prokinetic

Hello gadabouts! Sorry for the recent long-form radio silence, but my current schedule allows a few hours each week for generative activities, and two weeks ago it occurred to me that I was scheduled to give Grand Rounds to my department at the beginning of December. Am scheduled. Also, we don't technically call them "Grand Rounds," rather "Education Lecture" or (perhaps more to the point) "CME-Getting Exercises"; but I just continue to call them "Grand Rounds" for ease of reference.

Upon hearing that I was giving a lecture soon, and perhaps more thrillingly, that I would be giving my talk off a series of PowerPoint slides (well, Keynote if you want to get brand-specific), Cal got very excited, because--and I don't know if I've ever shared this particular quirk of his on the blog itself--CAL LOVES MAKING POWERPOINT SLIDES.

CAL

What are you doing? Can I help? Maybe I could make your slides for you!

MICHELLE

Well, maybe I'll pick a slide or two and you could help import the images or something, but a lot of it I think I'm going to need to do myself, because it's kind of technical. You know, science-y.

CAL

Like what?

MICHELLE

Well, like I have to look at a lot of scientific journal articles, and pick the information to present, and it might be a little complicated for you to understand at this point.

CAL

I can do that. What's the talk about?

MICHELLE

Well, it's about developing a standardized protocol for treatment of postoperative nausea and vomiting.

CAL

What's that? The last part, I mean.

MICHELLE

Postoperative...well, it means...sometimes after people have surgery, they feel nauseated, and they barf a lot. So it's about what kind of treatments we have to prevent barfing.

CAL

Your talk is about barfing.

MICHELLE

Well...kind of, yeah.

CAL

(Reverently)

Cool.

So anyway, my point being that the few hours I've had per week for generative activity has been shunted away from the blog and towards getting my barf talk together. Of which I've spent maybe way too much time deciding (between wading through RANDOMIZED CONTROLLED TRIALS and META-ANALYSES and CONSENSUS GUIDELINES of course) whether I should include this picture on one of the slides.

So...probably no, right?

*          *         *

Well, in other news from the world of Cal:

As some of you may already know, two weeks ago Cal broke his left clavicle at school. He's fine, didn't need surgery (as you can see from the film there is clearly a break but it is not displaced) and just needs to wear a sling for three weeks while avoiding cage-fighting for six weeks total. 

Cal's story is that he and a friend were playing tag at recess, when another kid ("A fifth grader," he told me ominously, as if that explained EVERYTHING) playing a parallel game accidentally tripped him mid-run, and down he went. And that's fine, these things happen, I'm certainly not blaming anyone (Cal, the fifth grader, any of the teachers) for the fact that Cal broke his clavicle, because that's what happens when you don't encase your kids in a Beanie Baby box and perch them on a shelf For Display Purposes Only.

I also don't blame the school nurse for not making the diagnosis of a broken clavicle when he reported to her office after recess, though--and I say this charitably--it was not a subtle diagnosis. Or...well, you tell me. A kid falls hard onto his left shoulder on the concrete of the school playground, a fall witnessed by his teacher, after which point his shoulders are asymmetric (like the left one is significantly lower than the right), he can't lift his left arm, and is crying about pain while pointing to the exact spot over his left clavicle where a clear angled deformity can be seen through the skin. Even so, I don't begrudge someone for not making that diagnosis, as clear as it may have been to me and anyone (including, may I add, the twenty or so elementary school kids who were shouting at me out the schoolbus window, "Cal broke his arm at school today!"). School nurse? Maybe more attuned to diagnosing disease of the infectious and rapidly-spreading variety than the orthopedic? Fine. I'll give you a pass.

But what I do mind? I do mind that fact that I didn't get a single call about Cal's injury--not one single call, text, e-mail, anything--and in fact did not know anything had happened until I picked him up at the bus stop and received him wincing down the bus steps, in tears, his friend carrying his backpack for him because even a fourth grader could tell Cal could not carry it himself. That the school nurse basically told him to walk it off and sent him back to class, where he sat for two more hours with a broken clavicle without me or Joe--both of us listed as emergency contacts and both of us never without our cell phones--getting single call so that could pick him up, check him ourselves, and cram in some Tylenol before taking him to the emergency room for a plain film to confirm what we could clearly see with our non-X-ray vision. THAT I DO MIND.

After he got back from the ER and we knew that he didn't need surgery, I wrote an e-mail to the principal to let him know about the situation. And again, I wanted to be perfectly clear what exactly it was that I was upset about. As a medical professional, I am more than aware about the perception of Asshole Patient Syndrome--namely that medical people sometimes expect unreachably high standards on their own medical practitioners, and can be, well, assholes about their own care or the care of their children. I reiterated that I was obviously holding no one to blame for Cal's accident (I think I may have used the phrase "these things happen" not one but three times in that e-mail, mostly as code for "DON'T WORRY I'M NOT GOING TO SUE YOU") and I again reiterated that while the fracture was quite evident, I did not hold the school nurse to the same standards of diagnostic acumen as an ER nurse or even a first year medical student. Fine. Maybe it wasn't obvious when it happened. Maybe it looked worse three hours later. Whatever. 

But I made a strong point that I was very dismayed (while, I hope, aggressively maintaining the mien of cordiality tinged with disappointment about the school's interpretation of in loco parentis) that although this was the kind of injury we should have been informed about, preferably close to the time it happened or at least at the point that he was in the nurse's office; we did not hear one word from the anyone at school even after that downward dog-shaped clavicle ambled off the bus in a miasma of osteoblasts and tears. In fact, if I hadn't e-mailed them, I probably would never have heard about the event, except from Cal himself. 

And frankly, we might never hear about it again. I just suggested to the principal, nicely (I thought) that he review with his school nurse what kind of medical events should trigger a call to a student's parents. He e-mailed back (addressing me as "Dr. Au"--I specifically did not make a point that Joe and I were medical professionals for fear that it would come off badly but either he knew that from our file or he saw it in my e-mail footer) that he would "look into it." And I can only assume that he has, since he hasn't e-mailed me back any follow up since. 

In the weeks that have followed, whenever I pick up Cal from school and walk by the administration, all of them know his face (or perhaps recognize his sling) and exclaim to him with bluff cheer, "HEAL UP THERE, BIG GUY!" and "LOOKING GOOD! FEEL BETTER!" But never, not even as an aside to me, has anyone ever mentioned any kind of addendum to our e-mail exchange, or apologized to me for not being contacted in the first place. Honestly, I don't even want an apology at this point for not being called, because that's somewhat beside the point. But some follow-up would be nice.

So my question is this: what would you have done in this situation, keeping in mind that I don't want anyone to be punished or lose their jobs or anything like that--I just want to make sure that no other kids break bones or have seizures or swallow chicken bones and have to sit writhing in class for two hours. Also: do you think that the fact that Joe and I are doctors makes any difference in a negative way, in the sense that it gives the impression, warranted or not, that we are holding the school nurse to unfairly high standards? 

Please to discuss.