but can't. Needless to say, I did not receive a thank you card from Max or his mother, but I still think about him often.
About the Author: Dr. Mary Beth Engrav is a Board Certified Emergency Physician. She has practiced Emergency Medicine for 20 years.