January 8, 2010

Monsters: Part 1

IMG_3117-sophia looking down 12-15-09 Jane was brought to the office because she didn't want to go to school.  Her mother said that she liked first grade, and so I was immediately worried. 

Was something bad happening to her at school?  Were her classmates being mean to her or making fun of her?  Was there a bully making her life miserable?  Her mother said she asked all these questions, but Jane denied all of them.  Her mother added that in the last week or so, Jane has had a couple of minor 'accidents' and now brings an extra pair of underpants to school, just in case.

I knew what this was, right away.  It was the mean 5th or 6th graders in the bathroom, hanging out and using bad language.  They could be brutal on the littler kids, so much so that the younger children are afraid to go in.  After a while, the inevitable happens.

But that wasn't the only possibility.  She could have an infection somewhere in her urinary tract.  The irritation of the bladder lining often makes holding capacity limited.  Among the other things, especially among girls, is something occasionally called giggle incontinence.  Do I have to spell out exactly what this is?

I asked mom to let me speak to Jane alone for a moment.  I was sure it was the older kids in the bathroom.  Jane admitted that she didn't use the bathrooms at school.  Gently, I asked if it was because of the other kids in the bathroom.  She said it wasn't.  Of course, I couldn’t be certain this was completely accurate.  So after several other uninformative questions and answers, I asked her again, and rephrased the question.  “Are you afraid of going to the bathroom at school?”  I asked.  She nodded.  “But it’s not because of other people in the bathroom?”  She nodded again.  Gradually, we narrowed it down.  She was afraid of the toilets.  Huh?

All of my presupposed diagnoses were wrong.  Someone creative had invented something entirely new since the time that I had attended elementary school.  The Toilet Monster.

The Toilet Monster would--unpredictably and only occasionally--emerge from the toilet at one of our most vulnerable moments.  Without warning, some accounts say that the unwitting victim is devoured completely and disappears without a trace.  Other versions have the monster lingering to inflict painful bites on our most confusing parts.  Always, it would attack without warning of any kind.  Jane reluctantly recounted the sad but completely true, she swore, tale of a kindergarten student from 2 years ago who went into the toilet stall and nobody ever saw her ever again even her mom and her dad.

She wasn’t sure but it might be in the toilet at home also.  Only after being asked, her mother thoughtfully recalled that now that I mention it, she hasn’t seen Jane use the bathroom at home in 2 days.  She assumed she was going extra at school.  In fact, she was holding it in until it overflowed.

After hearing about this, with me as witness, Jane’s mother told her that it was ridiculous and there were no such things as monsters and nothing can live in a toilet. Stuff in the toilet goes down to the sewer and not back up, ever.  Big girls, she said, don’t believe in monsters.

Jane started to cry.

I make a point of speaking directly to the child as much as possible during doctor visits.  This, I believe, empowers the child and enhances rapport with the doctor.  This situation in the meeting I have described, however, is a notable exception.  Jane was looking at me and sobbing.  I didn’t make eye contact with her, but looked straight at her mother and used the adult authoritative and expert voice I might use when giving a lecture at the University, or when explaining how to use some sort of serious medicine.  “What about Blue?” I asked the mother.

“Blue?  What do you mean?”  The poor woman was completely ignorant about Blue.  She was also in the dark, of course, about the fact I was making this up as I went along.  Her face showed  blank confusion.  Jane stopped crying, looked interested.

Obviously, they needed me to share more of my years of training and considerable expertise.  “Sure,” I continued, “everybody knows what toilet monsters do.  But I’m surprised no one explained what they are afraid of.”  Turning to Jane, “Did they?”  She shook her head.  “Everybody knows that toilet monsters are afraid of the color blue.”  Jane looked incredulous.  Her mother couldn’t see where I was going.  “I’m going to write a prescription and I want you to take it to the drugstore as soon as you leave here and I think that will help with this problem.”  Jane was starting to look relieved just as her mother was looking more confused.

I used a real prescription, which might be a violation of section 409(b) paragraph 11 of DEA regulations.  I wrote:  Toilet bowl insert--the kind that makes the water turn blue--for every toilet at home.   I wrote for 5 refills.  On the line for a second prescription, I wrote for blue food coloring (washable) in a small bottle with an eyedropper.  I explained to the patient that just one drop in a toilet bowl prior to using will repel toilet monsters and prevent their attacks.  blue-toilet-bowl-mumbai-lands-end-306x459It was very strong medicine!  Just one drop is all you need!  Adverse side effects could include blue hands, blue splotches on clothes.

About a week later, I called Jane’s mother.  The incontinence problem appeared to have resolved completely.

Jane, ever helpful, boasted of her newly-acquired knowledge of the species to her classmates.  They were very impressed with her expertise and her mother’s and her doctor’s trust in sending her to school with bottle of strong medicine.  She showed them how she uses the medicine, and shared it with them when they needed it.  Even some of the boys!

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