Chapter One – Like Ships Passing in the Night

Chapter One
Like Ships Passing in the Night

Imagine yourself in this scenario. It is the middle of the night and your two-year-old son has just awakened you with his crying. When you go into his room you find him to be fussy and uncomfortable. You cannot really tell what is bothering him, and you are not even sure he recognizes you; his eyes have a glazed look to them. He cannot tell you if anything hurts, but his forehead feels warm to the touch–he has a fever. He also has a rash all over his chest and belly that was not there when you put him to bed. All this comes as a complete surprise to you because he seemed fine six hours ago.

Even though it is the middle of the night you think he is too sick to wait until morning to call his regular doctor, so you decide to take him to the emergency department at the nearest hospital. The odds are overwhelming you will meet a doctor there who does not know you or your child at all. Do you know how to talk to this stranger and explain the problem well enough so your child gets the best care?

Or imagine yourself in this scenario. For the past month your four-year-old daughter has been increasingly tired and listless. Her appetite has decreased and she has started taking afternoon naps again. When you ask her what is wrong–and you have been worriedly doing that more and more–she does not complain about anything in particular. You know something is wrong, but have no idea what it could be, so you schedule an appointment with her regular doctor. The doctor is so busy she only has a brief visit appointment slot available to see her. Will you be able to make the best use of this abbreviated encounter with the doctor to communicate how concerned you are and why?

These two scenarios are real-life situations and both are examples of how difficult it can be to diagnose illness in children, how hard to distinguish the serious problems from the not-so-serious. Children present unique challenges to physicians. Our little patients often can tell us nothing about what is bothering them; we rely on observation, seasoned by experience, to figure out what the problem is. It is a time-worn medical cliché that pediatrics is in that sense a little like veterinary medicine. We doctors very much need parents’ help to figure out what is wrong, but few parents understand how doctors actually think, how we conceptualize and solve problems.

The issue is not one of language; it is rather one of viewpoint. Both sides–doctors and parents–often think they understand each other. But like those famous ships that pass each other in the night, only communicating with blinking lights dimly seen through the fog, parents and doctors often do not understand one another. In these days when visits to the doctor are increasingly brief and harried, effective communication between parents and their child’s physician is more important than ever.

Misunderstanding between doctors and families is frustrating, wasteful, and sometimes even dangerous. There are various reasons why it can happen, but often the misunderstanding derives from the fact we physicians inhabit our own mental world with its own rules and procedures. It is a different world from that of non-physicians. This book will introduce you to the physician’s mental universe, teach you some of the rules, and show you how our ways of doing things work. The book will not make doctors of you, but it will help you understand your child’s doctor and thereby communicate better with her.

Practicing medicine is a black art. This is more true about some aspects of medicine than it is about others, but the fact remains: medicine makes use of science, even relies on science, but it is not science. It is a mixture of experience, intuition, common sense, and blind guesswork–all guided by science, but not entirely controlled by hard scientific facts. Most parents do not understand this. Hollywood has not done medicine a favor by portraying what we do as always highly scientific. At the other extreme from overly credulous movies, critics of our health care system have sometimes claimed we doctors often have no idea at all what we are doing. As you will see, the truth lies somewhere between.

These problems of mutual incomprehension between doctors and families are not helped by the fact that these days many, many encounters between sick children and doctors take place in hospital emergency departments and walk-in clinics. They are often encounters between strangers, because the doctor has usually never met the child or the family before.

Of course if the child has been seen before in a particular medical system, the doctor may have some previous medical records about the child to help describe past problems. That helps some, and is becoming more common as computers and rapid access to both paper and electronic medical records become more common. Parents should not count on this, however; it is possible, even likely, that all the emergency department or urgent-care clinic physician knows about their child is what they, the parents, can describe during their brief allotment of time with the doctor.

The problem is not limited to emergency departments and urgent-care clinics. Although such groups as the American Academy of Pediatrics have vigorously promoted the notion of a “medical home,” a place where a child’s entire history is known and understood, many children bounce from one doctor or clinic to another. Often this is because families’ insurance plans change frequently. Confusion can happen even if the child remains within the same medical system–these organizations are getting larger and larger all the time.

The emergency department or after-hours urgent-care clinic is particularly fraught with the potential for miscommunication between a doctor and the parents of a sick child. These are often high-volume places, where there is considerable emphasis on through-put, on getting the children seen, treated, and back out the door. The interactions can also start out on the wrong foot when a harried doctor meets parents who have been waiting a long time, often hours, just to get in to see the doctor; too often both sides are already cranky before the interview even starts. But before we examine the dynamics of how communication between doctors and patients can go awry, it helps first to understand a little bit about how these facilities are usually organized.

Once through the emergency department door and registered with a clerk, the first medical person a parent with a sick child meets is a nurse. The waiting children are typically sorted by how sick they appear to the nursing staff. It is not first-come-first-served; the sickest get seen first. This is called triage, a term derived from the French word to prioritize patients into thirds: the critically ill, the seriously ill, and the not so ill. This is how it should be.

The triage nurse typically has only a few minutes, sometimes even less than a minute, to spend with the child. The nurse asks the parents a few questions, glances at the child, and makes a quick assessment to see how ill the child looks. Sometimes at this point the nurse checks the child’s temperature, pulse rate, and breathing rate; sometimes this happens later. If the child is in one of the top tiers of the triage pyramid the nurse hustles the child to the examination area. If, like most children, the child is in the least ill third of the triage pyramid, the family then waits to be seen, these days sometimes a very long time.

When the family is called back to the examining room a nurse again asks the parents a few questions. The child and family then wait some more; since the typical emergency department has many more examining rooms than it has doctors, families wait in one of these until the doctor gets to them. Finally the doctor comes to the examining room door, looks at the brief note written by the nurse, which consists of statements like “fever for three days,” “coughing for a week,” or “vomiting since yesterday,” and then whisks into the room.

Parents should realize this doctor they are meeting nearly always has other things on her mind besides their child. The doctor in a busy emergency department is typically juggling the problems of several other children in other rooms at the same time she is evaluating your child. For example, she may also be thinking about one child sent off to the radiology department for x-rays, about another with blood test results pending, and perhaps a third awaiting an evaluation from a surgeon about possible appendicitis. It is a difficult thing for an emergency department doctor to approach your child with a mind totally cleared of other things–there are built-in competing issues. In a very busy emergency department, it is often nearly impossible to have a brief interview with a doctor that is not interrupted by others calling the doctor, who for the moment is your child’s doctor, away to the telephone or out into the corridor for some discussion or other.

It is not an ideal system, but it is what we have. It usually works, but it is easy to see how this built-in pressure and chaos can sometimes lead to problems. The best way for you to understand this is for me to tell you a couple of stories, detailed examples of what can happen when both sides think they are hearing one another, but are not. These misunderstandings are rarely anyone’s fault–everyone wants to give every child the best possible care–but the system can conspire against our good intentions. These are all stories of real children whose problems defied for some time several doctors’ efforts to understand them. In some places I have structured parts of the encounters between families and the doctors as a dialogue to show what I mean. In all cases, however, I had long conversations with the parents afterwards, and the stories occurred pretty much as I have written them.

Case #1: Not Your Usual Croup

Johnny was a happy, inquisitive two-year-old who had generally been healthy since birth. He had a few ear infections and a couple of rashes, but no previous difficulties of any sort with his breathing. One day he got a typical toddler cold, what physicians call a URI–an upper respiratory infection. He had the standard runny nose and cough, in spite of which he was active and playful. After a few days of this he seemed to his mother to be getting better. However, the next day he suddenly began to cough quite forcefully so she took him to the emergency department of the hospital.

It was Sunday evening, a very busy time for most pediatric emergency departments. This is because parents often wait out their child’s symptoms through the weekend, then come to the doctor just before Monday morning comes around with its work, school, and daycare concerns. I am not condemning parents for doing this; it is a natural thing to do. But it does add to the staff workload when large numbers of children arrive at the same time to be treated by the doctors, and late Sunday afternoon and early evening are usually times like that.

The triage nurse placed Johnny in the bottom third of the list, so he and his mother took their place in the line to see the doctor. After three hours in the waiting room, they finally made it back to the examining room, where they waited another half hour before the doctor came in, cordial but obviously very busy. Their initial exchange went something like this.

“Hello, I’m Dr. Jones. So Johnny‘s been coughing for two days?”

“Yes, he started out with–

“What’s the cough like? Dry or thick with mucous?”

As he spoke, the doctor whipped his stethoscope from his neck and listened to Johnny’s chest. Since the doctor asked questions while his stethoscope was still in his ears, Johnny’s mother was not even sure the doctor could hear her answers.

“Pretty dry.”

“Anyone at home sick?”

“His brother has a cold.”

“Any fever?”

“I’m not sure. He never felt warm.”

“Well, he hasn’t got a fever now,” said the doctor as he put his stethoscope away and took a ten second look in the child’s throat and both his ears. “Johnny has croup, a viral infection that makes him cough. We’ll give him a breathing treatment and a shot of steroids. If he’s better in an hour or so we’ll send him home. I’ll check back on him later to see how he’s doing.”

With that the doctor zipped out of the room. In the hallway he wrote some quick orders for the medicines and told the nurse to give Johnny’s mother an informational handout to read about croup while they waited for the medicines to work. Then the doctor moved on to the next patient. The entire encounter probably took only five minutes.

The doctor made such a quick diagnosis based upon several things. It was winter, and he had already seen dozens of children with croup over the past few days. Croup is a common illness, especially during the winter. The doctor thus began moving down his diagnostic decision path toward croup even before he went into the examination room, especially because he could even hear Johnny’s typical “croupy” cough, along with a raspy breathing sound called stridor, from out in the hallway. In effect, the doctor went into the examination room looking for reasons Johnny did not have croup; when his quick evaluation showed none, that was that–the diagnosis was croup.

Johnny’s mother told me later she recalled the doctor was cordial but clearly in a hurry. Body language is important at times like this, and doctors in emergency departments often do not sit down beside the patient. This one did not. Standing over the patient is not conducive to conversation. He asked his questions while examining Johnny, and was not really looking at his mother when he asked them. That, too, does not encourage a parent to volunteer much additional information. Johnny’s mother told me later she did not want to bother the doctor with questions–he was so clearly very busy. They had already been waiting a long time and she was anxious for Johnny to get the breathing treatment, the steroid injection, and then get home.

The doctor was a competent, well-trained physician. From his viewpoint, he was probably relieved by his quick scan of Johnny’s chart in the hall and the sound of the child’s cough through the door. To him it meant this case would be a quick one, allowing him to move on to more challenging and sicker children. What parents should understand is that doctors in this setting are usually making diagnostic decisions in their minds before they even see the patient, and this process continues from the moment they walk in the examination room, even before anybody says anything. As you will read, Johnny’s case turned out not to be straightforward at all. Better communication would have helped, particularly if Johnny’s mother knew how to present the information in a way that gave important signals to the doctor.

The breathing treatment, a cool mist containing a medicine called epinephrine, made Johnny’s breathing better. Croup causes inflammation of the airway just below the vocal cords, and epinephrine shrinks some of the inflamed tissues there, allowing air to flow better in and out of the lungs. He also got an injection of dexamethasone, a steroid medicine that reduces swelling in the airway. The emergency department kept Johnny there for another couple of hours to make sure he did not need any more treatments. The doctor then did a fifteen second repeat examination, found the stridor to be gone, and sent Johnny home.

Johnny’s mother agreed he actually was significantly better after the breathing treatment and the steroids. Over the next couple of days, however, Johnny never returned to normal. He still had a cough that made him sound like a seal. The cough was worse at night when he lay down, although the odd thing about the cough was that it came and went suddenly at intervals. He still looked well otherwise and had no fever or other symptoms. The runny nose went away completely, but still he had that raspy cough. Johnny’s mother made an appointment for the child to see his regular doctor the next day, but that night his cough was as bad as it had been at the beginning. He also was having more breathing troubles–the stridor was back. She decided to take him back to the emergency department.

Their wait in the emergency department was again several hours before Johnny made it back to the examination room. The doctor on duty was a different doctor than had seen the child the first time, although this doctor did at least have a copy of the record of Johnny’s first visit. Later I read the note from the previous doctor. It was brief, as they usually are in situations like this: Typical croup following two days of URI (upper respiratory infection); responded to epi neb (the breathing treatment); home after IM decadron (the steroid shot); follow-up with PCP prn (to see his regular doctor as needed).

The new emergency department doctor looked at this note, again heard Johnny’s cough and stridor from the hallway, and knew what to do even before she went into the examination room. This doctor was even more harried and harassed than the previous one had been–it was a particularly busy night. She ordered another epinephrine breathing treatment for Johnny even before seeing the child and then went on to another child, planning to come back in fifteen minutes or so to see Johnny after the treatment had time to do its work. She also ordered an x-ray of the child’s chest and upper airway to make sure there was no pneumonia present, even though she knew this was quite unlikely in the absence of fever.

When the doctor got back to Johnny, he was indeed better; his cough was less harsh and his stridor was once more gone. His x-ray was normal. The doctor decided Johnny’s problem was most likely persistent viral croup, being just a longer, more severe case of this common illness. Even though she thought this was the cause of the cough, the doctor hedged her bets by treating Johnny for another possibility–asthma. Asthma generally causes wheezing in the lungs. Sometimes, however, children with asthma manifest their illness with a very prominent cough, but only mild wheezing.

When the doctor sent Johnny home this time it was with a prescription for a five-day treatment course with oral steroids, rather than the single shot he got last time. This would treat both croup and asthma. She also prescribed inhalations of albuterol, a medicine that treats asthma, just in case that was the main problem. The doctor told Johnny’s mother to make an appointment to see the child’s regular doctor the following week, after the steroids were done, to check up on how he was doing.

Johnny’s mother did take him to his regular doctor six days later. She said by then he was again better, in that his stridor had not returned, but he was still not entirely well. He continued to look well, had no fever, and had a good appetite, but he still coughed, especially at night. As before, the episodes of coughing came on abruptly, then disappeared. He also had an increasingly hoarse voice, something that he had not had at first, and which was getting worse in spite of the steroid medicine.

I spoke later with Johnny’s regular doctor, and he told me the one thing that particularly struck him when he heard the entire story was how sudden the original onset of the severe cough was; although the child had a runny nose and a mild cough for a few days, his mother said the cough became abruptly and dramatically worse in the middle of the afternoon before she first took him to the emergency department. Even after a week of symptoms, the cough was still disturbingly sudden in its appearance. The doctor believed this important bit of information meant something was clearly not right in Johnny’s upper airway, and that it was time to find out exactly what was going on in there.

Johnny’s doctor asked an otorhinolaryngologist, an ear, nose, and throat specialist, to see the child. The specialist agreed Johnny’s problem sounded like more than simple croup, so later that day he used an instrument with a light on the end to look down into the airway, a procedure termed bronchoscopy. It is not a simple procedure, and it is not one entirely without risk, but it was the only direct way to see what was wrong. Bronchoscopy is uncomfortable for the patient and potentially frightening to a small child, so an anesthesiologist first gave Johnny a drug to sedate him.

The specialist found Johnny’s airway just below his vocal cords to be a little inflamed, just as one would expect in relatively mild croup. But that was not all he found: beneath one of Johnny’s vocal cords and stuck firmly into the side of his trachea, his windpipe, was part of the plastic base of a small toy soldier. The object blocked about a third of the diameter of Johnny’s airway, and it moved back and forth as the child breathed. The doctor was able to grab and remove the plastic using a tool he passed down through the bronchoscope. When Johnny awoke from the procedure he was already breathing better. By the next morning the swelling the bronchoscopy itself causes was gone, and the child was normal. He went home later that day.

The medical aspects of what happened to Johnny were by then clear to everybody. He really did have mild croup at first, something which often follows several days of viral respiratory illness. But then he inhaled, or aspirated, a small piece of plastic that lodged in his airway, and that is what caused most of his symptoms and landed him in the emergency department twice. Because he did really have a bit of croup, and because the plastic probably inflamed his airway tissues a little, the breathing treatment and steroids did actually make him better. However, he never got back to normal in his breathing because his airway was still partially blocked by the piece of plastic. Since plastic does not show up on an x-ray, the doctor did not see it on the image of Johnny’s neck taken during his second visit to the emergency department.

The non-medical aspects of Johnny’s case, the social and interpersonal events, are key to understanding why his story unfolded as it did. From them one can easily see what may happen when well-meaning parents and physicians do not make a communication connection. Johnny’s story had a happy ending, but this is not always the case; sometimes communication failures have serious or even life-threatening consequences.

I met Johnny and his mother just after his bronchoscopy, when it was my job to make sure he recovered safely from his anesthetic. I had a chance to talk with her about what had happened. She was not annoyed at the physicians at all; rather, she was mad at herself for not intervening in the situation on behalf of her child, of not knowing best how to communicate with the doctors effectively in the brief amount of time she had to interact with them.

Case #2: An Unusual Bonk on the Head

Our next story is about Sean, a sixteen-year-old boy. He was playing basketball one afternoon in the driveway with his brother when he stumbled and fell, hitting his head on the pavement. Sean could not remember anything about the event, although his brother told their parents Sean did not appear to trip over anything–he just fell down. Sean was a little dazed for a few minutes, but was not obviously “knocked out.” Afterwards he complained of a headache, so his father brought him to the emergency department. He vomited once in the car during his trip to the hospital.

The triage nurse put Sean in the lowest-risk category because by the time he arrived in the emergency department he felt fine except for the headache. After the usual several hour wait Sean saw the doctor, who asked him and his father the routine questions one asks in these situations: what happened, did he remember any of it, what was bothering him now? Sean said he still did not recall the exact moment he fell or even much about what went on for the minutes following, but that he had “tripped over his feet.” The doctor examined the boy and did not find anything wrong other than a sore lump on the side of his head. He sent Sean for a special scan of his head (of which you will read more later) to see if he had fractured his skull and to make sure there was no bleeding or swelling of his brain.

Based on his examination, the doctor did not expect to find anything on the scan, but he wanted to be sure. Before he left for the scan, the doctor very briefly asked Sean’s father a few other standard questions: was the boy “otherwise healthy,” did he take any medications regularly, had he ever been in the hospital before, and was everyone else in the family healthy? Sean’s father answered that everyone at home was fine and that Sean had “always been healthy.” Sean vomited once more on his way to the radiology department, but the scan was normal; his skull and his brain looked fine.

The emergency department doctor made a diagnosis of a concussion, largely on the basis of Sean’s brief memory loss. A few episodes of vomiting are also common following a concussion. Very rarely the brain can swell dangerously after an injury like this, and children need to be checked on frequently for the next twelve hours or so to make sure that is not happening. Sometimes this can safely be done at home if there is someone available to watch the child through the night; sometimes such children are admitted to the hospital. It is a judgment call based on the particular circumstances. In this case the doctor admitted Sean to the hospital overnight, to the pediatric “step-down unit,” a place where he could be checked on frequently through the night.

I met Sean and his father soon after the child arrived in the unit. He told me he felt better; his headache was nearly gone and he drank some juice without vomiting. As we talked the nurse hooked the boy up to the monitoring system we routinely use in this situation. It measures heart rate, displays the heart’s electrical rhythm on a screen, and keeps track of breathing. The heart rhythm tracing did not look entirely normal. It can be difficult to tell much from just the picture on the screen, so I ordered an electrocardiogram, a test which tells us what is going on in the heart’s electrical system. The electrocardiogram confirmed what I had suspected when I looked at the simple tracing. Sean had a problem called prolonged QT syndrome.

This syndrome, which is often an inherited problem, causes an abnormality in the way the heart muscle conducts electrical impulses, and it is those impulses that control how well and how often the heart beats. The heart is a muscle, and it is the zap of electricity that makes a muscle twitch and contract. When the heart muscle contracts it squeezes the blood from the heart.

Persons with prolonged QT syndrome, on rare occasions, have their hearts simply come to a standstill. The risk of this happening with any individual heart beat is very, very small, but since our hearts beat constantly, the lifetime risk of this happening for a person with prolonged QT is significant. When it happens, sometimes the heart starts up again on its own; sometimes, however, it does not, with catastrophic and potentially lethal consequences. One of the things that increases the risk of the heart stopping is exercise, because exercise normally increases the heart rate and faster heart rates are more dangerous to patients with prolonged QT syndrome.

Once I saw the electrocardiogram I sat down with Sean and his father to ask them some important questions about Sean’s past medical history and that of other members of his family. What they told me strongly suggested Sean had been troubled by this syndrome for several years. It also explained how he got his concussion.

Sean’s father told me that on at least two occasions in the past Sean had collapsed inexplicably. One of these times had been after running a foot race at summer camp. The camp physician evaluated Sean after the fainting spell, which lasted less than a minute, and decided Sean was likely dehydrated. It was a hot day, the child had been out in the sun for hours, and he had drunk little fluids. The diagnosis made sense; after all, passing out briefly after running a mile in the hot sun is not an uncommon thing to happen to a dehydrated boy.

The other time Sean apparently fainted was a little more ominous. He was swimming in their backyard pool with his family when he suddenly sank below the surface. At first his father thought Sean had just gone down to swim underwater, but after a few seconds he noticed the boy was not swimming. The father fished Sean off the bottom of the pool and by the time they both came up to the surface Sean was wide awake and sputtering. He told his dad he had choked on some water and “lost his breath.”

I then asked Sean’s father if anyone else in the family had a history of heart problems. In families with prolonged QT syndrome it is especially important to ask if any relatives had ever died suddenly and unexpectedly, particularly at a relatively young age. It turned out an uncle had dropped dead from what was assumed to be heart attack, even though he was only thirty-five at the time and had no prior heart problems.

Prolonged QT syndrome also explained Sean’s concussion. He had probably experienced what is called an arrhythmia, an abnormal electrical impulse in his heart, while playing basketball, and then fallen, striking his head. His two previous fainting spells were most likely episodes of the same thing. Luckily for him, they resolved on their own each time.

The next morning a cardiologist, an expert in the heart, came to see Sean and confirmed the diagnosis of prolonged QT syndrome. The cardiologist also asked the rest of the family to come in for electrocardiograms, and he identified the same syndrome in Sean’s father, even though the man had never fainted before. The syndrome has a usually effective treatment, and Sean and his father both began medication for the problem. This all occurred a decade ago, and as far as I know both have done fine since.

It was fortunate for Sean and his father we had occasion to put cardiac rhythm leads on the boy, even though we did so for a completely different reason than suspecting a heart problem. This case made all of us go back over Sean’s evaluation in the emergency department to see what went wrong. It was clear that communication was the root issue in this situation; there was a misunderstanding between doctor and parent over what each understood key questions to mean.

The doctor asked Sean’s father if the child had always been healthy. This was a general question, phrased in a general way, and most parents naturally take it to mean frequent illnesses like infections, wheezing, and intestinal problems. In fact, Sean had fainted under strange circumstances on two occasions. One might think the doctor should have asked if Sean had ever fainted or collapsed, but remember the child was there for a head injury, one caused in the child’s own words by “tripping over his feet.” The doctor was already traveling down the simple concussion pathway with his diagnosis.

If Sean had been in the emergency department because he clearly had fainted, the doctor would have asked a whole set of different, specific questions, found out about Sean’s previous mysterious fainting spells, and most likely done an electrocardiogram right then. The doctor also would have asked specific questions about fainting and sudden death in other family members. Circumstances conspired against arriving at the correct diagnosis immediately.

Case #3: A Mysterious Swelling

Our final story of the chapter is a little different from the first two. It is not about ships passing in the night, but rather about ships that never passed each other at all. It provides an excellent example of showing, by default, how important is good communication between doctor and family. In this case we had no parents at all to talk to for many hours–they lived far away and the child was air-lifted to our hospital–so we had little idea about what happened to him before he arrived at our facility. His story represents an extreme instance of what can happen when no communication at all occurs, in this case not because of misunderstanding between doctors and parents, but because there was no communication to be had.

Danny was an four-year-old boy who lived in a remote, rural part of the state. That afternoon his parents had found him unconscious beside his tricycle. They called 911 and Danny was flown by helicopter to our hospital, arriving in early evening. In the emergency department he was confused but conscious. He appeared to have suffered a concussion, as did our last patient, Sean. In addition to that, however, Danny had a broken arm. The orthopedic surgeon placed his arm in a splint and Danny was admitted to our pediatric intensive care unit to recover from his concussion. Over the next several hours his mental state improved, and it appeared his head injury was a relatively minor one. He also had quite a few superficial scrapes on his skin, mostly his hands, arms, and face, which we attributed to him rolling in the gravel when he fell.

Even though his broken arm was safely in a splint and he had awakened enough from his concussion to drink fluids well, Danny’s nurse began to notice a strange thing. His other arm, the unbroken one, was progressively swelling, right down to and including his hand. We had x-rayed that arm so we knew it was not broken, but we had no explanation for the now rapidly advancing swelling. Then a very astute nurse, one who happened to grow up in the same part of the state as Danny lived, pointed out the swelling looked very much like what happens after a rattlesnake bite. There were no fang marks on Danny’s arm or hand, but the large number of scrapes on his skin made it difficult to be sure.

There is a blood test, a clotting test, which is nearly always abnormal following a significant rattlesnake bite; we ordered the test, and it was markedly abnormal. By this time the swelling was worsening so rapidly we decided it was best to assume he had been bitten. We gave Danny the specific anti-venom for rattlesnake bite, and his swelling rapidly resolved. His abnormal blood clotting test also returned to normal. Once the swelling was down we carefully scrubbed his arm, looking at every scrape carefully. Once we knew what we were looking for, we found buried in the abrasions clear evidence of rattlesnake fangs.

By the next day Danny’s parents had arrived and could help us fill in the details about what probably had happened, although they, like us, first assumed he had fallen, hit his head, and broken his arm. They did not know about the snakebite. Once we told them, though, they were not surprised. Danny himself could not tell us anything; his concussion had apparently wiped out any memory of being bitten, or even of falling.

Danny’s parents told us he was an active boy. He was so active that he ranged far up and down the road outside his house on his low-slung tricycle. One of his favorite things was to zoom a quarter mile up the road to a construction site where workers were putting up a new house. His mother always went with him because of his age. She also watched him closely whenever he was outside playing because on a couple of occasions she had caught him peddling furiously up the road by himself to see the action at the site.

Late on the afternoon of his arrival in the PICU Danny’s mother went into his room to get him up after his nap. She found his bed empty and the screen on the ground floor bedroom’s casement window off; Danny had escaped on his own. His mother ran toward the building site, very concerned but also very sure where he had gone. She found Danny at the edge of where the construction workers had been digging part of the basement. The child had fallen from his tricycle and was lying on his face, unconscious, with his arm bent crookedly under him. It appeared to his mother that he had lost control of his tricycle and tumbled about ten feet down the embankment that was the partially-dug new basement. She called 911 and paramedics flew the child to our hospital.

The parents also told us the construction had apparently gotten into a rattlesnake den, since they saw many more snakes in the area after the digging began. Putting it all together, we surmised Danny fell from his tricycle, hit his head and got a concussion, broke his arm, and probably landed on or near a rattler, which bit him and then left the scene.

* * * * *

This book is about how to help you help the doctor give your child the best possible care. Subsequent chapters will take you step-by-step through how doctors approach clinical problem-solving, how we use different kinds of information, such as the story of the illness, our physical examination, and laboratory tests, to reach a decision about what is wrong with your child. As you will learn in the next chapter, getting the story about the details of a child’s illness is crucial to making the correct diagnosis and giving the right treatment. We cannot count upon having a perceptive nurse around who knows about rattlesnakes.

The key concept for this first chapter is that, in situations such as those of Johnny and Sean, doctors often have already made some preliminary decisions about what is wrong and what they are going to do even before they have laid eyes on your child. This is not necessarily a bad thing; after all, the ability to do that is what makes a doctor experienced. Sometimes, though, such prejudging of the situation makes an initial direction down the wrong diagnostic path hard to correct. As a parent you can help a great deal, but you can best be a full participant in this process if you understand how and why doctors make medical decisions. The rest of this book will give you that understanding.