A quick physical examination of the infant had revealed what the untrained observer could not have perceived: this one-year-old had a time bomb within, ticking at 120 beats per minute. A severe heart defect present since birth had gone unrecognized. The associated heart murmur was so loud that it could even be heard along the patient's back. Her heart was having to work so hard that her chest was visibly heaving. Her heart was beginning to fail. The infant had been brought to the ER for an unrelated complaint. That problem turned out to be minor, but she was quickly admitted to the hospital for a proper cardiac workup.
Why hadn't the heart problem been diagnosed earlier? One possibility was that the baby's physician had missed it (if so, the doctor should be investigated by the state medical board). Another possibility was that the infant had never been seen by a doctor. We quickly discovered that it was the latter, and untangled a story of striking child neglect. The state assumed custody of our patient and her parents were forbidden from entering the pediatrics ward. The infant would remain on my panel of patients until the state figured out her next move.
When I rounded on the patient in the early morning, she was lying sideways in her crib, had kicked off all of her blankets, and was sprawled out on her stomach, asleep. I lowered the crib railing and roused her. With some effort, I managed to roll her onto her back so that I could perform my physical examination. Each time I placed my stethoscope on her chest or tried to palpate a peripheral pulse, she pushed my hand away with remarkable force. She eventually gave up, grabbed her bottle of juice, and put it in her mouth. After feeding for a long time, she nodded back off to sleep, still with the bottle in her mouth. Wait a minute, I thought. Infants shouldn't go to sleep with bottles in their mouths, right? It will rot their baby teeth. She could even aspirate the liquid.
I tugged on the bottle. The infant woke up and groggily pulled with all of her might. I relented and waited for her to fall asleep. Then I delicately tried prying the bottle yet again from her clutches. Still no luck. I considered trying more forcefully, but decided not to bother. This infant had had an incredibly rough day. She deserved some comfortable sleep.
I tucked the infant back into her blankets. By the time I had raised the railing of her crib, she had already kicked the blankets off. Although I knew I only had a few minutes to round on my other patients, I spent some moments peering down at the sleeping infant, my chin resting on the crib railing. She looked innocent, even with that bottle resting in her pursed lips in an act of stubborn defiance. This child no longer has parents, I mused. For the time being, my colleagues and I are the closest thing.