Forty-one years have elapsed since tightrope artist Philippe Petit made his world-famous illegal walk 1,350 ft in the air between the twin towers of the World Trade Center. He was 24 years old at the time.
“My focus on the wire is the result of a lifetime of training,” Mr. Petit explained in a recent interview.1 “At the beginning I decided to put on blinders, because the only thing important is the wire. That was a mistake. That focus is dangerous. Because when you are on the wire, the universe that is around can be aggressive and actually deadly. So then I started creating a focus which now I would describe as: I only focus on the wire while I completely listen to my surroundings.”
As I examine the bump on this 2-year-old boy's head while his mother jabbers at his side, I think that Petit's words are a succinct explanation of what takes place in the mind of the clinician during an encounter with a patient.
“His father and I are divorcing,” she says, rambling on. “Actually, it's been 14 months, and it's still not resolved. I've got a restraining order against him, so we don't talk, you know. Anyway, I just got my son back this morning—he spent the weekend with his father—when I noticed that bump on the side of his head. What does it look like to you? His father had him outside in the yard, gardening. He says it was probably a mosquito bite, but that doesn't look like a mosquito bite, does it? No, sir. To me it looks like he probably got hit with something on the side of the head—maybe a rake handle? Plus he's got blisters on his feet”—she pulls off the boy's socks—“from the boots, I guess; his father says he was wearing boots, I wonder if he even bothered to put socks on him. There, see the blisters on his big toes? What do you think?”
Her smartphone rings. Without hesitation she answers the call. “Yes, this is she. Overdrawn? Oh, I doubt that. There must be some mistake. Are we talking about the same account? Because I had a joint account with my ex-husband—actually he's still my husband, but hopefully not for too much longer—is that the account you're referring to? Because if so, he's the responsible party. I suggest you give him a call. Look, I can't continue this conversation right now; I'm in the doctor's office getting my son checked out, okay?” She touches the screen to end the call.
“So what do you think, Doc? I mean, that doesn't look like a mosquito bite to me, does it to you? I wonder if he got hit with something—just like my ex to not look out for him, he's so careless—and violent at times. Do you think he might have hit him with a rake handle or something?”
“The bump isn't black and blue,” I say, palpating the edges of the diffusely swollen pink mound. “Not tender, either. It doesn't resemble a bruise from a blow to the head.”
“Well, what else could it be? I mean, it's certainly not a mosquito bite.”
“Hard to tell,” I muse. “The only way we'll know for sure is to have you follow up with your son's pediatrician in 48 hours. We'll have a better idea of what we're dealing with by then. I suspect it will probably subside on its own.”
The woman seems crestfallen. “So you think it's a bite?” she says.
“It's not clear to me,” I say. “But I don't think it's secondary to some sort of trauma to the head.”
“What about the blisters on his toes; what about them?”
“They are indeed friction blisters, most likely produced by the rubbing of footwear—nothing serious. Put some antibacterial ointment on them under a bandage. They'll heal up in a few days.”
“And if not?”
“Your pediatrician can see how they're doing when you take him in for followup for the bump on his head.”
She tosses her smartphone into her purse, pulls the boy off the exam table and drags him back down the hallway by the hand.
Like a small performance on the high wire, there's an art to tightrope walking in clinical practice. Blinders are useless. The clinician must learn to focus on the wire, of course; but as he works his way across a looming chasm with no safety net below, it becomes equally important—in some encounters perhaps even more important—to remain attentive to the surrounding noise.
Sometimes that noise turns out to be more clinically relevant than the wire itself.