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Her clear blue-green eyes sparkled as she played with the blocks, and for any other 21 month little girl, they would have been considered adorable and envy-inducing. For “Ana*”, however, her beautiful eyes were dwarfed by her profound cephalomegaly and as she walked around the room she seemed almost off-balance, as if she could tip at a moment’s notice. I met Ana for a simple ear check as part of her pre-operative clearance for placement of a ventriculoperitoneal shunt, and while her exam was easy to perform, digesting the rest of her short and complicated story was somewhat more difficult.

Throughout my third year I had met many patients whose stories lingered with me – from an old man who stoically digested his unexpected cancer diagnosis, to a young woman struggling with her psychiatric illness. I always enjoyed getting the chance to talk to those individuals, to hear precisely what was important to them and how they wanted to be treated. Children, on the other hand, especially ones who are not even two years old, cannot always tell you what happened, what they feel, or what they want. Therefore pediatricians must rely the parents can tell us what the problems are, but what happens when the parent is the problem?

Ana’s enlarged head was from subdural hygromas caused by subdural bleeds thought to be due to non-accidental trauma. There was a woman in the exam room, who gently held Ana’s head as I peered at her tympanic membranes, but this woman was her foster parent, not her birth mother. Although this woman had been assigned to Ana by CPS, the affection between the two was palpable and even as she squirmed on her lap, it was clear Ana felt comfortable. This was a therapeutic alliance that I could understand –clearly both of us had Ana’s health and wellbeing as our primary goal.  
What I struggled with was the appropriate way to interact with Ana’s biological father, who sat awkwardly on the other side of the room. This young man was alert, eagerly asking questions about her lab results, and clumsily held her tiny hands during the ophthalmoscopic examination. Without knowing the full details of the CPS report, how do you include a parent in a visit who has been judged unfit to take care of their own child? Even if you are privy to all the information, how do you respect parental rights when they have been stripped away? Clearly the child’s best interests are the priority, but what level of parental involvement with medical care when a child is in foster care is appropriate? With the possibility that Ana may one day be returned to her parents’ custody, physicians must keep a balance between not alienating the parents while also keeping them at an appropriate distance. We are trained to see the red flags of child abuse and how to sound the alarm, but I do not know much about the aftermath of child abuse as it relates to the family structure. While the technicalities of the process of rebuilding a safe parent-child relationship are not strictly within the physician’s domain but at the same time a pediatrician will take care of a child for nearly two decades and throughout that time can offer guidance as well as serve as a safe harbor.

*Not the patient’s real name.

- A, M4

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I can understand how outsiders might see what surgeons do as borderline barbaric—slicing into people’s bellies, opening up their skulls, taking out their organs—but to me it has never seemed that way. Even with a patient’s small intestines splayed out across their abdomen during an exploratory laparotomy, within the environment of the operating room somehow that process seems controlled and purposeful. On the table, under the halo of the OR lights, something as brutal as sowing someone’s flesh back together becomes an art of approximating skin flaps precisely so they line up – not too far apart, not too close together. This is the way I felt until I met Mr. Crow.* The first time I saw Mr. Crow was in the Emergency Department where his MS-ravaged body lay rigid on a gurney; his face was pale and sweaty with strained breathing despite a CPAP strapped to his face. His hemothorax on CT was obvious even to me, and combined his esophageal perforation, so was his need for emergency surgery. Despite the patient’s wincing, the most agonizing part wasn’t the physical discomfort of multiple IV sticks, or the struggle to breath. I saw the painful side of medicine as I stood in the corner and watched as the attending realigned Mr. Crow’s expectations with reality. Tracheostomy. Discharge to a SNF. A 50/50 chance, given his co-morbidities. “Not yet. Not yet.” He strained over the hum of the CPAP machine, referring to the tracheostomy, as his eyes frantically swept the room. Even in the OR, with ET tube in his throat, a chest tube between his ribs, and later a scalpel in his chest, I never felt his pain as acutely as that moment in the ED, as his eyes bulged and his wife sobbed in the background. The emotional pain that we inadvertently bring upon our patients is often overlooked in favor of treating the physical pain we have inflicted. Physicians bring people nose to nose with their own mortality and after a conversation of that magnitude people on both sides of the table need emotional support.
I believe the emotional distress associated with surgery, particularly in emergent cases, can be devastating. Trauma of that nature can be harder to reconcile with the spirit of medicine and more difficult for patient and provider alike. As a medical student, I couldn’t talk to him about his chances of surviving the operation. Nor did I have any experience to lend about inserting a chest tube. I could not alleviate his physical pain, but I did the one thing I could do – as they sedated him in preparation for intubation, I held his hand. *Not the patient’s real name.

- Anonymous, M4