Touching Theresa

It was one of those beautiful summer Sunday mornings when the jet stream flows over Canada and the San Francisco Bay Area sits under a seemingly perpetual Pacific high while the coastal fog tries daily to claim the Bay from the summer heat. I was driving over the Richmond San Rafael Bridge on my way to work at the Pediatric Clinic in the old Kaiser Field Hospital in Richmond.
The tide had already started to ebb and was swirling around Red Rock when I looked down from the bridge toward the Long Wharf of the Chevron Refinery. It had been over 15 years since I had sailed as third mate on the JL Hanna, a T-2 tanker left over from WWII that had still been in service carrying crude oil down from Alaska and then taking gasoline and jet fuels out to Hawaii and Wake Island. I reflected as my truck bounced along the bridge that it had been such a long journey from that wharf to medical school. Medical school was followed by residency in Pediatrics in Kansas City, then three years as a US Navy General Medical Officer stationed in Scotland. A fellowship at the University of California San Francisco followed. Now I find myself now working two miles inland from where I had started working in Richmond those many years ago.

I could see Leroy cleaning off the loading ramp in front of the ED entrance as I parked my 1982 Datsun pickup across the street. He leaned on his broom and asked, “Hey Doc, when are you going to start driving a real doctor’s car?” I laughed and told him I liked my ”dirt-colored” truck—all four corners had been dented and it appeared the least likely vehicle to attract a thief or a vandal in our Marina Boulevard parking lot.

The Emergency Room was quiet. Grace and Linda were the RNs working that morning. Larry, the ER doctor on duty, was sitting at the work station with his feet up on the desk reading theChronicle. He looked up and grinned a boyish grin through his graying beard and spoke to me over a round belly that made him appear six-months pregnant, saying “Hi Chuckles, are you back for more?” I told him, “Not today.” I had worked the 8-to-8 shift the day before and had gone home exhausted after dealing with a knifing, a GI bleed, two gun shots along with the other Saturday afternoon and evening emergencies that seemed to find their way to us from the streets of Richmond. It was now Sunday morning and Sunday mornings were usually quiet; that was just the way I wanted it. I hoped to catch up on my reading and perhaps borrow the sports section and see how the As were doing in the Pennant race.

Grace walked over and told me that I should help Larry clean his shoes as he still had some chicken feathers stuck to the soles from walking around his poultry yard in Sebastopol. I laughed and said we were lucky that at least his shirt was tucked in. Larry is one of those eclectic ER Docs who is great to work with and who always steps up when the ambulance pulls in with lights on and siren announcing a Code 3 arrival, but he didn’t care much for appearances. Grace and Linda had both worked in that ER from a time before we had such a thing as an Emergency Medicine specialty and they took it upon themselves to make sure all the doctors who showed up to work a shift in their ED did a good job and harmed no patient. Of course Emergency Medicine was now a Board-certified specialty and Larry and I had both grandfather’d in and passed our specialty exams. I had been asked to join the Pediatrics Department after a Peds doc had retired and such a small facility as Richmond had both the flexibility and willingness to allow me to work half time in both departments.

The Pediatric clinic was down a hallway, colored a light hospital green. It was right of the ED and around the corner from what had been the front door the Kaiser Field Hospital for the Richmond shipyards roughly a half a century earlier. Jodi was my clinic nurse that morning. She had already roomed my first patient; a little boy with fever, vomiting, and diarrhea. He didn’t appear too ill and after checking his vital signs and examining him I went over diet instructions with his mother and advised her regarding home care and follow-up for what appeared to be a viral gastroenteritis, which we had seen frequently over the past few weeks.

The clinic was then quiet. We had no patients for at least half an hour. I did manage to borrow the sports section from Larry and yes, the As had defeated the Orioles in ten innings and they were now 1/2 games behind the Angels for the lead in the West. I was about to read an article about how the Giants always seemed to find a way to lose and to break their fans’ hearts when I heard the crying.

His name was Brendan; he was eight years old and had a two-inch redwood splinter in the palm of his left hand. It was not too deep, fragmented under the top layers of skin over the thenar eminence at the base of his thumb. His father was holding his right hand and looked appropriately concerned. He said Brendan had fallen while trying to roller blade on their wooden deck. His immunizations were up to date. I asked Jodi to get some EMLA cream, which we could apply to numb the area before digging out the splinter and she smiled knowingly, saying “Yes, Doctor,” as she handed me the tube of EMLA, which was already in her hand. I wasn’t very surprised that she had been ready with that cream before I spoke and I briefly wondered just how many different meanings could be attached to such a simple phrase as “Yes, Doctor.”

The cream was applied and the tears slowed as the pain diminished. I told Brendan I would be back in a few minutes and we would clean his hand really well, remove the splinter and get a comforting bandage. I promised him we would explain everything we did before doing it and that it shouldn’t hurt. He managed a little smile while he sat there with his father.

I told Jodi that Sunday morning splinters were fine with me—they were usually easy to remedy and their removal was satisfying to patient and doctor alike. She handed me a chart and said the patient in the next room may not be as easy.

Her name was Kate. She said that she was five, but would be a six-year-old next month. Her left front tooth was missing and it looked like its neighbor would soon be coming out as well. She was looking down and only briefly making eye contact. She appeared scared. Her mother had red sunken eyes and looked as if she had been crying much of the night. I introduced myself and sat down asking, “How can I help?”

Kate’s mother told me that Kate had gone to a friend’s house for a sleep over. Shortly after midnight Kate had called home and was crying. She wanted her mother to come and get her and take her home. Kate was a smart little girl and could give a good history after her mother told her that she should trust the doctor and should say what had happened. Kate said she was awakened when her friend’s daddy had come into the room; that he had reached under her covers and touched her bottom.

At this point in the history Kate’s mother started to cry. Kate looked at her mother and became quiet, worried; not sure if she should continue telling the doctor what happened if it made her mother cry. We paused in the history-taking as it was now apparent the simple Sunday morning Pediatric Clinic was facing a problem involving the inappropriate touching of a child by an adult. This raised the question of possible, or suspected sexual abuse or assault.

I was very thankful to be working with such a good and experienced nurse as Jodi. Our county had not yet created, nor identified, an exam center for forensic evidence collection on cases of suspected sexual assault. Each ED and hospital in the county was expected to handle any cases that came to them.

I had been working with the Suspected Child Abuse and Neglect (SCAN) team to improve our ability to respond in Richmond while also working to help the county to identify one centralized location for what was becoming a specialty exam pertaining to evidence collection and probably even more specialized regarding the unique psychologic and emotional issues that surround questions of abuse. We had recently had a department educational session from the Rape Crisis Center. We had evidence collection kits and the necessary Office of Criminal Justice Planning (OCJP) 923 reporting forms. Now Jodi and I would see just how well the two of us could respond.

I asked Kate if the man had hurt her, or caused her pain and she said, ‘No, he just scared me and I cried and he went away. My friend’s mommy came into the room and she called my mommy to come and get me.” I reassured her that we would not hurt her and would explain everything during the exam and that we would give her a good medical check-up and make sure everything was all right. I asked Jodi to get the evidence collection kit and assured Kate’s mother that she had done the right thing, and it sounded like the friend’s father had a problem that the police and the Center for Child Protection could help address. They would make sure other children weren’t being touched inappropriately. It sounded like he hadn’t caused any physical injury and we would be careful to document a thorough exam. We would also make a phone call and arrange to have an interview conducted at the new Child Interview Center where specially trained forensic child interviewers could take a history which could be videotaped. The videotape could be used as evidence so Kate wouldn’t have to face the trauma of being asked repeated questions. She would not have to give the detailed history more than that one time. She would be protected from repeated questioning and any cross examination associated with possible criminal proceedings.

While Jodi was getting the evidence kit I excused myself to make a phone call to the police and to remove a splinter. The EMLA had had ample time to work and there was no pain around Brendan’s splinter. I cleaned the skin and carefully lifted away the top layers of skin with the beveled tip of an 18 gauge needle. The fragments of redwood washed away easily. We applied antibiotic ointment and a bandage and Brendan and his father both smiled; Brendan said, "Thanks Doc, that was painless.”

By the time I returned to Kate’s room her mother had collected herself and was not crying. She encouraged Kate to let the Doctor check her. We started by looking in her ears and then checking her mouth and throat. These are familiar parts of an exam and seemed to put Kate at ease. I checked the reflexes of her knees and she laughed a little when her lower leg reflexively kicked forward after I struck under her patella with my little red rubber hammer. I then told her I wanted to check her bottom, just as we had checked her top and she agreed. She had given a brief, but clear history that the man had touched her bottom. He had not put his hand inside her underpants and had done nothing else. She seemed impressed with our ultraviolet lamp as we checked over her skin and found no stains, no marks. It was almost as though the ultraviolet was both revealing and cleansing some of her anxiety around having been touched, or possibly damaged in some way. The exam of her genitalia was entirely normal without any sign of scratch, stain, or injury.

At the end of the exam I told Kate that she was perfectly normal. She seemed very relieved that we were done and happy the doctor had said all was well. I asked Jodi to take Kate to the waiting room and to give her some stickers that we keep as rewards for all brave girls and boys.

I then turned to Kate’s mother and said again that the exam was entirely normal. The OCJP 923 would record the exam and document the normal findings, consistent with the history. It was obvious that even though the exam may be normal, the situation wasn’t and there was still a great deal of pain and anger. I said to Kate’s mother that the question of damage or injury might now be influenced by what we said and how we explained it to Kate. Kate would be looking to her mother to see if she should still be worried. Her exam had been normal. We would get a one-time, videotaped, interview tomorrow that would be legally admissible to speak for and represent Kate in any further proceedings. It was really important that her parents and adults not send continuing messages that tell her she is damaged or unclean.

These words didn’t seem to be sufficient. It wasn’t as simple as saying to Larry he should clean the chicken feathers from the soles of his shoes. I was glad there were no other patients waiting and that we had time. I asked Kate’s mother about her religious beliefs; did she pray? She told me that her family belonged to St. Cornelius Church in Richmond. I sighed with the relief of finding a shared understanding and asked if we might pray together.

I tried to recall the words I’d heard Father Frank say so often in his Homily. “Lord, please give us strength and courage, relieve us of any needless fears about the past, or useless anxiety about the future.” I continued, “Help us to see Kate as the beautiful child she is and to recognize she is as clean and whole today as she was yesterday. Help us to not shame, or injure her with our angry or worried thoughts and not to burden her with our fears. Help us to continue to trust in You Lord and to trust the people she will meet at the Child Interview Center tomorrow.”

We were both silent. I looked up to see a tear and a smile. She said, “Thank you.” I believed her when she said she knew Kate was now and would be fine.

I marveled to see that the sun continued to shine just as brightly on the Bay and the sky was just as blue as I drove back home across the Bridge after the clinic closed that Sunday. The fog was starting to cover Angel Island.

When I got home the sound of our children’s playing seemed more joyful than I had remembered. I grabbed Molly, our five year old, as she ran after her big sister, Emily Sarah, and gave her a big loud kiss on the neck. I breathed in deeply the clean smell of Molly while she giggled as my beard tickled her neck and her ear. My wife, Monica, called out from the kitchen, “Hi Chuckee. How was clinic? Save any lives today?” She noticed the tears on my cheek as I turned from kissing Molly and said to her, “God only knows Monique. I did pray with a mother in clinic today and I do believe some pain was relieved. Her name was Theresa. I had touched her and she had touched me.