In the course of her work, commentator Janette Kurie sees a lot of troubled people come through the doors at Good Samaritan Hospital in Lebanon, Pa. But it's the people she doesn't see who sometimes worry her the most, as she explains in this excerpt from an essay in the journal Health Affairs.
We found him in a pile of "no-show charts," records of children who missed their scheduled doctor's appointments.
What caught our eyes was the number of appointments this boy had missed. And his growth chart. Instead of curving upward to show a height and weight increase, it swerved south.
It took protective services to physically bring him in.
The nurse who undressed and weighed him left the room in tears. A beautiful blond-haired 18-month-old boy lay silent on the exam table, weighing only as much as an average 6-month-old. At an age when most toddlers are running and babbling, he was unable even to sit without support.
We hospitalized him that day for failure to thrive, a diagnosis of severe malnutrition that is usually the result of parental abuse or neglect.
At the meeting with the family to discuss foster care, the boy's dad, dressed in a "Born to Raise Hell" T-shirt, never said a word. I searched his face for what might have been happening at home. Why had he not called for help earlier?
The case for medical neglect began to build. The mother responded defensively to each detail. Finally the decision came. The protective service worker said, "We have no other choice, for your child's sake, than to place him somewhere where he'll be safe and get the attention he so badly needs."
The father's eyes never left a patch on the floor. The mother's eyes were red and welling up with tears.
"You're going to take my child away from me?" she asked. "Where were any of you when I was a child? Where were all of you when my mother locked me in closets? Or when I was starved? She kept me in there for days. None of you people ever came to save me."
Then she raised the sleeve of her shirt. "See these burns? My own mother did that! I've been a good mother. He doesn't have one mark on him!"
The boy was placed with a foster family for almost a year. He's back with his family now. His parents have divorced and his mother has remarried.
At 16, he has a seizure disorder, severe attention deficit disorder and a hearing loss. The family continues to be seen at our office.
This child taught us that health care providers need to be concerned, not only with the children we see, but even more with those we do not. No law requires that a child be seen for a well-child exam. How do we reach the "missing" children to learn if they are in danger?
After we found this little boy in our no-show pile, we began looking more closely at who else wasn't coming in. We developed a Family Support Program for thousands of these children.
Once a chart is filed back into the system, that child is out of sight, out of mind, and possibly at risk of real tragedy. Maybe there is hope for other children if health care providers make that first phone call to find out: Where is he?
Janette Kurie is director of behavioral medicine education at Penn State/Good Samaritan Hospital family medicine residency program, Lebanon Pa.