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The Art of Medicine

Treating fear itself in the clinical setting

Maurer, Brian T. PA-C

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Journal of the American Academy of Physician Assistants: April 2016 - Volume 29 - Issue 4 - p 58
doi: 10.1097/01.JAA.0000481400.21841.7b
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It's been a tough evening at the after-hours care center. It's the middle of the cough and cold season, patients are showing up in droves, and I'm the only clinician available to see them. I pick up a clipboard with the next patient's encounter form attached, take a deep breath and let it out slowly as I step across the threshold into the examination room where a family waits.

“I've got a 2-year-old son at home with strep throat,” this young mother says. “I just wanted to make sure that my daughter isn't coming down with it, too.”

“When was your son diagnosed?” I ask.

The mother's brow wrinkles as she contemplates my question. “About a week and a half ago,” she says.

A week and a half is certainly well outside the incubation period for strep throat, I think to myself. I press on with a few more questions.

“What symptoms has your daughter had?” I ask.

“She's out of sorts,” the mother says. “She's just not acting herself.”

Now it's my turn to wrinkle my brow, albeit internally. “Any fever, sore throat, headache, vomiting, bellyache?”

The mother shakes her head. “No, nothing like that,” she says. “It's just that every little thing seems to upset her. She's really been extremely difficult to deal with these past 2 days at home.”

“Let's have a look at her.”

I move to examine the little girl. She's afebrile, her throat looks normal, there are no palpable lymph nodes in the neck. As I retreat to the counter to jot down a few notes, the mother gives me an inquiring look.

“She really seems fine,” I say. “It doesn't look like she's coming down with strep throat.”

“Could you run a quick test on her anyway?” the mother asks. “My kids come up with strep in the most bizarre ways.”

They're probably carriers, I think to myself. As much as I abhor the thought of performing an unnecessary test on a perfectly well-appearing child, I can see that in this instance I will have to do it to appease this parent.

“Okay,” I say, “I'll run the test, but most likely it will be negative.”

I reach for a swab and a tongue blade. The little girl is remarkably compliant. In a moment I've collected the specimen.

“I'll be back with the results in 5 minutes,” I say, dashing out and pulling the door closed behind me.

Just as I had suspected, the test is negative. Thankfully so—otherwise I would have had to explain the likelihood of a carrier state.

As I step back into the examination room, I make it a point to put on a pleasant smile. “The test is negative,” I reassure the mother. “No sign of strep throat.”

“Well,” the mother says, “that's a big load off my mind.” Then she adds: “Thanks for doing the test. I just had to be sure.”

“You see, last year my husband came down with strep necrotizing fasciitis. He developed pain in his thigh after getting hit in a soccer game. The next day his leg was red hot, swollen twice its size. I took him to a local urgent care center, and they sent us to the hospital by ambulance. By the time we got to the emergency room, he had developed toxic shock. His hands turned white; his blood pressure dropped to 60/40. They pumped him full of IV fluids and antibiotics before taking him to surgery.

“The doctor told me he had a 90% chance of not making it through. He spent the next 21 days in ICU; he was in coma for 10 of them. I thought for sure we were going to lose him, but somehow he pulled through.

“His soccer playing days are over now. He's got some horrendous scarring on his thigh and decreased muscle mass, but still—he's alive.”

“That's quite a story,” I say, standing motionless in near disbelief.

“Now you understand why I asked for the test,” the mother says. “When you've gone through what I've been through, you don't rest easy until you know.”

Her words make sense. Clinically, there was no reason to have run the test. Emotionally, it was another matter.

Sometimes when simple reassurance won't do, we can leverage our modern medical technology to allay fear itself in the clinical setting.

Copyright © 2016 American Academy of Physician Assistants