by Robert J. Lanz, LCSW
I knew the large family of “little people” because I was once asked by one of the county residents to do an intervention with one of the kids for a medical condition, abbreviated as FTT. “Failure To Thrive” means that the kid didn’t meet the normal developmental milestones in terms of height and weight. FTT occurs for a lot of reasons. Sometimes it’s due to undiagnosed medical conditions. Sometimes it’s the result of poor parenting practices and sometimes from other parental pathology that probably has a diagnosis of its own and would have been called “evil” in an earlier time.
There is a growth curve chart that shows how much a baby should weigh at a certain age. FTT kids fall at the low end of the spectrum. They generally appear sickly, look dehydrated, have sunken eyes and maybe even a bloated belly. It’s a look most Americans are familiar with from TV commercials about children from third world countries where everyone is starving, so starving children become the norm. But the growth chart on our wall reflects the norm for American children.
The “little people” were a big family most likely from the south of Mexico or Guatemala. I had spent plenty of time in that part of the world and knew that the indigenous peoples stayed pretty much within their own cultural group. Many of them were descended directly from the Maya with no genetic input from European conquerors, and lived far enough from our border that their height genetics were not affected by the bigger body genes that we tend to have in the US. So while your average American male grows to about 5’9”, the average Mayan descendent will be several inches shorter. In general, they aren’t overweight, either.
According to the report, the patient, whose name was Pedro, had taken a header off his bicycle and was brought to the ER where, after being treated for his injuries, he was found to be at the low end of the growth chart. I was asked to help with an evaluation for FTT. Luckily for the kid, I knew the family, having translated for them a few times on previous visits. They were always shy yet polite, and the kids were well behaved. They ranged in age from infants to teens, the oldest being of baby-sitting age. I believe that they were probably low on the chart where they came from also, if there was one. Little people.
Even grandma, who usually came with them, was under five feet tall, as was mom. They were all so small, it made guessing their ages difficult. Despite their sizes, they all appeared healthy. And from my interactions with them, they all appeared to have met their developmental milestones for walking and talking and those important skill sets that help determine how you turn out in life. They always greeted me with, “Hola, Senor Bob,” and seemed comfortable talking with me.
So when the ER resident, who didn’t know me, just my title, asked for the evaluation for FTT despite the kid looking all right otherwise, I asked if the kid looked neglected or abused.
“Not obviously, but look where he fits on the growth chart. I’m sending him over to X-ray because he took a pretty good hit when he fell off his bike. While he’s gone you can talk to his parents.”
I knew what to do. I had done lots of these evaluations so I was probably more familiar with the outcomes than the resident was. No matter. I just went out into the waiting room, found grandma and the rest of the kids and brought them back to the kid’s treatment room and closed the door behind them.
In a few minutes, Pedro was back from X-ray and joined the group. Big group, little people. Pedro looked like he always looked. Small but robust. He had some significant road rash but it didn’t seem to slow him down much. In a few more minutes the resident came in with the X-rays and put them up on the light box. He was pretty engrossed in the process and took no notice of the extended family in the room.
When the doctor finally turned around and saw all the little people he sort of rocked backwards.
“Oh, hello. Pedro’s X-rays look OK. Nothing broken. We’ll have the nurse dress those wounds and get you going.”
I translated. The nurse came in and wrapped Pedro up and the family left.
As they were leaving, the doc called me over.
“Never mind that FTT workup Bob. Wow. Really little people.”
“Yeah, I know. Big family. Little people. I’ve been translating for them for a year or so. From the south I think.”
“Really little,” he said again.
And that was the end of that.
But on a later date, Luis, one of the older brothers, was brought in by the paramedics. He looked like someone had played soccer using him as the ball. His nose was bleeding. His mouth was bleeding. His face was bruised and swollen. When we cut his shirt off, he was black and blue in any place he could be black and blue. He stripped down to his underwear and I could see he had even been bleeding from his penis.
“Hola, Senor Bob.”
He didn’t seem to be in a lot of distress given that he had obviously been badly beaten.
“Luis, what happened?” I asked.
“I was on the cart at the lavamatica and fell out. I hit the shelf on the way down.”
Hardly, I thought. He was thrashed. Our doctor freaked out.
“X-ray everything. Draw labs. Call the cops.”
That’s when Luis’ mother and the rest of the family arrived. I took one of the older sisters aside, my favorite in the pack and the one who did the baby sitting. The one who always smiled so sweetly when she said “Hola, Senor Bob.”
I asked her what happened to Luis.
“We were at the lavamatica and Luis was standing in the cart and fell out and hit the edge of the table and then the ground. He hit hard. But he didn’t cry.”
“You saw him fall?”
“We all saw him fall, Senor Bob.”
If I hadn’t known this family so well, maybe I would have been more suspicious. Anyone might be. But no one in the family acted differently than they normally did. No one was furtive or defensive. They were as friendly as always. They were as polite as always. They made good eye contact. No signs of guilt.
“You were there too, mom?”
“We were all there, Senor Bob.”
Something was wrong. Was I the only one who felt it? In my business that’s called cognitive dissonance, trying to hold two competing thoughts or feelings at the same time, unable to make sense of it. I felt extremely dissonant. My brain felt like Luis’ body looked.
The sheriffs came in, asked a few questions and went to look at the kid. The paramedics had called them from the Laundromat, as they should have. I was about to return to the exam room to translate for them when the doc grabbed me.
“Take a look at these labs, Bob. This kid’s in trouble. He’s got thrombocytopenia.”
Thrombocytopenia is a deficiency of platelets in the blood. Platelets are what do the clotting and Luis didn’t have as many as he should have, so his blood couldn’t clot properly. There are a lot of diseases and conditions that can cause thrombocytopenia, but suffice to say it would take an admission and major work up to figure it out. We weren’t going to learn the answer to that question down here in the ER. All we could do was try to answer the question that started it all.
He fell out of that cart, hit the edge of the folding table and landed hard on the ground. Another kid, a kid without thrombocytopenia might have gotten a bloody nose. A kid with thrombocytopenia would be just like Luis, with a bloody everything. No clotting equals bleeding—under the skin and through any orifice. Something to remember.
Both the doc and I tried to explain that to the deputies who were escorting mom, handcuffed, past the nursing station. They didn’t want to hear it. They just took her away. As they passed she looked into my eyes and I could hear her silent plea. “Help me, Senor Bob.”
Luis got admitted. I explained everything to grandma and the rest of the little people family. Somehow they took it in stride. Probably because they had no clue as to the possible cruelties coming their way from so many levels.
I learned two important things that night. First, always listen to your instincts. And I came up with this trick: When a kid comes in that looks like he was vigorously beaten and blood tests will take between sixty to ninety minutes, there has to be a way to get answers sooner. So I invented my own test and didn’t tell anyone. Now when I go to look at a child who seems like he’s been beaten, I hold his hand for a moment while I talk to him and when he isn’t paying attention I will give a good squeeze with my thumb somewhere on his hand or arm. Hard enough for him to feel it but not enough to hurt. If a bruise develops within ten minutes, I let the doc know so we can hold off on the cops until clotting tests come back. With that sneaky move I put us all in a position to avoid participating in another serious family disruption. What happened with Luis and his family wasn’t our fault, but we could have helped to prevent it.
I hope when I see the little people again I’m still Senor Bob. Until then, I’ll be in a lot of pain, too.