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The Art of Medicine

When the dust settles

Maurer, Brian T. PA-C

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Journal of the American Academy of Physician Assistants: August 2018 - Volume 31 - Issue 8 - p 58
doi: 10.1097/01.JAA.0000541485.39363.2c
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“How could it have gone up so fast?”

“I've asked myself that question. I wish I had a good answer.”

“From 14 to 44 in 3 months?” This young mother's eyes flash in my face. “Should we have done another test sooner?”

“We tested according to the guidelines,” I say. “No one could have predicted that the lead level would have gone up so quickly. I'm at a loss to explain it.”

The young mother sits in one of the plastic chairs in the examination room, struggling to contain her little girl. The toddler writhes in her mother's arms, throws her head back, then head butts her mother's shoulder.

“You see how she acts? She's crazy! None of my other kids acted that way at this age. Do you think it could be the lead?”

I shrug my shoulders. “It's hard to tease out what's what. Many toddlers are headstrong; many toddlers throw tantrums. The lead level isn't high enough to where we usually see behavioral problems, but I can't tell you for sure.”

The little girl reaches out a small hand and slaps her brother in the face. The brother covers his eyes with his hands and starts to cry.

“That's enough!” the mother says. “Not nice! Say you're sorry. Say it!”

The toddler regards her mother's face, then reaches out and slaps her brother again. The mother puts her down on the floor at her feet. “Not nice!” she barks. The little girl crumples to the floor and begins to sob.

“Did you make it to the appointment at the lead clinic yesterday?” I ask.

The mother collects the little girl from the floor into her arms. “Yes,” she says. “They took more blood. They're supposed to call me with the results by the end of the week. If it's any higher, they want to admit her to the hospital for the weekend to chelate her.”

“Did you get the X-ray of her abdomen?”

“We went to the X-ray place afterwards, but they didn't have an order on file, so they wouldn't do it. They said I would have to bring her back when they have the order.”

“I thought the doctor at the lead clinic was supposed to have taken care of that.”

“I guess there was some mix-up,” the mother says. “Everything's mixed up.”

“Did the public health nurse come out to your new apartment?”

“Yes, she came with the building inspector. They took some samples, wiped the window sills, told us they would get back to us with the results. There might be lead in our new place as well.”

The mother's eyes begin to well up. “I can't believe this is happening,” she says.

The little girl nuzzles her head into her mother's neck. Three other children sit together on the two remaining chairs. “Can we go home now?” the oldest says.

“As soon as we're finished,” the mother says.

“I'll write the order for the X-ray,” I say, pulling a pad from the cabinet drawer. “I'll have one of the nurses fax it over to Radiology and give you the original to hand carry, just in case.”

“How's her weight today?”

I glance at the chart and flip up the page. “Up over half a pound in the past month,” I say. “Better than it had been.”

“I can't get her to take anything but breastmilk,” the mother says.

“I've got some samples of a high-calorie drink for toddlers,” I muse. “I'll get them for you.”

I hand the handwritten order to our nurse and ask her to fax it to the hospital.

“How's the mother?” she asks.

“She's upset, understandably so. It looks like the ball's been dropped any number of times, and we're just getting started,” I say.

I make my way to the storage closet and root out several samples of toddler supplement. Poverty, I think. The word pops into my head. Poverty. Substandard housing, the only housing affordable for poor families like this one. Two working parents, four young children. Public transportation. Insufficient resources. And now this additional burden: lead in the household, lead in the pipes; lead in the paint, lead in the dust; lead in one more toddler's blood and bones.

I pull several containers from the pasteboard box, curse under my breath, and hurry back down the hallway.

Copyright © 2018 American Academy of Physician Assistants