Indexing Title: RCHAN’s Medical Anectodal Report [04-6]

MAR Title: The Babysitter

Date of Medical Observation: November 2003

Narration:

            A four-year-old female child was referred to our department because of a two-day duration of hypogastric pain, crampy, not related to food intake accompanied by fever, anorexia and vomiting of previously ingested food. Upon physical examination, the abdomen was flat, with normoactive bowel sounds, with tenderness and guarding over the hypogastric area more pronounced on the right lower quadrant area. Our primary diagnosis was that of acute appendicitis. We then transferred the patient to our department and booked the patient for emergency appendectomy.

After four hours, we brought the patient to the operating room. Upon opening up the abdomen through a right lower quadrant incision, we noted purulent non-foul smelling material in the peritoneal cavity. We took a sample of the peritoneal fluid. We suctioned out the peritonitis and began to explore the right lower quadrant area. And there was the appendix retrocecally located which was grossly normal in character.  It was not distended, no fecalith within was noted, no fibrin was attached to it and vessels were not even congested. We explored the ovaries, fallopian tubes and the uterus. The right and left fallopian tubes were dilated to 2 cm in diameter. We milked each one and purulent material came out from both of them. The patient had pelvic inflammatory disease after all. And this was in a four-year-old child!

We gave the appropriate antibiotic regimen for pelvic inflammatory disease. We did our daily rounds on this patient like any other patient admitted at the ward. Since this was a pediatric patient, she was being co-managed by the department of Pediatrics. Their residents however decided to take the treatment of this child to a higher level without our knowledge. They referred the patient to their Developmental Pediatrics consultant. She talked to the child one on one and eventually gained her trust. Using a doll as a representation of the patient, she asked the child if someone touched her “down there” pointing to the doll’s genital area. The child nodded and slowly she related how her mother’s cousin would violate her when he babysits her when her mother is away.

We only learned of this revelation when an audit was held between the Department of Surgery and the Department of Pediatrics.

INSIGHTS: (discovery, STIMULUS, reinforcement) (physical, PSYCHOSOCIAL, ETHICAL)

            I felt ashamed of myself while I was at the audit. Why didn’t I investigate further as to what can cause pelvic inflammatory disease in a four-year-old child? Why did I miss out on eliciting the history of sexual abuse in the patient?

As the attending physician, it should be my responsibility to treat my patient holistically. I should not stop at treating her medically or surgically. Her disease is just the tip of the ice berg. She is also stricken with an emotional and psychological illness from the abuse she underwent from her supposed “care giver”. These too should be addressed. Had the Pediatrics people not dug deeper into the case of this patient, then the molester will not be apprehended and caught. He will continue to violate her and maybe other children as well. The child will grow up dysfunctionally had the act not been discovered. Who knows what effect it will make on her future?

            We as members of the society should protect and uphold the rights of the child. We as physicians should make sure that we deliver the best quality health care to children as well. It is their right to have a healthy future, whether it be physically , mentally, or emotionally.