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Vestigial reflexes, gut reactions: When time is not enough to heal

Maurer, Brian T. PA-C

Journal of the American Academy of PAs: April 2013 - Volume 26 - Issue 4 - p 60

Brian T. Maurer, PA-C, practices pediatrics at Enfield Pediatric Associates, Enfield, Connecticut. He is the author of Patients Are a Virtue and a member of the JAAPA editorial board. Visit the author at



She sits up very straight on the exam table, clothed in a colorful Johnny top. She doesn't respond to my greeting, doesn't mirror my smile. When I ask her name, she says it loud and clear—her full name, with no inflection in her voice. In the face of perceived danger, defiantly she broadcasts her identity.

The little girl has never seen me before; this is her first visit to the practice. She's accompanied by her foster mother, who tells me that Shania has been living in her household for the past 6 months. During that time, Shania's health has been excellent—only a few minor bouts of selflimited illness.

The foster mother doesn't know everything about Shania's past—but when I inquire, her watery eyes tell me that she knows enough. She hopes that Shania and her younger brother will be able to stay in her care for a long time.

I ask Shania how old she is. The answer comes back loud and clear: “I'm 5 years old!” She holds up 5 fingers to emphasize the fact.

We proceed with the examination. I take extra time to explain things to her—“This is just a funny flashlight. We're going to look into your ears. It won't hurt. Want to touch the light and make your finger light up? Pretty neat, huh?” I give her some space, take things slow; I make no sudden moves, speak in a gentle voice. She's compliant; but despite my best efforts, Shania remains detached, aloof. Her dark eyes divulge no secrets.

Several years ago, when I was laid up for 6 weeks with a fractured ankle and hand after a hiking accident, my wife decided to get a dog. She and my daughter drove to the pound to scout out prospective candidates. They came home with a scraggly terrier, rescued from certain annihilation.

The dog had her hind quarters shaved as part of the treatment for mange. For the first couple of days in our home she merely sat and trembled. When approached, the dog would immediately lie down and roll over on her back, baring her belly in an act of total submission. It took some time for her to settle in.

For weeks, the dog strained at leash on walks. Many times she pulled so hard she would choke and vomit. Whenever a school bus or commercial truck went by, the dog would throw a fit, yelping and straining, her tongue turning blue from the lack of blood perfusing her head due to the choker chain collar.

Neighbors in our village commented that they could track the dog's position by her cries. If anyone outside the immediate family approached the dog, she would nip at them. At home, she growled if anyone came close to her dish while she scarfed down her food.

“I wonder what could have happened to her?” my wife mused one afternoon in the kitchen.

“I'm sure she was abused,” I said, hovering close by on a set of crutches. “She'll probably never be completely normal. Animals carry the vestiges of abuse inside them for the rest of their lives. It's tough to condition it out of them.”

Eventually, the time came for my casts to come off. Gingerly, I got back on my feet; but it took a long time to heal. Over several months, the dog gradually calmed down as well. She was still prone to fits when confronted with a passing bus, but overall the improvement in her demeanor was marked.

You still had to be careful not to make any sudden moves around her. I took pains to speak softly and move slowly in her presence.

As I finish up with Shania's exam, I explain to her foster mother that Shania will need to have three shots today— boosters to enable her to start kindergarten in the fall.

I return with the vaccines and show the foster mother how to hold Shania in her lap: “Have her give you a big hug under your arm, then hold her forearm like this.”

As I take a syringe from the tray and grasp the little girl's slender arm, thoughts flood through my head: Even though we've just met, even though you barely know me, I am going to hurt you. I have made a decided effort to win you over, and now I am going to have to hurt you—for your own good.

As I administer the vaccines, tears roll down Shania's cheeks; but she doesn't scream. After the first injection she barks, “How many more?” I tell her the truth and work as quickly as I can.

Shania sits in her foster mother's lap in silence, then lies back with her head against the woman's breast, belly up—the position of submission.

My stomach muscles tighten, and for a fleeting moment I feel a sudden tug, then witness a choking sob—the vestiges of past abuse: unknown, perhaps unquantifiable, but still present.

I step back and wonder how long it might take for them to subside for good. JAAPA

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