by Robert Lanz, LCSW
Social workers don’t have a lot of say in medical matters except when we occasionally point out the obvious, which may not have been obvious to everyone else, including the county resident pulling a shift in the ER. Including the ER attending physician who was supposed to be supervising the county resident. Including the pediatric resident who went along with the consensus, believing that, after 20 years of practice, the ER attending had to be right. In this case, the obvious was obvious only to me, and I was only working on a strong feeling I had, independent of medical knowledge.
A baby was brought in with a rash on his bottom, and the resident made the initial diagnosis of herpes. Herpes can only be contracted by intimate contact with someone with active herpes lesions, which could include contact occurring during the birthing process. It’s known that some docs even use an expectant mother’s herpes lesions as a reason to perform a C-Section. I don’t know much about that.
What I do know about, after traveling south for most of my life, is the culture of rural Mexico and Central America. The folks who live in these regions are called campesinos and many of them are fairly typical of the desert border-crossers trying to get to the U.S. in order to have a better life. In the 80’s, when this event occurred, my experience had been that most of the campesionos were shy people, easily embarrassed. And it was a shy, easily embarrassed couple who were waiting to see me because the ER resident didn’t speak much Spanish. He was suspicious about what he thought was herpes and considered it a reportable finding.
This made me somewhat uncomfortable because people who looked like this couple had welcomed me into their homes many times. I knew I was going to be causing them significant discomfort with the sexual nature of the questions I would have to ask regarding the little pus-sacks on the infants bottom. But my personal feelings didn’t matter, so I went ahead and did what had to be done. I looked over the baby’s body for any other marks and found nothing but a healthy baby who reached for his mother when not in her arms. I asked the parents if either of them had herpes, but they didn’t understand, so I had to explain. Lucky for me, they thought I was a doctor, too. Very shy people. Easily embarrassed.
They both denied having herpes. They both implied they had never been intimate with anyone else but each other. Given my cultural and language disadvantages I had no choice but to believe what they told me. The resident wanted to admit the baby because if the initial outbreak of herpes virus is vigorously treated, it may be the only occurrence. He also wanted to isolate the parents from the child during the investigation about the herpes exposure. To be honest, it didn’t look like any herpes I had seen on other kids, but I wasn’t the doc. Fortunately, I was the guy who wanted to cover all bases when feeling uncertain about a diagnosis.
“Call over to the main ER and have Dr. J. come over,” I said to one of the nurses. “I want the attending to see this kid before we start some investigation.”
That didn’t work. Dr J. said, “The kid’s got herpes, Bob. Admit him and call Children’s Services.”
It was late and the Children’s Services people said the same thing. Admit the patient and they would come over in the morning. I had a feeling they were all wrong but what could I do? The pediatric resident came down and I told her that it didn’t look like herpes to me and that the family really didn’t seem like people that would neglect their kid.
“Looks suspicious to me, Bob,” she said. “I’ll admit him. We’ll culture those lesions.”
So I left a note for the pediatric social worker. Then I left a voice message expressing how I really felt. Can’t be writing my feelings in the chart, an official document. But I had worked with the peds social worker on many cases and I knew she believed that I had sound judgment. Still, at that point it was Docs three, and SWs zero.
The next day I was busy from the moment I arrived and didn’t think about the kid upstairs, at least not until I ran into the pediatric attending in the cafeteria.
“I saw your notes on that kid you guys admitted last night. You sounded a little tentative about the situation.”
Here we go, I thought. Docs four, SWs still zero.
She said, “I got the feeling you didn’t think those lesions were herpes.”
“Well, they didn’t look the same as the herpes we usually see.”
“That’s because they weren’t. I was all over the resident for missing that and getting social services involved. I don’t know how they got impetigo confused with herpes, but they did.” Then she suggested, “Maybe you ought to say something to your docs down there.” Oh yeah, I thought. That’ll work.
I said to her, “I have a better idea. You’re the pediatrics doc. Why don’t you go on over there and tell them and keep me out of it?”
I guess she did, because I never heard another word about it.