A Sentinel Event

I entered the room midmorning in good spirits. Running on time, and by the brief description on my schedule, “6-month old female with viral symptoms,” I thought this would be a quick one. Per the nursing notes, the baby was seen in the community hospital emergency room the night before and diagnosed with “viral pharyngitis.” When I entered the room, she was sitting upright in mom’s lap, holding a toy and looking quite well, giving me clinical peace-of-mind. As my training guided me from patient to mom, I caught her eye. She was young, I guessed not yet 20. Her other child, approximately 2 or 3 years old was in nonstop motion, tearing apart the exam room and causing this mother to be both annoyed and distracted. She told me she thought the baby seemed better, but was instructed by the emergency physician to bring her in for a recheck today.

After getting a few more historical details, I suggested I examine the baby. I reached for the tongue depressor and began to peer into her oropharynx. I hesitated, and in an attempt to get a better look, asked mom to hold her head for me. I felt puzzled and somewhat blindsided, unsure of exactly what I was seeing. There was a nickel-sized ulcerative lesion on her right posterior pharynx, surrounded by red inflamed tissue and what appeared to be linear abrasions along her palate. What I was looking at was unlike any other lesion I had ever seen. I needed one more look to reassure myself that my eyes were not deceiving me. The mom reluctantly held the head of the now crying infant.

“Did she fall with something in her mouth? A toy perhaps? Did anyone put anything into her mouth?” I asked quizzically. The words came out before I could even process them, wistfully hoping that this mother would be my partner in solving this medical mystery. In an attempt to remain transparent I added, “I am just wondering because this lesion does not really look like a viral infection to me.”

The mother’s initial response was angry, “No one SHOVED anything into her mouth.”

She paused, readjusted and then trying to sound nonchalant revealed, “My boyfriend let her suck on a candy bar with peanuts yesterday. Could this be an allergic reaction?”

The wheels in my brain began to churn, taking me to a place of agony and concern that had become all too familiar to me over the years. I responded with conviction, attempting to divert her from that unproductive path, that this could not be allergic, probably was not infectious, and quite honestly looked more traumatic in origin. She glared at me angrily and like kindle beginning to transform into a flame, I could feel the tension escalating. Trying to maintain my professional demeanor despite being flooded with my own emotions, I treaded tentatively, not wanting to misspeak and fuel her fire.

“I would like to obtain the records from the Emergency Department visit last night so I can understand if this has evolved and best advise you. “ I needed to buy some time to figure out what to do next. “I am going to have my staff call and get the records faxed over. I’ll do my best to expedite that, but we will likely have a little wait time.” Silence. I left the room, closed the door, and in the blink of an eye, knew my day had taken a dramatic turn for the worse.

It is an odd dichotomy of feelings. Anger and concern for the well-being of the child, but also fraught with self-doubt, not wanting to falsely accuse anyone. Was I missing something in my differential that may have been obvious to another physician? My instinct told me this was oral trauma, and the likely weapon, inadvertently revealed by mom, a nutty textured candy bar! Although my training and career have exposed me many times before to child abuse, it never gets easier. Never becomes mundane, as if I know exactly what to say or have the foresight to confidently enact the right next steps. At what point in a child’s life do their wounds turn into scars? When is the damage too much for the soul to bear, and are their youthful spirits fundamentally changed beyond repair? In many cases of severe child abuse, there is a history of previous trauma. Was this a sentinel event for this child? Could her fate be altered?

I picked up the phone and called social services, feeling badly for the rest of my patients who would now be waiting for me a very long time. I took a brief moment to just sit quietly in my office. Although my clinical decision making was complete for now, it was with a heavy heart that I moved on to my next patient. Unsettled that despite my intervention, this child’s story was far from over.