“This next patient has come all the way from Springfield,” our nurse says. “The mother googled pediatric urgent care and found our website. Her little fellow got hurt at daycare; he won't move his arm. I spent some time talking you up—more than 35 years' experience in pediatrics and all that—so go in there and sell yourself.”
I rise from my desk chair and take the clipboard with the patient encounter form from the nurse's hand. Although the after-hours care center has been open 3 months, we still haven't seen very many patients outside my supervising physician's practice. Here is an opportunity to market our services to the community—one patient at a time.
I step into the exam room to find a little boy sitting in a young woman's lap. He holds his right arm across his thigh close to his belly. His mother flashes a smile. “I hope you can help us,” she says. “When I picked him up from daycare, they told me another boy had fallen on top of him when they were playing. He won't move his arm. Do you think it's broken?”
“Let's see if we can find out,” I say, bending down to eye level with the child. Wide eyes betray his fear—fear of pain; fear of me, someone he has never seen before. “Has he ever injured his arm before? Ever broken a bone?”
The mother shakes her head. “No, he's been healthy as a horse since the day he was born.”
“Did anyone witness the fall?”
“One of the women said she saw him take a tumble when another boy was chasing him. He went down and the other boy fell on top of him. When they got up, my son wouldn't use his right arm. He hasn't wanted anyone to touch it since.”
“I see. Let's look at his left arm first—the one that doesn't hurt.”
Gently, I take the boy's left hand and palpate the pulse at the wrist. “What's your name?” I ask him, as I run the fingers of my right hand across his left clavicle.
“Jeremy,” he says.
“Jeremy, with a J,” I say, palpating the bony prominences of his shoulder. “And how old are you, Jeremy?” I ask, moving my hand down his arm to the elbow.
“Four,” he says.
“Can you squeeze my finger tight, tight, with your hand?”
“Show me your palm,” I say. Jeremy turns his hand palm up. Supination and pronation are intact.
“Very good,” I say. “Now let's check your other arm. We'll start in the same way.”
Clavicle, shoulder, wrist, and distal forearm are fine. The boy's grasp is weak. There's no tenderness over the olecranon process, but he actively resists supination. I cradle his elbow with my left hand, place my thumb over the radial head, slip my right hand in his and prepare to hyperpronate the forearm. In a moment the maneuver is done. Immediately, he lets out a yelp and reaches for his mother's neck with both hands.
“What happened?” she says to her son. Her questioning eyes meet mine, when suddenly she realizes that the boy is actively using his right arm again.
“We call it nursemaid's elbow,” I explain. “One of the bones was pushed out of alignment in the fall. I popped it back in place.”
“You're sure it's fine?”
I reach into my pocket and pull out two lollipops. “One for each hand,” I smile. Simultaneously, the boy reaches up with each arm to take the candy.
“Wow, the doctor made you all better!” the mother beams, hugging the boy to her breast. Then to me: “Thank you so much. I'm so glad we came in.”
This child was attended to in a timely fashion, and the outcome was good. Perhaps this incident might be the start of an ongoing professional relationship, I muse—you never know. As clinicians in primary care, much of our success depends directly upon how we relate to the patient. In most instances these relationships are built slowly over time. Eventually, patients either become comfortable with clinicians or reject them hands down.
With time and skill and experience, seasoned clinicians learn the art of how to deal effectively with patients. This is most easily accomplished in primary care practice venues where patients come to identify a particular clinician as “their clinician.” It is much more difficult to garner complete trust at the initial clinical encounter—difficult, but not impossible.