He talks to me with his eyes

Because Javier Gonzalez, a 6-year-old boy with spastic quadriplegia and a shunt in his brain to drain off the excess CSF, could not speak; and because his mother spoke no English (even though she understood quite a bit of it), it was his 9-year-old sister Laura who answered my questions. I was the resident working in house the evening that Javier came into the pediatric ward at Mount Sinai Hospital as a direct admission from his primary care pediatrician, who had called me from the inner-city clinic where he had stayed later than usual to evaluate him.

According to the pediatrician, Javier had developed a sudden high fever, chills, and cough earlier that day. His breathing became more labored; he refused to eat. The pediatrician had noted decreased breath sounds at the base of the left lung. He suspected pneumonia and called ahead to the hospital to arrange for Javier to be admitted.

As Laura answered my questions, I jotted down her responses in medical shorthand notation on the tablet attached to my clipboard. Javier lay in the hospital bed, head on the pillow, the rest of his tiny body oddly twisted under the hospital gown. His mother sat in a chair by the bed. She watched my face as I queried her daughter, then turned to look at her son as Laura did her best to give me the information I needed to know.

“When did your brother first get sick?” I asked.

“This morning, early.”

“Dile que no durmió bien anoche,” his mother added.

“She says he didn't sleep too good last night.”

“How so?”

“He was moving around in the bed or something like that.”

“What made you call the clinic?”

“He wasn't breathing too good. He was breathing hard. Like this.” She demonstrated a little pant.

“How's he doing now compared to this morning?” Laura looked at her brother. “He's doing okay. But he's a little scared,” she added.

This intrigued me. “How can you tell?” I asked her.

“He talks to me with his eyes,” she said.

I completed my questioning, then explained that we would have to do some blood tests on Javier. “He's also
going to get a chest x-ray. That won't hurt.” I tried to show him a little smile. He did not smile back.

A high WBC count substantiated the diagnosis of infection. The chest film showed a pneumatocele in the left lower lung. It also showed fluid in the pleural space. I called Javier's pediatrician with the results. “Get a surgical consult,” he said.

This was a community hospital. There were no pediatric surgeons available. So I called the general surgeon who was covering ward service that day and explained the findings to him. “I'll come by to see him. He may need to have that effusion tapped. If he's as sick as you say he is, it may be an empyema.”

We made it a point never to do procedures on a child at the bedside. A treatment room on the ward was reserved for this purpose. This supposedly allowed the child to feel safe in his bed; he didn't associate pain with his safe place. I suppose the theory made sense to an adult. To a child— especially a child with spastic quadriplegia who relied on others to move him, feed him, and clean him, who could not run away or cry out, but only watch what someone else was going to do to him, someone he didn't know or trust—I often thought the difference was minimal. Once inside the hospital, you were at the mercy of the staff.

The surgeon looked at the radiographs, borrowed my stethoscope to listen to Javier's chest and back, stroked his chin, and said: “Let's tap that effusion.”

I called a nurse, and we took Javier to the treatment room. His eyes darted back and forth between his mother and sister as we carried him out of his room and down the hall. Once the heavy door had sealed shut behind us, the surgeon became very chatty. He asked for a thoracentesis tray and proceeded to scrub his hands at the sink.

“Ever do a tap before?” he asked me.

“No,” I said.

“It's easy,” he said. “Nothing to it, really. You just go in slow with the needle, bevel down, over the top of the rib. Keep a little negative pressure on the syringe until you see a return of fluid. Easy as pie. Wanna try? Go ahead; you gotta do one sometime.”

I swallowed hard. “Okay,” I said, and went to the sink to wash my hands.

We had to sit Javier up on the exam table to do the tap. When he saw the instruments on the tray, he let out a sound that defies description. It was hard to support him in the sitting position because of the spasticity in his legs. Almost like trying to bend a board, except this board was warm and bony and unforgiving.

With the surgeon's directions, I succeeded in locating the landmark on his back. I raised a small bleb on the skin surface with xylocaine, then pushed the needle down into the little mound to inject more anesthetic into the deeper layers. Still Javier struggled, twisting his torso as best he could, bellowing the same monosyllabic sound over and over again.

I placed the small plastic syringe on the tray and picked up the large glass Luer-lok syringe with the 18- gauge needle. An inch away from the skin, I hesitated; the syringe shook in my hand.

“Go ahead,” said the surgeon. “I haven't got all night.”

I pushed the needle through the bleb on the skin and over the top of the bony rib, clearly visible on this emaciated boy. He was crying now, crying and bellowing, like a wild animal caught in a trap and struggling desperately to free itself.

Suddenly, there it was, a cloudy, yellowish fluid flowing steadily through the needle into the clear glass barrel that I held in my hand. “Get a Gram's stain and culture on that,” the surgeon said. He had stripped off the latex gloves and was washing his hands again. He dried them on a paper towel, pulled on his sport coat, and left.

The evening nurse and I took Javier back to his room, where his mother and sister were waiting. “What did you do to him?” Laura asked.

“We took some of the fluid out of his chest, like I told you.” I showed her the dressing. “See?”

We laid him back down in the bed. His small head rested against the pillow. “He did fine,” I said, trying again to smile.

My eyes moved from Laura to Javier. I searched his face for any emotion. In his eyes I saw the look of terror that saw through my smile, the look that knew I had betrayed his trust.

He talks to me with his eyes, Laura had said. I knew now what she meant. JAAPA

Brian T. Maurer, PA-C, practices pediatrics at Enfield Pediatric Associates, Enfield, Connecticut. He is the author of Patients Are a Virtue and a member of the JAAPA editorial board. Visit the author at http://briantmaurer.wordpress.com.