July 12, 2009

A Mistake

“Experience is the name everyone gives to their mistakes.” Oscar Wilde, from Lady Windermere's Fan, 1892

Yes, I know. Everyone makes mistakes. Every parent makes mistakes, nearly all of them invisible to a child. To a child, what we do has to be right just because we're doing it. Parenting books are filled with sure-fire techniques to get your kid to do everything from eating something besides white food to success in college. But those authors haven't met your children. Sometimes the best thing to do just isn't that clear.

Doctors make mistakes, too. In my particular line of work, I'm relieved to report, failure isn't usually associated with a really bad outcome--you know what I mean. Still, I look upon my job as making children feel better and making their lives better. I work hard at it and do my best.

Three days ago, a favorite patient came to the office with his mother. He had acquired a splinter in one of the worst places to get one, the center of the palm of his hand. It's a bad place for several practical reasons, not for elaborate medical reasons. The skin on our hands is quite thick, not quite as thick as the soles of the feet, but very thick. Unlike the soles of our feet, however, our palms are covered with sensitive nerves for feeling things. Our palms have a flexibility that makes it difficult for us to flatten our palms completely. And once we start grasping things as babies, we never stop, so the muscles of our grasp are very strong. Lastly, the palm is fully visible to the motivated child.

He had been healthy and was playful with me when they first came into the office. He was glad to show me the splinter. It was clearly visible, only about 2 or 3 mm long. But it was in an awkward position, as if it had been put straight in and then broken off at the surface. Because of this foreshortening, it was difficult to see a way to expose the deepest part of the splinter without digging a deep hole in the center of his hand. The nearest part, however, was close to the surface, and should be an easy grab with my sharpest surgical-quality tweezers. Because of the thickness of the skin in the palm, I thought I could get it on the first try without hurting him.

After about 20 minutes of the most upsetting screams possible, as this child stared at me, wearing a headlamp, using needle-sharp instruments on him, I gave up in a sweat. I had to try a different way.

I prescribed some numbing cream for him, and asked his mother to bring him back with the cream, for me to apply. The next day, I put the cream on, covered it, then wrapped his whole hand in an elastic bandage so he wouldn’t mess with the cream. He was happy to play with the office toys for about an hour. He didn’t mind the unwrapping, or cleaning off the cream. But the screaming started as soon as the tools came near him.

Granted, these are some fairly scary-looking tools. Everything was shiny and needle-sharp. We had a reasonable control ratio. (I have defined this invented term—I wonder if it’ll catch on—as the ratio of adults to the age of the child, in years. In this case, the ratio was a usually-effective 1.0: there were 3 fully grown adults to a single 3-year-old child. The 3 adults didn’t have a chance of restraining this warm and affectionate child. I though it might be helpful to use the numbness provided by the cream to allow a small injection of local anesthetic, to really be sure he wouldn’t feel anything.

I won’t keep you guessing. That didn't work, and the 3 of us never got his hand still enough even to get a good look. I never took out the splinter. Luckily, I haven’t been exaggerating about the patient’s mellow personality, and though he was absolutely impossible to restrain for even 20 or 30 seconds so I could get the thing out, he was immediately forgiving, both of me and his mother.

First, some information about splinters. Usually, they have to come out. By definition, they are little irregular slivers of something, torn or broken off of something else. Broken or torn edges are rough, though you might need a microscope to see that. These rough edges can be packed with bacteria that can cause nasty infections. It’s a sign that you absolutely must get the thing out if it becomes swollen and red and painful to touch. It’s a particularly bad sign if this red/swelling/pain develops just a few hours after getting the splinter in the first place. If that happens, either get it out yourself, or if you can’t, get to an ER. In this case, there was no redness after a day when I first saw it. There was still no redness the following day. No swelling. It hurt him a little to press right on it, but not too bad.

So this was my mistake. Honestly, I don’t think it’s a mistake I make very often. I think of myself as a minimalist, using the least possible intervention that will have the best result for the child. It just looked so easy, no big deal, right there near the surface...all it would take was a few seconds of him holding still. But that’s a common error in judgement. I focused on what would be reasonable medically for all kinds of rational reasons. That wasn't an empathic approach. What was in the best interest of the child? How did he look at this issue? He certainly didn’t see it as a problem that needed what appeared to be an inappropriately serious response.

He was right. Though most splinters need to come out, what happens if they don’t? If small enough, the body’s immune system can literally digest them, and make them disappear. Sometimes, the skin will push them out over time. And sometimes the body can wall them off with scar tissue, and they are with us forever. After a really long (maybe an hour) bath, the top layers of skin on his palm might be soft enough to come off with a vigorous drying, and that might take care of it.

His mother certainly thought it needed to come out, and I did too, at the time.

It's important to try and see things from the child's perspective. It's something I consciously try to do with all my medical encounters. This time, however, not so much.

Being sensitive to the child's viewpoint is really important--but that's not the same as letting that viewpoint dictate what has to happen. Part of the price we pay for having the privileges of being grown-ups is that sometimes we have to make tough, unpleasant decisions. Just because your children would like to play on the freeway doesn't mean you should let them!

If the splinter had been infected, it would be out.

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