Northern New Englanders enjoy befuddling tourists by telling them, "You can’t get there from here." Closer to the truth is the observation that when you leave Maine by plane, it will take you at least a full day regardless of your destination. Our remote location and terrorist-induced paranoia guarantee that I am going to spend a large chunk of my travel day sitting in airport terminals. I plan ahead by stockpiling unread copies of Pediatrics in Review, but they lose their appeal after a few hours. This leaves me enough time to observe the river of humanity streaming down the airport concourses.
How did we allow ourselves to get so fat? "Have you thought about what that tattoo is going to look like in 20 years?" Every few minutes the torrent of travelers divides to flow around a knot of people who have stopped to play out a little scenario for my entertainment.
On my last trip, a young family with a 2-year-old in tow was moving easily with the flow when the toddler stopped suddenly to look at the cowboy in full regalia sitting across from me. One bark and tug on her hand by her mother and they continued on down the concourse.
I’m sure it was a nonevent to anyone else who saw it. But to a pediatrician with time to kill, this ripple in the traffic flow was food for thought. What if the mother had jerked a little more firmly? A tearful little girl with her left arm hanging limply at her side would be standing within my arm’s reach.
Had this occurred on the grassy mall in the center of Brunswick, there is no question what I would do. If the mother didn’t recognize me, I would introduce myself and reduce the joint on the spot. But this was a very different environment. While I don’t look like someone who has just staggered out of a biker bar, I was bereft of any doctor paraphernalia. I carry my American Academy of Pediatrics card in my wallet. But have you looked at yours lately? Mine is a pretty sad and flimsy excuse for an ID. I’d be more likely to convince this mother of my authenticity with my AARP card.
In today’s litigious climate, should I even bother to intervene? The injury was minor. As long as the child could keep her arm at her side, she would be comfortable. Eventually, her family would find their way to an ED or an urgent care center. The elbow might even pop in place on its own. But this was going to put a major wrinkle in this family’s travel plans. She might have a needless x-ray. If she were lucky, she would be seen by a physician who could correctly diagnose and reduce this subluxation on the first attempt. But it could be worse.
What were my risks? My lifetime success rate at reduction is 99%. It’s actually 100% in the last 20 years, since I adopted the habit of keeping the child’s elbow flexed for at least 5 minutes after I felt the reassuring pop. At home I order an x-ray only if the injury was unwitnessed and I am uncomfortable with my exam.
But here I was in a strange town facing parents who didn’t know me from Adam. If they trusted me, could I trust them? Were they traveling from a state with an unfavorable malpractice history? The chances that I would do more harm than good were slim. The fact that our society has reached a place in which I was even having to think this through depressed me more than watching the parade of obesity.
During our vacation, I continued to mull my hypothetical dilemma. Eventually, I decided that I would introduce myself, describe the child’s problem, and explain how it could be fixed. I would suggest that if they had a choice when they reached their destination they seek out a pediatrician instead of going to an ED. But I would stop short of offering to do the reduction myself.
I’m still not happy with my solution, but I guess that’s the definition of a compromise. I would enjoy hearing what you would have done on that airport concourse.
Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine.