MEDICINE, SCIENCE, AND SOCIETY

Tapping the Child’s Perspective KEITH WRENN, M.D., Rochester, New York

I t had been a long day. I had watched a long-term patient of mine with lung cancer die, unable to do

anything about the final part of his inexorable slide. I knew he would die, and he and his family knew he would die, but I couldn’t find anything positive in the experience. An older tobacco farmer with a pen- chant for his own crop, he had accepted his fate with equanimity which, paradoxically, made me feel worse about the situation. The tumor was not oper- able, and he refused further palliative therapy. Dur- ing the next 18 months, he would come in occasion- ally with an exacerbation of his chronic obstructive lung disease to get some antibiotics. He continued to work and looked surprisingly well.

Then he began to die in earnest. The pounds dropped away, and he became so short of breath, he couldn’t tend to his land. That was the only marker that temporarily caused him to lose his composure. Hospitalizations were frequent, and he was usually discharged looking as bad as when he was admitted. He would leave because he wanted to, and we both knew he might as well go home. He always acted as if I had really helped him. During his last hospital stay, tethered to the bed by oxygen tubing, IV lines, a Foley catheter, and his own weakness, he was still remarkably clear and resigned. He had signed the do-not-resuscitate papers months before with his usual self-deprecating humor. His family was as stoic as he. When he died, his wife cried softly and his son shook my hand and thanked me for all I had done. All I had done, however, was to let a good man die.

Now I was feeling sad, tired, and more than a little guilty. I just wanted to be left alone. After supper, I shooed the children from the living room and settled down with my thoughts and a novel.

It wasn’t long before I noticed a fluttering noise that seemed to be coming from the fireplace. I couldn’t see anything through the glass doors be- cause of the reflection from the lamp next to me. I slowly pulled myself up and moved across the room, the hairs on the back of my neck beginning to stand up a little as I became aware something was moving

From the University of Rochester School of Medicine, Rochester, New York.

Requests for reprints should be addressed to Keith Wrenn, M.D., Uni- versity of Rochester Medical Center, 601 Elmwood Avenue, Box 655, Rochester, New York 14642.

Manuscript submitted December 12.1991, and accepted January 29, 1992.

in there, trapped. I peered through the glass doors into the darkened fireplace and could just make out what appeared to be a bird. . . or was it a bat? The thought of a bat in the house scared me. I went to the kitchen pantry where, inexplicably, we keep the flashlight and returned to the fireplace. With the flashlight shining in at an angle, I was pretty sure it looked like a bird.

My initial relief was shortly replaced by renewed anxiety. Now what? How do I get the bird out, not only from the fireplace, but from the house, without hurting it (or me, for that matter)? To compound the matter, our cat had become interested in the situation. I yelled for help, forgetting that my wife was out for the evening. My nine-year-old son im- mediately responded. It was his manner to get in- volved in everything full speed ahead, usually with lots of questions and suggestions. He liked to stick his head right into things, usually obstructing my line of vision. I generally get exasperated by his enthusiasm, and tonight was no exception.

“That bird’s gonna get hurt in there,” he said seriously.

“I know that! But we don’t want it in the house!” I answered sternly.

“Why not?” he asked patiently. “Well . . . because . . . then we’d have to get it out

of the house so it won’t . . . have bowel movements all over the place. Your mother would kill me!”

He laughed, clearly delighted by the prospect. He also knows me well enough to understand that my attempts to remove the bird from the house would be a great show.

“The cat might get it,” I added darkly. That wiped the smile away. He was never a blood-

thirsty sort. “Could we put a light at the top of the chimney to help guide it out?” he asked sincerely.

“I’m not climbing up two stories in the dark and put up a light,” I snorted.

“I’d go,” he said earnestly. My only response was a stern, slow look. It didn’t

faze him, because not only was he familiar with my lack of courage, but he knew I wouldn’t allow it. He quickly forgave my disposition, cowardice, and lack of faith in his physical prowess.

“How about putting a box in front of the doors?” he suggested.

“That’d be pretty hard. I mean, it would be pure dumb luck if it flew into the box and didn’t get out again,” I said derisively.

July 1992 The American Journal of Medicine Volume 93 83

TAPPING THE CHILD’S PERSPECTIVE / WRENN

“I’d help,” he said confidently. “We’ve gotta do something.”

“Do we have a big box?” I asked helplessly. “Yeah, in my room, the one we keep the blocks

in!” “Go get it,” I sighed, knowing this would never

work. He raced up the stairs, dumped 50 pounds of

wooden blocks on the floor with a crash, and pound- ed back down with a beat-up old cardboard box, one flap of which was mutilated. He was breathless and grinning.

“This is great,” I thought to myself. Today I’d lost a patient. Now this bird was going to get injured and probably die, and my son would see my failure.

“OK. Let’s put the box up right here,” I ordered. “Open up that flap. Now, when I say, open that door a little and I’ll do the flaps. Wait! Not yet! Go open the back door so we can get it outside quick.”

He raced to the back door, threw it open and raced back, eager to get on with our mission.

“Are you ready?” I asked gravely, the tone clearly implying we had a heavy responsibility.

He just nodded his assent, concentrating on the fireplace, tongue poking out of his mouth.

“OK. Open the door now just a little” . . . I mur- mured . . . “A little more . . . That’s enough!” I yelled.

The bird went straight for the opening and into the box. I was shocked and did nothing. My son slammed the flaps (my job) and the bird was con- tained, sort of. I popped out of my momentary tor- por, grabbed the box and rushed outside, my son at my heels. I put the box down, opened the flaps and jumped back. With a burst of motion, barely per- ceptible in the dark, the bird was gone.

“That was great, Dad!” A huge grin was on his face. This was a story he’d tell over and over to his mother, his friends, his grandparents, or anyone who would listen over the next few days.

I smiled at him. I knew we’d been lucky. The bird should, by all rights, be flying around inside our house “having bowel movements” or be flopping on the ground crippled by a broken wing. Instead it was free, alive, presumably unharmed. I was left wondering why my patient’s death wasn’t just as uplifting as the bird’s escape. Both were now free of a trap that was no fault of their own or mine.

After a few minutes of standing in the dark, I asked, “Well, what do you want to do now?”

He screwed up his face, thought for a minute, and then asked back, “Have we had dessert yet?”

I laughed until the tears came and he joined in. “Why are we laughing?” he asked. “Because this was a good day. Get your sister and

brothers and let’s go out for some ice cream.”

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