Taking The Right Approach To Medical Curveballs

   I tried to apply a soft fiberglass cast to the leg of a screaming 4-month-old baby boy last week. It was toward the end of a very busy day and, in most cases, a screaming baby would not be an opportunity I would seek. In this case, the child’s screaming was music to my ears.    The baby boy was one of my curveballs. A curveball is a category of patient that presents with particularly difficult foot problems or health problems. This baby was referred to me by Isaac Pope, MD, my most reliable source of “curveballs.”    Isaac is a pediatrician who retired from a large general pediatric practice and started a clinic for medically fragile infants and children. Most have severe birth defects or severe congenital medical problems.    The baby boy he sent was two weeks old, had a septal wall defect in his heart, no rectum, a defect in his upper respiratory tract and a clubfoot. When I first saw Tristan, he had already undergone open heart surgery, bowel surgery and nose and throat surgery. He had a blue-gray complexion and was too weak to cry.    Isaac had called to tell me the child was coming and that nothing had been done for the clubfoot because it was considered a low priority compared to the other health problems. I also suspected that the child’s prognosis was too dismal to be concerned about the foot.    I prepared my new office assistant by telling her that we would be working with a very sick baby. I insist that babies, especially medically fragile ones, be referred to by their names as opposed to “that baby with the clubfoot and heart problems.”    I also like my assistants to talk to the babies. It is tempting not to personify a very sick infant for fear that the infant’s death will be too traumatic for caregivers. It is important to babies and their parents to be treated with respect. Using the baby’s name shows he or she is respected as a person.    Tristan’s mother told me of a university specialty clinic where babies were laying on rows of exam tables as a team of specialists went from child to child, conferring with each other but saying nothing to the baby and close to nothing to the parents. She likes our clinic better.    Tristan’s care was particularly challenging since he made frequent trips to a major children’s hospital for crisis with his heart problems.    I chose to use the Ponsetti technique for manipulation and correction of talipes equinovarus. The first time I manipulated Tristan’s foot, he quietly watched me with half-closed eyes. He was on medications that I mostly see with elderly heart patients. In my heart, I suspected that he would not survive to benefit from my care.    I saw Tristan for weekly cast changes until he was 3 months old. His color and his health slowly improved. At three months, I got a consult with a pediatric orthopedist to help determine if a posterior release would be needed. He agreed with me that it would not be necessary and returned Tristan to my care.    By this time, Tristan liked having a snug, warm cast on his leg. The transition to a night splint and straight last shoes was difficult. His parents brought him in after a few days in the splint and begged me to put one more cast on so they could get some sleep. I did and Tristan fell asleep when the cast was drying.    I fooled him the following week. After manipulating his foot, I applied stockinette and cast padding, and then put on the straight last shoes and night splint. He figured out what was going on, turned red in the face and started raising hell.    The screaming, red faced, fighting baby was a beautiful contrast to the blue-gray flaccid 2-week-old infant who was too weak to cry four months earlier.    The “curveballs” are my biggest challenges as a podiatrist. I cherish the opportunity to be part of the team that gives them a chance at life. I will always be grateful to my good friend, fishing and cooking partner, Dr. Pope, for teaching me that with his patients, the impossible just takes a little longer. Dr. McCord is a Diplomate with the American Board of Podiatric Surgery. He practices at the Centralia Medical Center in Centralia, Wash.