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Not as First Appeared

Greenstick tibia

The snow was falling the day before Christmas. Stephen Smith, M.D. sighed softly to himself and thought of his warm recliner next to the fireplace that awaited him as soon as his shift was done. Since graduating medical school, Stephen had made this city his home. Raised in Cape Breton, he had always loved the countryside and the ocean; especially the Highlands. As a child whose parents had taken him to the family summer cottage at Tignish, PEI, and later, he spent his summers fishing in the cold waters of the North Atlantic. That life seems 1000 miles away today. Gazing out the window of the residents lounge at the skyline of Halifax, he thought about all the times he had spent Christmas with his family back on the farm. But he was a new Doc, and low man on the totem pole. It didn’t come down to drawing straws, it came down to seniority. And Stephen had none. So it was 11 AM on what would soon be Christmas Eve, and here he was. Almost on cue, he heard his name being paged and made his way to the ER.

Around 11:40 AM, a woman had come into the ER with her six-year-old son. She said that he had tripped going up the stairs to his bedroom, and hurt his leg. The nurse examined it and found no swelling or discoloration; however, it was sore to the touch. His vital signs were all within normal parameters, and after getting information such as age, weight, and height, she asked the secretary to page Dr. Smith. When Dr. Smith arrived at the ER, he saw the mother and son sitting in the exam room. “What seems to be the issue” he asked, smiling at the boy who quickly smiled back. His mother quickly explained the situation, adding that “Keegan is a very clumsy child.” Dr. Smith smiled it Keegan and asked “Is that so?” The boy smiled back and simply said “Sometimes.”

Upon palpitation of the area, Dr. Smith found Keegan’s injury, and found no swelling or discoloring. Yet when he attempted to stand, he experienced obvious severe pain. Dr. Smith was new to medicine, but not new to life. Growing up in the country was hard, and although his parents were stern, they were at heart kind people. He also knew that some parents were not. His best friend Billy used to be kept home from school some days because his parents didn’t want the school to ask why he had bumps and bruises. This injury did not look like it came from tripping on a stair. Dr. Smith turned to the nurse, asking if there was anybody in x-ray that morning. The nurse dialed the extension and reported that there was both a technician and a radiologist there, although the radiologist was leaving at lunchtime. Dr. Smith looked at his watch; it was 11:55. He dialed radiology and asked to speak to the radiologist. “This is probably nothing” he began, “but I need an x-ray of a child’s leg.” The radiologist explained that he was due to leave in less than five minutes and asked if it was truly important. Dr. Smith remarked “I’m not sure.” Within a few minutes a young lady with a wheelchair appeared at the exam room door and Keegan went for a ride. After he had been wheeled out, Dr. Smith turned to the nurse. “Did the child seem frightened in any way” he asked. To which the nurse said that he appeared to be a happy little boy.

Distracted by reviewing records, Dr. Smith was surprised to hear his name paged. Picking up the phone he recognized the voice of the radiologist. “I think we have an issue,” he said. “Can you come down to my office?” Dr. Smith was just getting off the elevator when he passed Keegan and his mother, and the x-ray technician headed back to the ER. Upon entering radiology, Dr. Smith was handed two x-rays. The first one, a focused view of a green stick fracture of the tibia; Dr. Smith looked at the x-ray and asked “Keegan’s?” Then, reviewing the second x-ray, a wider view of the entire leg revealed several fractures, some 2 to 3 years old and healed, Dr. Smith looked puzzled. The radiologist looked stern. “This is not a single accident,” he remarked, “This is a series of injuries going back, probably to infancy.” Dr. Smith was taken aback. Usually children who are abused are withdrawn, yet he would hardly call the child upstairs withdrawn in any way. Dr. Smith turned to the radiologist, who stated clearly what needed to be done. “I’m putting in a call to child protective services,” he said. Dr. Smith understood the radiologist’s need to contact CPS. All physicians are mandated reporters. In the event of suspected abuse, CPS must be alerted as soon as possible.

Dr. Smith took his time getting back to the waiting room. He knew he would have to let Keegan’s mother know what had transpired. When he did, she was quite angry. “You have no right to accuse me of anything like that,” she yelled. Dr. Smith explained that in the event of suspected abuse he was mandated to alert the authorities. Keegan’s mother stated that she had never abused her son, nor would she ever do that or allow anyone else to do it. Her anger was palpable. At this time the nurse came in with the news that CPS was closed for the holiday and that no one would be in until the following Monday. This put Dr. Smith in a very awkward position. The radiologist suspected child abuse, and based on the x-rays, it certainly appeared that way. He couldn’t allow Keegan to go home with his mother until the investigation had been conducted. At this very moment Dr. Smith could easily imagine 1000 places he would rather be. Certainly this child did not seem like a victim of abuse. Dr. Smith had a thought, one that might change the outcome of the situation, or the very least give Keegan’s mother someone else to be angry with. Opening the door, he called to the nurse.

“Can you call downstairs to occupational health and see if we can get a psych consult?” The nurse returned in a moment saying that the office downstairs had been closed for the holiday. Of course it was. Then, the nurse asked if she might call Dr. Simpson? Although he had only been at the hospital for a few months, Dr. Smith thought he had met everyone in occupational health, including the two psychologists who worked there. He turned to the nurse and asked to whom she was referring to. She replied, Dr. Simpson upstairs in diagnostic medicine.” Dr. Smith scratched his chin and said that what he needed was a psych consult. The nurse replied that prior to becoming an epidemiologist, Dr. Simpson had been a child psychologist. “Please do make the call and let us hope he is still here.”

Dr. Simpson had been the clinical epidemiologist at the Halifax Medical Center for three years. Prior to that he had been a private practice psychologist in the town of Digby, a fishing village and ferry terminal just west of the city. Michael Simpson had what was known then as a rough upbringing. The son of an alcoholic lobster fisherman, Michael would sometimes not see his father for days at a time, and then he would show up and beat Michael and his younger brother Peter for whatever reason the old man happened to think about at that moment. Then he would pass out. In the morning, as the boys carefully crept down the stairs, their eyes often met their mother’s face, bruised and puffy from hours of crying. The old man had already gone back to his boat. He had studied psychology he admitted as more of a way to understand himself than to understand anyone else. He had enjoyed his practice. Working with the kids, helping them to come to grips with the world they found themselves in. But American medicine was exerting its influence on Canada, and parents wanted easy solutions to problems they had created a dozen years. When he was asked to refer kids to physicians for medications, he closed up shop and looked for something that would make a real difference.

After seven years of study, first earning a Master’s in Public Health and then a PhD in clinical epidemiology, Michael Simpson had focused his energies on preventative medicine. When the position opened up in diagnostics, he had applied and was surprised to have been offered the position. He spent his days devising new methods of increasing the accuracy of diagnostic tests, and streamlining the diagnostic process. He seldom discussed psychology; if anyone asked he simply said it was getting to prescription oriented for him. And now, if he understood the phone call, he was being asked to wade back into that shallow pond yet again.

Arriving at the exam room, Dr. Simpson was greeted by the nurse. Quickly explaining the situation, and the radiologist’s concerns, Dr. Simpson said he would do what he could. Entering the exam room, pushing the curtain aside, he saw a young boy possibly four to four and a half years of age, sitting on his mother’s lap. She was holding him quite firmly and he was beginning to squirm. The physician sat opposite on a stool writing notes, and looked up to see Dr. Simpson enter.

Dr. Smith quickly rose and extended a hand. He apologized for not having met Dr. Simpson prior, to which Michael Simpson simply shrugged his shoulders. “What do you know so far,” he asked Dr. Smith. Dr. Smith explained the reason for the ER visit, he repeated what the mother had said, and he then explained what the radiologist had found. Michael Simpson looked again at the mother and son. She did not appear to be an abuse victim. In fact, neither did the child. He knew firsthand the behaviors of abused children and abused wives. Clearly there was an issue, but he very much doubted it was abuse, at least with the parents. Pulling up a stool across from Keegan, and slouching down to his eye level, Dr. Simpson asked him how he had hurt his leg. Hearing the story of the tripping and falling on the stairs, Dr. Simpson asked to look at it. When he pulled his pants leg back up, Dr. Smith looked over and was surprised to find the injury had turned from purple into a dark black. “Did you bump your leg again since you got here,” he asked Keegan. “No,” he replied, “it always does that.”

Dr. Simpson looked at the mother and asked, “It always does what?” She explained that Keegan was rambunctious and very clumsy. When asked about the multiple injuries, she said that she just did not know how that could have happened. She would certainly never harm her son nor would she let anyone else. “How old are you Keegan,” Dr. Simpson asked, to which he promptly replied six. Dr. Simpson had worked with hundreds of children, yet he had never seen a child of six years so small. He also noticed Keegan’s head looked slightly large, but that was hardly diagnostic. Lots of kids have larger heads and it doesn’t really mean anything. He himself had been such a kid, and his grandfather the kindest man he had ever known, had told him it was because his head was full of brains. But something didn’t seem right. Dr. Simpson asked Keegan to stand up, if his leg didn’t hurt too badly. Keegan said that his father told him that he was becoming a young man, and young men didn’t cry about a little pain. He stood next to his mother, and Dr. Simpson took his thumb and traced Keegan spine. He noticed a slight but distinct curvature to the right. Dr. Smith came over, and tracing in the same fashion looked at Dr. Simpson and asked, “What you make of that?” Dr. Simpson asked Keegan what he liked to do for fun, to which the boy replied play football, hockey, baseball, and riding on the snowmobile.

Dr. Simpson asked if he got hurt when he did these things. Keegan smiled and said that he was tough so he didn’t let it ruin his fun. When he smiled the epidemiologist noticed what appeared to be large chips from his front four teeth. “I was just noticing Keegan’s teeth,” he said to the mother. “Have his adult teeth started to come in yet?” She replied that those were his adult teeth. He was always breaking them on something, although she couldn’t really explain what. Dr. Simpson sat back on his stool and thought. Spinal curvature, frequent fractures, brittle teeth; he turned to Dr. Smith who was busy writing a progress note. “Is there an otoscope handy,” he asked. Dr. Smith reached in his pocket and produced the instrument, puzzled at what was about to happen. Dr. Simpson stood up, and asked the nurse to switch off the light. When the room was dark, Dr. Simpson switched on the otoscope and asked Keegan to look as far up as he could. Then he asked him to look as far down, as far right, and as far left as he could. There it was. Dr. Smith nodded in agreement.

Dr. Smith turned to the nurse and asked her to call Child Protective Services and to let the answering service know that there would be no need for an interview. Keegan’s mother, perhaps more perplexed than ever, asked what was going on. Dr. Smith explained that Keegan had a genetic disorder called osteogenesis imperfecta. “What this disease does is weaken the bones causing deformities and usually bone pain, although Keegan seems to be a bit tougher than most people.” Keegan smiled at this. Keegan’s mother asked how he had known. Dr. Simpson responded that he hadn’t, he simply made an educated guess and then worked backwards to see if the facts fit the model. He explained that Keegan seemed small, very short of stature for a child of six. He also noticed that Keegan’s teeth seemed cracked and chipped, more so then the average active six-year-old. He noticed that Keegan’s spine had a slight curvature. It wasn’t much, but any curvature in a child that young is diagnostic of some disorder or injury. Finally, he had checked, along with Dr. Smith for a slight blue tint in the sclera of Keegan’s eyes. It was very faint, and might not go observed for years. But in a dark room with the right instrument lighting it was very possible to see the coloring.

At this point, Dr. Simpson excused himself, and asked them both to enjoy the holiday season, stating they were in good hands with Dr. Smith. Dr. Smith explained that there were some tests to confirm the diagnosis, but that the symptoms clearly pointed to osteogenesis imperfecta. By this time, Keegan’s father had arrived. Listening to Dr. Smith, the couple was told that while there is no cure for this disorder, that overprotection would be detrimental as well. Long-term immobilization can weaken bones and lead to muscle loss which will lead to even more fractures. The only real treatment was physical therapy and exercising more safely. “Although with such a rambunctious child that may be a tall order,” Dr. Smith remarked.

As Dr. Simpson poured his eighth cup of coffee of the morning and looked around the mostly empty diagnostics department, his phone rang once again. It was Dr. Smith. He had discharged Keegan and his parents were taking him home. But they wanted to say thank you. Would it be okay if they came to his office? “Tell them I’ll meet them at the ER exit.” Setting his cup down, he pressed flat the wrinkle in his khakis and once again headed for the elevator.

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