Lockjaw Still Lives Underground

“Alright doc, I have a 6 year old who fell in her back yard in the dirt and cut her right palm.” Bill, the ED paramedic gave me his report.

“Do you think it’ll need stitches?”

“Probably”

“Grab a suture tray, 1% lidocaine with epi, and 5-0 prolene. I’ll numb it up, wash it out, and we’ll get her home.”

I walked into the room, introduced myself and took a look at the wound. 4-5 stitches would likely do the job. It was a clean, straight cut – the easy kind to close.

“This should be quick'” I think to myself.

I love lacerations, they are the closest thing to actually fixing something I get to do in my practice. Someone comes in with an injury, they leave put back together. It usually isn’t terribly hard, but it is a discrete problem with a discrete solution.

It is a nice break from the parade of our health system’s failures I usually see.

Isn’t there always a catch?

I numbed the wound and irrigated it. It was straight, clean, and pink in her hand. About 2 inches long. I quickly placed 5 simple, interrupted sutures and it came back together nicely.

I told Bill the kind of dressing to place on it, inverted my gloves, and threw them in the trash.

Offhandedly, I asked her mother, “And she’s had all her vaccinations?”

“No, we don’t vaccinate.” Her mother responded, as if it were an integral part of her moral compass.

“Goddamnit.” I think to myself. “This was supposed to be a simple lac.”

I turn around, sit down on the stool and look seriously at the mother.

I start in calmly but firmly, “Tetanus is a soil microbe. It is everywhere. There is real risk she has been exposed because of where she cut her hand open in the dirt. Now we cleaned it out as best we could, it is very unlikely she would contract tetanus, but if she did it would be a life threatening illness. What would you like to do?”

I had to breath slowly and calmly through the silence until she answered. “We didn’t have to be here having this conversation,” I think to myself. “She chose this.” I fumed internally.

Love, Fear, and Distant Demons

I saw her expression change from defiance to honest concern. I had seen that face before. My annoyance softened, I know most parents who don’t vaccinate honestly think they are doing what is safest for their children. They love their children like I love mine, they want to keep them safe.

The world is a big, scary place, full of things capable bringing harm to our children and our families. We assess these emotionally. The more fear they generate in us, the more threatening they appear. In the end, as human beings, we worry most about the dangers we feel to be closest to our families.

The face she made was the face I have seen other parents make when a danger once felt to be theoretical becomes real. I saw that face when I had told an expectant mother she was not Rubella immune (because her mother had decided she didn’t need any vaccinations).

I explained if she were to get rubella it could cause damage to her unborn child.

The knowledge that she could not undue her mother’s decision until after the pregnancy only made the fear more real. I looked into the mother’s face of the child with the laceration now and saw that same look.

It is the look of previously dismissed dangers made manifest. Of looking at a real and present threat, not weighing theoreticals and philosophical “freedoms.” It is the look of talking about the possible illness and death of your child.

It is a look I didn’t have to see that day.

Cursing Our Impotence in the Face of Death

Soldier Dying from Tetanus – Charles Bell (1808)

When I think about vaccine preventable illness, it is hard to communicate the despair and sadness doctors and nurses feel about them.

I think of a 5 month old baby I once cared for as a resident in the PICU. I think of watching his tiny body convulse in status epilepticus. He was unvaccinated and had streptococcus pneumoniae meningitis.

His mother just hadn’t gotten around to vaccinating him, she had no moral objections. Things just got in the way. To this day, I am not sure which is worse, but the “why” didn’t matter to him.

As we loaded him with ativan, then keppra, then phenobarbitol his seizures eventually abated. I remember the PICU attending looking at us during rounds and saying softly under his breath, “This will not be a good outcome, he will not have a good outcome.”

He, like all of us, were looking for ways to distance ourselves from tragedy. Using the language of peer-review and metrics he isolated himself from the picture he saw in his head of this child’s future.

He had been previously healthy, on a path to a normal life. That future was now gone. He would have permanent brain damage – probably a crippling seizure disorder for the rest of his life. He would become one of the “chronic kids.” Who are in and out of PICUs their entire lives.

He survived that hospital stay, but his life was forever altered. It is so painful to watch these things because society places its hopes and dreams in children. As adults we glory in their blanks slates, their possibilities.

We put on them the hope of correcting the failures of current generations. It is a lot to bear, being a child, being the symbol of hope and the future for a whole society.

As physicians and nurses, we watch this suffering and know it was not random chance, something simple could have prevented it. We seethe with rage, because accepting and living through the sadness would be too much to bear. It is easier to be angry, to blame.

We are furious someone has taken that future, has destroyed a receptacle for our dreams. Yet, anger gets us nowhere. Sure, we feel righteous, but it changes nothing. Its only real purpose is to insulate us from feeling the true depth of tragedy.

Our rage is for us, not for the child who lies attached to a ventilator. My anger certainly did that boy no good.

A Pound of Cure

Back in the ED, the mother and I discuss options. Being a struggling, rural hospital, we don’t have tetanus toxoid on hand. The nurse manager tells me they can have it by tomorrow, otherwise they will have to go to the City to a facility that can administer it. Either today or tomorrow.

We do have vaccinations. Hesitantly, the child’s mother agrees to a vaccination. She balks at the compound vaccine that also protects against pertussis.

“Do you have just the Td? Without the pertussis part?” She asks.

I mentally roll my eyes. Apparently, only tetanus now seems real. She is willing to have her child inoculated with the human blood product of the toxoid, but is only willing to have the minimum amount of “vaccine.”

I don’t go into long explanations about deaths from whooping cough, how it is not eradicated, how it is a real disease. I have already had too much magical thinking for one day.

We give her daughter the Td, and make arrangements for her to go to the City to get the tetanus toxoid. It seems like such a farce. So, much unnecessary effort and risk for something that could be so simply prevented.

I watch them walk out of the ED, it is hard to let the anger go with them.

It Feels Personal

As people who regularly battle death and provide comfort and care for the suffering, the rejection of vaccines feels like a personal affront. So much suffering and premature death occur in this world over which we have no power.

The idea of choosing to increase the risk, of adding more suffering unnecessarily, cuts us to the quick. We know these old disease, the previously forgotten harbingers of death. As physicians and nurses, we see the rare case that sneaks through modern defenses. They are still real to us.

We keep their secrets, we still study the demons who live underground. We know in other countries they still kill people by the thousands. Those monsters are still real to us, they keep us up at night.

We go home and kiss our children and thank God there is at least one threat in this big, dangerous world from which we can easily protect them.

This is why we respond with so much anger and vitriol sometimes. It is because vaccine preventable disease hurts us so deeply. We bear witness to so much suffering, because this is out job.

But to have suffering added to our plate, to have it piled on unnecessarily – this can be too much to bear.

Deep down, I know people love their children and are trying to protect them as best they know how. I only wish I knew how to make them feel the fear of those long-forgotten demons who still live underground.

If they were to live with the fear we know, I don’t think we would even be having these conversations.

4 thoughts on “Lockjaw Still Lives Underground”

  1. Great piece HP. I continue to enjoy your posts and it’s been nice to read so much new material in the last couple of weeks.

    A patient of mine trashed me on RateMD, one of her chief complaints: that I had recommended Tdap vaccination in pregnancy (the current ACOG recommendation for newborn pertussis prophylaxis) “she was very pushy, mentioned it several times” (as an aside, this same patient refused routine glucose screening, and also refused c-section for transverse lie at 40+ weeks…)

    You’re right. It feels personal. And frustrating. And maddening. And some days it is just SO hard to deal with these patients calmly, empathetically.

    Career death by a thousand paper cuts (this is just one of them).
    -Kristina

    1. Thank you for reading.

      I know “back in the day” there was a lot of paternalistic abuse by physicians. Sadly, the patient’s right movement has been coopted by corporate medicine into a Fast Food Model. We have gone so far the other way. I would like to think we’ll find balance, but if we do it will be a long way off.

      People only want relationships with their doctors if their doctors just agree with everything they feel a priori. The fight against commoditized medicine has already been lost.

      Survival in the least painful way is the best we have.

  2. Awesome piece.
    I’ve always had this emotional detachment from my patient’s decisions. Feel like that makes me feel less confident in myself as a physician. As in, I would like to feel what you feel as you elegantly put it, mentally rolling your eyes. I think it’s a good thing, and a better thing, to feel that sense of responsibility for the patient and feel emotionally vested in their decision and your own knowledge. Kudos dude.

    1. Like most balancing acts, I feel like I rarely am where I want to be. Sometimes too invested, sometimes less than I feel I should be. But, I do feel like writing helps me find that space a little more clearly. I am happy to know you enjoyed it.

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