There’s a 3-year old kid on our pediatric hematology-oncology service who has a high-risk, stage IV, disseminated neuroblastoma: a bad cancer with a terrible prognosis. The mass in his liver is huge, and distends his abdomen way out of proportion to his limbs. He is otherwise a truly beautiful child, with big, blue eyes and an open, winning smile.

I went in last night at about 3 a.m. to examine him because he had spiked a fever. When I laid my hand flat on his belly, he opened his eyes and said, in full voice, “Don’t hurt me!”

In my training, I do both adult and pediatric medicine. However, although I’ve been on pediatric rotations for months now, it’s the nature of my program that I spend very little time actually talking to and examining my pediatric patients. It’s possible that I know less about what kids are like now than I did before I started my intern year.

Perhaps that’s why I was stunned to hear him tell me not to hurt him. Adults rarely use those words–they usually just cringe, or make a grim face, or sit quietly. Perhaps they’ve lost the sense that they have a right to be comfortable.

This is developmentally appropriate, on some level: understanding that some unpleasant things are good for you and must be tolerated is a part of maturity. I only hope that it is maturity and not a sense of powerlessness that causes so many adults to remain silent when they anticipate pain.

In my overnight call-addled state, it seems like a good idea to try to hear this boy’s voice every time I go in to see a patient–perhaps especially when I return to adult medicine, which I do in two weeks.

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5 Comments on “Voice”

  1. Carol Says:

    Made me think of a couple of years ago when I was in hospital following major trauma – lots of broken bones. The night after all the surguries I remember coming out of my morphine, dilaudid, fentanyl fog long enough to feel horrible pain in my left hand – my IV access had blown and the nurse was trying to re-establish so I could get more happy drugs. She was having a hard time and I was crying out in pain. She was apologizing – she knew she was hurting me. I remember telling her “It’s ok I know you’re trying to help me. Do what you have to do. I know you’re trying to help me.”

    Maybe the difference is that as an adult I understood that the pain would result in a good thing, and wasn’t pointless.

  2. Juliana Says:

    I just wanted to comment on an episode I had on Christmas day last year. I ended up in the hospital with an acute pancreatitis. One morning, after a long painfull night, I had to go for a cat scan and the nurse told me that I *looked* well enough and didnt need to go in a stretcher, so I trusted her say, toughened up and silenced about the pain I was in. Just stupid, and from everything that has happened during my hospital stay, I always go back to that moment, where I should`ve said that I just wanted to be comfortable. Nice point taken Young Doctor. I learned to voice my true feelings, a year has passed, many hospitals stays and a chronic pancreatitis have taught me that.

  3. docwhisperer Says:

    In adult medicine terms, “primum non nocere” ( I hope I got that right), first do no harm, but what about pain? Children are more honest about their reactions, whereas with adults, you have to figure out psychologically what’s going on (secondary gain? fear? don’t they like/ trust me?) and try to work around it, if you can.
    As an aside, I know a good number of female docs read this blog, I’m referring you and them to the “Suicide and the Single Female doc” on my blog http://www.docwhisperer.wordpress.com for comment or just general info. Good luck on your Adult med rotation!

  4. Bryan Says:

    Very insightful. Love your voice.

  5. A.L. Says:

    It is represhing that you admit to have, certainly inadvertently, caused pain to a suffering little angel. Rather than dismissing it you magnify it to it’s deserved level of discussion.

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