A Big Decision

By Mark Nethercote, June 29, 2010 11:13 am

The woman looks at her son.  Then she looks at me, then across to her own mother, and then back at me.

“Oh,” she says finally, wringing her hands like she’s on a quiz show, “I really don’t know.  It’s such a big decision.”  I take a breath, quietly.  “I mean – you’re the doctor.  You tell me what to do.”

“Okay,” I say, “let’s go through it again.”  She nods in agreement.  “Jonah has enlarged lymph nodes in his neck, yes?”  I point across at Jonah, his neck as wide as a bullfrog.  He waves at me comically.

“Yes.”

“And he’s been treated with antibiotics for over a week, with no change.”

“There has been a change,” corrects Grandma.

“Okay, there’s been a little change,” I concede, “but not a lot?”

“Not a lot,” she agrees.

“Your GP sent you to the paediatrician for a second opinion.  He did some blood tests, a screen for glandular fever, and a blood count that came back looking perfect.

“Perfect?” Mums asks.

“The white cells were normal.  We look at these for signs of infection, and…for other nasty things.”

“Nasty things?”

“Like leukaemia,” I say, not wanting to get bogged again.

“Leukaemia?” Grandma pipes.

“Yes, one of the things we look for with this is leukaemia.  And there was no sign of leukaemia.”

“So it’s not cancer?” Mum asks.

“No,” I hear myself saying as a reflex.

“And it’s not an infection?”

“No, it probably is.”

“But you said that the blood test showed no infection?”

“The white cells were all normal…”

“…Which you said meant no infection.”

I pause for a moment, counting sheep.

“This blood test was done two weeks ago.  At that stage, his neutrophils were in the normal range.  I don’t know about today without a repeat test…”

“…If we agree to that test,” Grandma says, shaking her head.

“That’s right.”

“But you said that he looked fine, and that he wouldn’t need antibiotics?” Mum says.

“I said that if this a viral thing, then antibiotics wouldn’t make any difference.”

“And you think this is a viral thing?”  They say it together.

Looking at them, they’re like twins, except that one of them has been kept in a time capsule for twenty years.  Wrinkles aside, they are the same person -  same disposition, same head tilt, same cross-examination technique.

“It probably is.”

“Why?”  Again together.

“Because…”  I pause to gather my thoughts.  “Because he looks so well.  Because he’s never had a fever.  Because he has green snot coming out of his nostrils, and a slightly reddened throat.  And because if this was a bacterial lymphadenitis, he wouldn’t be able to turn his head, his glands would be hot and tender, and he’d be as sick as a dog.”

“But glandular fever is a virus?” says Grandma.

“Yes.”

“And it’s not that?” Mums chimes.

“Well, it may be.”

“But the test was negative.”  Grandma’s turn.  “I thought this was the one thing we did know.”

“The screen was negative, but it’s an imperfect test.  We’d need to do serology for a more accurate test.”

“Why can’t you people give a straight answer for anything?”

“Because unfortunately, medicine isn’t straight.”

They look at me like I’m mad.  Maybe I am.

Through all of this, Jonah has been watching, slightly amused.  I look directly at him and he grins widely, like he’s watching a spectator sport.  I get the feeling that I’m not the only male to get this kind of grilling.

“Oh, oh, I really don’t know about this,” Mum says, “I think I need to talk to Greg.”

“Sure, go for it,” I say.

“You know Greg?”  I look at her, confused.

“So he doesn’t have to be admitted?” Grandma asks, hijacking the conversation.

“You don’t have to do anything,” I say, slightly exasperated.  “It’s a free country.”

“It’s just that Greg is a naturopath, and I think he’d want to know if we were going to pump him full of antibiotics.”

There is a halt in proceedings.

“But he’s already getting antibiotics,” I say finally, confused.

“Yeah, he’s swallowing them,” Mums says, adjusting her woollen headscarf, “he’s not being pumped full of them!”

“Right,” I say, pretending to understand.  “I’ll let you guys talk to Greg, and then have a think.”

* * * * *

I head back in, fifteen minutes later.

“We’ve decided we want the blood test, but not the drip,” says Grandma.

“We want to go home after, and we want the paediatrician to follow us up if it’s not getting better.”

“And at that point, if it’s no better, he’ll come back for further investigation?” I ask, trying to clarify.

“We’re just trying to avoid the trauma.”

I find these people genuinely confusing.

“Which trauma?”

“Of staying in hospital.”

“Oh, that trauma,” I say, a little too candidly.

“It’s no laughing matter,” Grandma says shortly.

“No, fair enough,” I say.  “I guess…most people are worried about needles.  That’s the trauma people are usually scared of…”

“…Oh, we’re fine with that,” Mum says.  I look at Jonah, who does in fact, seem fine with that.  With everything, really.

“If we’re getting the blood tests, we often leave the drip in, in case anything else needs doing, so we don’t have to use another needle…”

“…We don’t want the drip.  We don’t want it to stay in…”

“Okay,” I say conceding.  “Let’s do the bloods, and a chest X-ray, and then we’ll see what they show.”

“And then we can go home?”

“And then you can go home.”  These people have a knack for getting me to say what they want to hear.  “But if things still aren’t improving in five days, you’ll come back in for the drip then?”

“Yep,” they say together.  “And Greg agrees, too,” says Mum.

“Great to have Greg on board,” I say.  “We’ll do the glandular fever test…”

“…I thought we did that one?” Grandma asks.

“Shut up Mum.”

“…And we’ll do one for CMV, and Cat scratch disease and a couple of other infections.”

“Sure.”

“And we’ll just get that chest X-ray as the last thing before you go, hey?”

“No problem.”

* * * * *

Jonah is a delight throughout the blood test.  He’s a special kind of kid.  A bubble of mucus plays at the edge of his nostril as he happily chats about his holidays, not even noticing as the needle goes in.  He then heads off to radiology, excited by a new adventure.  Even Grandma manages a smile, basking in the rays of this joyful child.

I’ve already printed their discharge letter by the time they return from Radiology.  I’m keen to get them out, happy for the paediatrician to sort this out another day, my own head throbbing from diplomacy.

“I’m back from getting my X-ray, Dr Mark!” Jonah yells on return.  I salute him, which he returns with a giggle of innocence that only goes with being eight years old.  His mother smiles, rubbing at his hair, knowing it won’t last forever.

I log into the computer to check the bloods.  The FBE is pristine.  The other tests sit there pending, not due to return till another day.

I minimise that screen, logging into the radiology program.  I punch in numbers, checking them against the name that pops up.  I click on it, and immediately pops up a black and white image.  A Rorschach ink blot.

My heart falls through the floor.   I feel sick.

I drop my head in my hands.

* * * * *

“Hey,” I say.

“Hey,” they all say together.

“Jinx!” Jonah shoots back, clapping his hands in delight.

“What is that?” I ask, pointing at the half-eaten chocolate bun, sitting on a plate beside Jonah.

“Dessert,” Grandma sighs.

“Leah and Trina,” I say, keeping my voice light, “can I just have a chat to you for a second?”

“Sure.”  They both rise and follow me.  “We’ll be back in a jiffy,” Mums says.  Jonah smiles, biting down on his treat.

They follow me into another room, another cubicle;  this one with a door.  There are three mismatched chairs laid out for interview: one covered in red vinyl, strings of cotton coming from it’s edges, one an anaemic green in hard plastic, and a third made of wood, designed for a toddler.  I’ve pre-arranged them so the two adult chairs face the baby one.

“You two take those ones,” I say, “I’ll take this one.”

“Are you sure?” they both ask.

“Quite sure,” I say.

We sit, the silence of the room suddenly very loud.  Those two seconds of deathly stillness sit in the pit of my stomach for a very long time.  Still now.

I take a breath, about to start.

“This doesn’t seem good,” Leah says, laughing nervously, looking across at her mother.

“It’s not,” I say.  Leah looks at me;  her head tilting and her brow knitting.  Trina looks up, mid-ruffling through her handbag.  I take another breath.  “When we did the X-ray, we saw a mass in Jonah’s chest.  Something that will be related to the lumps in his neck.”  They look at me, their eyes yet to register.  “We’ve seen a growth, sitting above his heart.”  I find myself touching my own chest, like I’m playing a piano chord on my chestbone.  “Right here.”

Leah lets out a little sigh, like a cough, like she’s just been winded.

“A growth?”  I see her eyes dancing, searching.  I say nothing, waiting for her to comprehend.  “What do you mean?”

I pause for a moment.  “We don’t know exactly, but I’ve been talking to the oncology team…”

“…Oh, Jesus,” Trina says.

“And we want to admit Jonah, so that we can investigate further.”  There is another silence.

“Is this cancer?” Leah asks.

I feel the acid in my mouth.  I can see my sadness reflected in her eyes.

“It could be.  We’re worried that this is lymphoma.”

Leah stands bolt upright, putting her hand to her forehead.

“No!  No!  No!” she barks, each word getting louder.  She walks around in a tight circle.  “Oh, Jesus.  Oh, Jesus, oh, Jesus,” she breathes.  She sits again, and then looks up.  “But it could be okay?  This might be nothing?”

“We really just need to bring him in to do some more tests,” I say.  “Maybe to get a bone marrow and a needle sample from the node.”

“This is not happening,” Trina says, as she dissolves into tears.  We all listen to her sobs for a while.

“How big is it?” Leah asks finally.

“About eight centimetres,” I say, measuring between my thumb and forefinger.  Trina continues to sob.  Leah is quiet and still.

“Who ordered the X-ray?” she asks.

“I did.”

“Thank you.”  I feel my own lip wavering, tears at the edge of my eyes.

“I’m sorry about before.  I really am.”

Leah moves forward, and takes me into a hug.  It leaves me totally thrown.

“It doesn’t matter,” she says, her voice now monotone.  “Nothing matters now.  All that worry about doing the right thing?  Thinking everything else is such a big decision?  It all just fades to bullshit, when this happens, doesn’t it?”

I frown, nodding.

“So he’ll need to come in now,” I say, eventually, quietly.

“Of course.  Of course,” she whispers.

She stands again, her hand returning to her head.  “I’m in a nightmare.  I’m in a fucking nightmare.  Somebody wake me up.  Please, somebody wake me up,” she groans.  “My poor boy.  My poor boy.  It couldn’t have happened to a better kid.”

I hear those words.  I think of Jonah, of his laughter, and his innocence, and I really hear those words.

I look back at Leah, a study in grief reaction.  In less than two minutes, I’ve seen her go through denial, anger, bargaining, and now depression.  She finally lifts her head and looks straight at me, her eyebrows folding at their edges.

“Why, Mark, why?”

I feel myself frown, trying to remain calm and professional.  But I can’t.

“I don’t know, Leah,” I say, finally, my voice cracking.  “I…I don’t know.”

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Sack Taps 101

By Mark Nethercote, June 18, 2010 10:02 am

It seems that Sack Taps aren’t confined to Melbourne.  Thank you to Clare for alerting me to the story reported by news.com.au just over a week ago, following a teenager who had his testicle amputated after playing sack taps with his friends.

Urban Dictionary explains that a sack tap is:

1. A trick played on a fellow athlete where the open hand smacks the target’s testicles with the knuckles in a sharp, wrist flicking motion.

“Dude, I sack tapped Brandon, and now he has the whole team trying to sack tap me.”

2. A Skateboarding Move:

a) Ollie out of a transition or a lip or even off the ground if you got enough hops.

b) Grab the board and pull it away from your feet.

c) Slam the board into your nuts…well you don’t have to slam it.

d) Pull the board back and put it under your feet.

This is, of course, to be differentiated from sack tacs, sack tack, and sack taffy, all of which, while equally disturbing, are far less dangerous.

On YouTube, there are any number of entries glorifying sack tapping – it seems, mainly by teenage boys and the military.  In fact, there are more video posts by military personnel than by school boys.

Studies have shown that the average mental age of a sack tapper is usually between the ages of 6 and 8, unless they are a member of the armed forces.

In that cohort, the number is likely to be lower.

Click here to read about how stupid kids can be…

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Behaviour Clinic

By Mark Nethercote, June 10, 2010 2:02 pm

I sit here, wondering how it has got to this point.  Well, not so much wondering.  Just trying to meditate, to make peace with the universe, to understand, to somehow sympathise.  To circuit break.  But my blood just refuses to settle.  It spills out of me, invisible lava.  But in a far more controlled manor than Candace’s spit, which flicks from her bottom lip.

“It’s just not fair, you see,” she slurs, her cogitation slowing, the dopamine receptors blocking and unblocking in a clunky way, “and I think what you did was really not right.”

There you go.  There we have it.  She said it.  She managed to name it.

Welcome to Behaviour Clinic.

“What was it that you objected to most?” I say, as Declan swings upside down on his chair, his feet threatening to kick the X-ray box off the wall.

“He’s good at home.  He doesn’t have any of the problems like he’s having at school.”  I look again at Declan.  She doesn’t notice.

“Okay, Candace, but he had to be physically restrained.”

“That’s right, they were ganging up on him.”

“He had a knife, Candace.  Anyway…”

“…They were picking on him!”

“Yes.  Okay, that’s okay,” I say, my hands moving like a slow motion bongo drummer, “but we keep getting distracted.”  Declan kicks again at the lightbox.  I look at him.   He grins.  I dare.  He stops.  “I still don’t understand what it is that you object to about what I did?”

“I just don’t think it was right.”

“Which bit?”

“All of it.”
“I’m sorry Candace, you’re going to have to give me a little more specific than that…”

“…And then you talked to Robyn, which I never gave you permission.”

I pause, her non-sequitur speaking style making me dizzy.  I take another breath.

“She’s his worker.”

“I never gave you permission.”  Again, I pause.  Declan kicks the box.  I don’t even look.

“No, I guess you’re right.”  Declan somersaults back, bored by the lack of reaction, the chair falling as he does.  He jumps up and onto the bed, the sheet sliding to the floor, dirty shoe prints planted on white.  “But these appointments are often distracting,” I continue, “and I guess I assumed that – as his worker – you would be okay with that…”

“…And I just don’t think it’s right.  I think what you did is shit.”

I pause for a second and look at Declan.  This is the hard bit.  This is the really hard bit.  I’ve busted my arse for Declan.  I’ve had repeated conversations with his school, with his principal, who is also busting her arse.  She is currently trying to gain extra funding for Declan.  He is so disruptive at school that he needs one-on-one support.  But in the Government schools, this is a real battle.  Over the last few weeks, the principal has even started bringing her retired husband to sit with him.  To just be with him.  At our last appointment, Candace told me she was worried that Declan was going to give him a heart attack, and I don’t blame her.

Now that is commitment.  That is novel, and inventive, and committed.

“And the school has done nothing,” Candace chimes.

The kid is a mess.  He really is.  But it’s not his fault.  His mum has bipolar disorder.  She is on multiple psychotropic medications, which does few favours to her, and even fewer to her unborn infant – her fifth child to a third partner.  At least they don’t affect her fertility.

“And you’re doing nothing,” she adds, a piece of tooth-food landing on the edge of the desk.  “And I’ve been speaking to my lawyers about the whole thing.”

Okay, okay.  Like I said, this is the hard bit.  I do it to help the kids.  I really do.  But with this level of venom, a degeneration in a relationship that has gone this far, a threat of legal action, and I’m pulling the pin.  I’m here to help;  I’ve worked hard to help to this point.  But I’m not a punching bag.

“Look, Candace.  I have no problem – absolutely no problem,” I stress, the umpire hands again in action, “with you going and seeing someone else.  Of having a new Paediatrician.  I’m totally fine with that.”

She freezes.  Even Declan stops pumping up the blood pressure cuff for a moment.

“Oh, I didn’t mean that,” she says.  I can’t help but shake my head.

“Well, what am I meant to think, Candace?  You’re bringing in lawyers because I spoke to his worker.”

“I only spoke to one.”  That she’d seen advertised on daytime television.

I nod, and look at Declan again.  He smiles, and I feel it – a damaged, growing child trying to break out of his hell.  But my heckles are raised, I’m feeling the heat.  We’re done.

“Let’s just call it a day, Candace.  I don’t think we’re getting anywhere today.  Let’s just…”

“I only spoke to one!”

“I’ll call you in a few days.”

I open the door, and Candace looks stunned, muted, admonished.  I wonder how her addled brain will remember this interaction.

“Time to go, Declan.”  He bows his head, before jumping off the bed, his demeanour mirroring his mum’s, his feet making two more foot marks on the bedsheet next to the others.

“I’ll call you, Candace.”

“To say what?”  It’s the plea of a little girl, trying to understand what she’s done wrong.

“I’m not sure.”  I pause, waiting for something to come.  “I’m not sure.”

I shut the door, and hear the noise travel away, a gust of sounds that follows them always.  I look back down at the floor, at the impressions on the linen, like dance-step instructions;  an intro to break dancing.

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Spud

By Mark Nethercote, June 2, 2010 7:05 am

I walk into the cubicle, with Ken in tow.  There I find an eight-year-old boy, hoeing into a packet of chips.

“Hey, Daniel.”

“Call me Spud,” he says, without looking up.

“Hey Spud.”

With that, he raises his head, and smiles from ear to ear.

“This is my Mum,” he says, gesturing across the cubicle.

“Hi Mum.”

Spud lets out a laugh.  “She’s not your Mum!  She’s my Mum!”

I look across at Mum.  She holds her head in her hand.  “He was sick when we brought him in here, I swear.”

“Hey, I believe you.  Kids turn around quickly,” I say.

I look around at the intern, who has been taking down everything I’ve said.  He looks confused.

“Kids turn around quickly?” he parrots.  I nod.  He scribbles some more.  It’s like owning a puppy that can write.

“These are admission notes, Ken.  You don’t have to write everything.  In fact, nothing that we’ve said yet should go in the notes.”  Ken looks deflated.  I look back at Daniel.  “In fact, just put the pen down, Ken.  I don’t even know that Spud is going to need admission.”

Spud lets out another little laugh, a delighted cry.   His Mum rests her head in her hand, shaking it some more.  Ken looks at me like I’ve scolded him.  It’s like the Charades Olympics.

“It’s okay, Ken,” I repeat.  “Let’s…just…listen.”  Reluctantly, he puts the pen on the bench.

I turn back to Daniel, just as he begins to pull the auroscope off the wall.

“So you weren’t crash hot this morning, Spud.”

“Nup.”

“What was going on?”

“Sore eyes.  Stiff neck.”  He fiddles with the expensive equipment, bouncing it up and down by the cord, oily finger marks trailing all over it.

“So I heard.  The emergency doctors were worried that you might have meningitis.”

“That’s what they said, yeah.”  He tires of the auroscope, letting it go by his side.  It springs back up like a bungy, hitting the wall, before bobbing up and down on its coil.  Its tip scratches the wall, making a sound out of a B-grade horror movie.  Ken looks frightened.

“Cool,” Daniel says.

I grab the auroscope, putting it back in its holder.  “Not that cool, mate.  Six hundred bucks cool if it’s broken.”

“I don’t care.”

“Sure you will.  Once mum pawns off your iPod, X-Box, Wii and PS3 to pay for it you will.”  He looks at me and frowns, stopping dead.  “That’s right.  All of them.  So let’s just settle down a bit, okay?”

I glance around the room.  Spud gives me his complete attention, his Mum has lifted her head out of her hand, and Ken now stands motionless.  We’ve gone from Charades to Statues.  Ken gives me one more pleading look.

“You can write if you need to, Ken.”  He smiles, picking up the pen, touching it quickly to the page.

“So Spud,” I continue, “the sore eyes and the stiff neck.  What happened?”

“Gone.”

“Headache?”

“Gone.”

“Problem with light in your eyes?”

“Nup.”

“Nausea?  Vomiting?  Lethargy?  Sore joints?”

“All gone,” says Mum.  Her head returns to its rightful place.

“So they all just kind of disappeared, hey?”

“Yup.”

“And no fever at any stage?”

“No.”

I shine a torch in Daniel’s eyes.  He doesn’t blink.  I stare at the back of his eyeball with the ophthalmoscope, the non-greasy companion-piece on the wall.   His eyes stay open.  I complete a neurological exam, testing his tone, power, reflexes and sensation.  Perfect.  I check his abdominal, respiratory and cardiovascular exam. Everything is completely normal.

Ken takes notes the whole time.

“There’s one more thing I want to do Spud.  I need to raise your leg while you lie still.”

“Yeah?  You really need to do that?”  He looks genuinely excited.

“I do, yes,” I say, a little confused.

“Then watch this.”

With that, Spud takes his leg, holding it at the ankle.  He takes it in a grip that looks odd, initially.  It begins to make more sense when he takes his leg and places it over his head.

“Is that what you wanted me to do?” he asks, a little breathless.

“Well, not exactly, Spud…”

“…What, you need it to go further?”

“No!” I yell, worried about what comes next.  “No, I was not going to take your leg and put it over your head.  I just wanted to lift it up off the bed a little bit.

“Oh,” he says, disappointedly.

“Did you know he could do that?” I ask Mum.  She shakes her head some more.

“Well it’s not meningitis,” I say.

“Are you sure?” asks his Mum.

“That last test is normally called the ‘Straight Leg Raise’, or – in Spud’s case – the ‘Over the Head Raise’.  It puts a stretch on the lining around your spine, the meninges.  With meningitis, raising the leg causes a lot of pain, as it puts pressure on the meninges.   The fact that Spud can stick his leg over his ear gives me a fair indication that he doesn’t have meningitis.  In fact, it gives me a fair indication that you’re somewhat of a freak, Spud.”

The Straight Leg Raise

Spud's Leg Over the Head Raise

Spud slaps his thigh like a good ol’ boy.  I just which he had a piece of wheat between his teeth.

“So I think you’re okay, partner.  You haven’t got meningitis, and you are free to join the circus.”  He laughs again.

“So why the headache?” Mum asks

I look at Ken.  He looks at me with fear, before returning to the safety of his page.

“Don’t know,” I say shaking my head.  “Headaches come and go.  Maybe it was a first-presentation migraine.  Maybe just a bad headache.  I’m not sure.  But what I am sure is that it’s not meningitis.  I’d suggest going home and having a good rest, Spud.  And try to keep your legs in front of your head, at least for today.”

“Sure,” he says, taking my hand in a shake.

“Thank you, Doctor,” says his Mum.

“Pleasure.”  I look down at the cheeky cowboy on the bed, the one who almost tore the equipment apart, until I threatened to confiscate his electronic pacifiers.  After that, he turned into a real character.  A real little lad.

“See you Spud.  It’s been a pleasure.”  He slaps me on the back, and winks at me.

“Pleasure was all mine, doc.”

I frown, looking at his mother.  She laughs.

“Just one more question for you Daniel.  Why do they call you Spud?”

“We live on a bit of property,” Mum says, interjecting, “and Daniel has always been interested in growing things.  So we got an empty wine barrel, cut it in half, and filled it with soil.  And Daniel grows potatoes in it.”

“I love potatoes,” he says shaking the chip wrapper like a talisman.

I pause for a second.

“What were you doing this morning?”

“Tending the spuds.”

“You do it every morning?”

“Most mornings,” he says.

“Do you use fertiliser?”

“Of course, man,” he says, “Dynamic Lifter.”

“And you used that this morning?”

“Yep.”

“How much?”  He looks back at me with confusion.  “How big is the packet?”

“Well, it was pretty big, I guess.”

“It was?” asks his Mum.

“You used the whole packet?”  He looks off to the side.  It’s the first time I’ve seen him look anything but confident.  “How long after you poured the whole pack of Dynamic Lifter over your barrel did you start to get sore eyes and a headache?”  He furrows his brow some more, before grinning sheepishly.   He raises his arms in a shrug.

“At least the spuds will grow though,” he says, finally.

Mum’s head returns to her hand.  Spud laughs.  I leave. Ken continues standing there, writing something.

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Medical Records 101

By Mark Nethercote, May 25, 2010 3:25 pm

Problem:  INJURY – ARM (FOREARM AND WRIST)

Assess:  “Fell off couch & now limited movement, distressed with any attempt tomove (sic) arm.  Has croup like cough & black eye from cat.  PainStop @ triage.”


From this descriptive triage assessment, we can interpret:


1. That the child fell off the couch, and since that time is acting like a teacup.

2. Becomes distressed when no longer allowed to play that game.

3. Also has a cough.

4. And a black eye from the cat.  No need to try to make this funny.  That’s actually what they wrote.

5. Has given their contact details as painstop@triage.com

This triage assessment was initially confusing to me, until I read the doctor’s notes:

* * * * *

* * * * *

Then it all made sense.

Brevity is the key to clarity.

* * * * *

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Plaster Master

By Mark Nethercote, May 20, 2010 6:29 pm

“Zeb?” I yell into the waiting room.

I stand and wait, while fifteen heads look at me, frozen.  This is my favourite part – being stared at.  The patient you call is never within sight, they’re always round a corner, taking years to get their things together.  While everybody else stares at you.  It’s the best bit.

“Zeb?”  I call again.  This time I hear a faint shuffle, and then movement.  And then the rattle of plastic bags.  Promising.  Very promising.

One of the staring people looks away, staring at something else.  Hopefully, staring at Zeb.

And with that, from around the corner, Zeb bounds.  All perky, and…green.  Fluoro green.

“How’s it going?” he asks in an Australian drawl.

“Good mate,” I return, and he giggles delightedly.  His mother rolls her eyes, and grandma tries the same thing.  “Nice colour, Zeb.”

“Yeah.  I like green.”

“This way,” I say.  “First door on the right.”

He walks off down the corridor ahead of us, and into the plaster room.  We follow him, waiting for grandma, who eventually places herself down on a stool.  The plastic bags fall to the ground in a heap.

“Can I get a different colour this time?  Sure, I like green, but this time I want red.  Or yellow.  Or, yeah, pink maybe?  Hang on, maybe not.”  It’s difficult to tell who he’s talking to.  Possibly no one.  “Yeah pink.  Can I, can I, can I?  Huh, huh, huh?”

I look at Mum.  She looks tired, but not as tired as you might expect.  Grandma is the one who looks beat.

“I think you’ll be getting white, mate.  I don’t think we’ll be getting out the fresh colours here.”

“Oh,” he whines, “why not?”

“Because I’m only a doctor.  I only do plaster.  It’s the plaster techs who do fibreglass.  That’s where the colours come into it.”

“Yeah, right, I get it,” he starts.  “Well, there’s a plaster under here.  From the start.  From, like, when this all happened.”  He nods, and his mother and grandma do too.  “And then we went back to the GP, like – I don’t know – like two days later, and it was only up to my elbow, right?  So he, like, sent me to the Children’s Hospital, and there the guy was like, ‘Dude, I don’t think it’s quite right, but I don’t want to re-break it for like a third time…’ ”

“…Third time?” I interject.  I get that interjection is the only way with Zeb.

“When he broke it was once, and when it was straightened made a second time,” Mum manages to say.

“…And so, re-setting it would make a third time,” completes Zeb, “and he was like, ‘That would be no good, man’.  So we were all, like, ‘Yeah, cool,’ and he was like, ‘Do you like fluoro?” and I was like, ‘Uh, duh, who doesn’t like fluoro?’…”

“You like fluoro?”

“Uh, duh!” says Zeb predictably.  We, the adults, laugh.   “And then he was all, ‘You can have any fluoro you want, and we can, like, cover up the whole white mess, if you want, dude.’  And so I went all, ‘Sure.  Do you have green?’  So he’s like, ‘Yeah, we got green’, so we, like, totally got it.”

He stops.  We all take a breath.

“That is a really amazing story, Zeb.”  He nods his head vigorously.  “But why are you here?”

“Yeah right,” he says, taking a breath.  I sit down, readying myself for a story.  “I got a pen lid stuck down there.”

He stops dead.  I do a double take.

“Is that it?  No story to go with it?”

“Nah, it’s, like, pretty boring.”

“So there’s a pen lid down your cast?”

“Yep.”

“Where exactly?”  He taps at his elbow.   “So pretty much half way down.  The furthest distance from either end.”  He nods again, like it’s a bore.  “And how did it get there?”

“I was, like, scratching myself.”

“With a pen lid.”

“Well, yeah.”

“You do realise, that you’re a goose?”

“Yup.”  He looks at his mum, raising his eyes.  “I’m a goose.”  We all laugh.

“This is a good story, Zeb.  Tell me, how did it get down there?”

“What do you mean?”

“Like, dude, like, tell me how it, like, got down there?”

“Is he making fun of me?” Zeb asks mother.

“Yes, he is.”  Grandma laughs some more.

“Well,” he says, cocking his head, “I was scratching, and, it, like, came off.”

“Oh, so it was on the end of a pen?”

“Dude!  I wouldn’t just stick a pen lid down there.  It might get lost.”  We all look at him raising our eyebrows in unison.  He ignores it.

“So, anyway, it came off the end of a pen?”

“Yup.”

“So then what happened?”

“I got some chopsticks out.”  We all laugh some more.

“This is great,” I say.

“Nah, nah, nah, I was really close.  I had it up to here!”  He points to the top of the cast.  “But I didn’t have enough hands left to grab it.”

“Why didn’t you ask for help?” asks grandma.

“Because I was embarrassed,” he says quietly.  It’s the first time I’ve seen him contrite.

“Lucky you managed to avoid embarrassment, eh?”

He raises his eyebrows, knowingly.

“So what now?  Do I get a different colour?”

“Not so fast, buddy.  Firstly, we need to get the lid out, right?”  He nods.  “So we’ll have to cut it down to here, so that we can split the cast and grab it.  You think you know where it is?”

“Yeah, it’s right here,” he says, pointing.  “I can feel it.  Right here.”

“Are you ready then?”

“Yup.”

I turn and open a drawer, one dirtied by years of plaster, revealing a treasure chest of torture devices.  Splitters, cutters, shears, giant bolt cutters – a whole stack of big metal things, with smooth handles at one end, and sharp bits at the other.

“Cool!” says Zeb.

* * * * *

We start with the shears.  It chews the fibreglass ineffectively.  I get about five centimetres in, before I give up.

“This is more like a crusher than a cutter,” I say.  I feel sweat on my forehead.

“You’ve got a long way to go,” says Zeb.

“Thanks for the reminder.”

“I’m just saying’s all.”

I look him in the eye, and then put down the shears.

“I’ll be back.”

I walk next door and return, wheeling in a machine on a cart.  I plug it into the wall, and the machine revs up.  From its end emerges a snaking neck, a buzz cutter on its tip.  A circle of teeth sits on the end of a rotor, a dangerous circular saw.  Zeb’s eyes pop.

“It’s okay,” I say, “it can’t cut you.”  I turn it on, the circular blades vibrating.  I place it against my skin.  I feel its vibration.  Zeb’s mouth drops wide.  “See?  The blade zigs back and forth – it doesn’t spin right around.  So it won’t cut skin, because skin’s not fixed.  Your skin just wiggles against it.  See?”  I put it against my arm once more.

“Cool,” he says.

We start.  I work my way down, the satisfying squeal of an electric saw with each stroke.  Each time it makes it through, I check Zeb’s face.  He’s freaked out, in a boy kind of way.  He doesn’t know if he’s thrilled, or filling his pants.  Or both.

We get to near his elbow, when I ask for guidance.

“Where is it again?”

“Right here.”

“I don’t want to cut the pen lid in half, do I?”  I pause.  “In fact, why didn’t I just cut out a window at the start?”

“That’s what I thought,” says grandma.

“Me too,” says Mum.

“I wouldn’t have minded suggestions, guys,” I say.  “I guess I’m so used to taking plaster off from the top, that I didn’t even think of that.  It’s not like I go fishing for pen lids in casts every day.”  They all laugh again.  “Where is it, Zeb?”

“Right there.”

I cut a hole, 4cm by 3cm.  I peel back the plate of fibreglass, it’s final fibres cracking.  I feel like an archaeologist.  I stick my hand in and fish around, finally feeling my finger against something round.  My eyes widen.  Everyone else’s do too.  I pull, trying to free it.  And finally, out comes the lid.

“There you go,” I say.  Grandma claps.  “I didn’t know that I’d find it that easily.”

“Why not?”

“The story is just such I good one, Zeb, I guess I didn’t know what I’d find in there.”  I hand the lid to Mum.

“Can I have it?” he asks.

“I think Mum should keep it,” I say.  He rolls his eyes once more.  All this family does is laugh, raise their eyebrows and roll their eyes.  It’s like they’re all having seizures.

“So what about fixing it up?”

“This will do for now,” I say, wrapping a crepe bandage, and taping it up, “just for overnight.  “But come back to tomorrow morning when the plaster techs are in.  Then you’ll get to choose a colour.  If I did it now, you’d only get white.”

“White, like, sucks man.”

“Like, I know.”

He rolls his eyes at my poor attempt at teen speak.

“Later,” he says.

“Hopefully not,” I say.

“Right.”  He jumps off the bed.  “You’re all right, man, you know that?”

He walks out the door.

“He never says that to anyone,” whispers grandma as she passes, shuffling her plastic bags between shaky hands.  “Especially not to men.”

I nod, watching Zeb walk off ahead, his mother and grandma in tow.  I catch him, looking back occasionally, making sure he doesn’t get too far ahead of his mother or grandma.

* * * * *

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Hospital Charts

By Mark Nethercote, May 14, 2010 12:41 pm

The following quotes are taken from actual patient hospital charts, mainly in the United States.  They have been reproduced before, but they never get old.  Enjoy.

“The patient has been depressed ever since she began seeing me in 1993.”

“Rectal exam revealed a normal size thyroid.”

“Bleeding started in the rectal area and continued all the way to Los Angeles.”

“She has no rigors or chills but her husband says she was very hot in bed last night.”

“Patient has two teenage children but no other abnormalities.”

“Patient had waffles for breakfast and anorexia for lunch.”

“The patient has no past history of suicides.”

“She can’t get pregnant with her husband, so I will work her up.”

“Healthy appearing decrepit 69 year-old male, mentally alert but forgetful.”

“A midsystolic ejaculation murmur heard over the mitral area.”

“Both breasts are equal and reactive to light and accommodation.”

“Occasional, constant, infrequent headaches.”

“The baby was delivered, the cord clamped and cut, and handed to the pediatrician, who breathed and cried immediately.”

“Between you and me, we ought to be able to get this woman pregnant.”


* * * * *

“The patient refused autopsy.”

“The lab test indicated abnormal lover function.”

“The pelvic exam will be done later on the floor.”

“Skin: somewhat pale but present.”

“Large brown stool ambulating in the hall.”

“Exam of genitalia was completely negative except for the right foot.”

“Examination reveals a well-developed male lying in bed with his family in no distress.”

“Patient’s past medical history has been remarkably insignificant with only a 40 pound weight gain in the past three days.”

“She stated that she had been constipated for most of her life, until she got a divorce.”

“While in the ER, she was examined, X-rated and sent home.”

“When she fainted, her eyes rolled around the room.”

“Patient has chest pain if she lies on her left side for over a year.”

“Exam of genitalia reveals that he is circus sized.”

“Discharge status: Alive but without permission.”

* * * * *

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Valium

By Mark Nethercote, May 11, 2010 3:57 pm

“Give her some Valium,” I say.

“Really?”

“Sure.”  I look up from my page, and across at the nurse.  She looks at me blankly, shifting awkwardly from side to side.

“What for?”

“It’s a really good muscle relaxant.  Great for muscle spasms.”  Her eyes widen.  “It’s okay in a fifteen year old.”

Eric nods his head beside me in consensus.  With this, the nurse walks away to complete the order.

“Thank you, Sir Eric,” I say.

“As you wish,” he replies, without looking up.

* * * * *

Fifteen minutes later, I walk into the cubicle.  The first thing I see is the red markings on the teenage girl’s face.  There are layers of skin peeling from her forehead, down her cheeks, and off her chin.  My heart leaps, as I compute, attempting to understand why triage had neglected to let me know that this child’s face had been through a cheese grater.

A mother stands at the girl’s side, holding her hand loosely.  The girl is otherwise dressed in sporting gear, her singlet top and limbs free.  There is blood down her arms too.  The only thing left unstained is the white blanket;  a temporary bandage over gaping war wounds.

“Lauren?”

The girl smiles broadly, her glazed eyes trying to open.  The kid is stoned.  If I’d been given Valium at fifteen, I probably wouldn’t have minded my face being torn off either.  “How are you?”

“Pretty relaxed now, I think,” says her smiling mother.  She pats at her hand as only a parent can.  She turns back and looks at me, as proud as a soccer mum.

I stare back down at the record, checking that I’m in the right cubicle.  Right hospital.  Right planet.  In my world, Mum’s don’t smile when their daughter’s faces have been torn off.

I take another step closer, and Lauren grins widely.  Another bit of her face falls free.

“Is that?”  I can’t help but touch the bit that fell.

“Don’t,” warns her Mum, slapping at my wrist.  I recoil like I’m four.  “It’ll stain, and then you’ll never get it off,” she coos, her best impression of a Stepford wife.

“Right, right,” I say, rubbing absently at the back of my hand, “I get it.  What’s the name of your school house?”

“Red House.”  Lauren rubs at her face, some more war paint falling.  Literally.  It isn’t blood all over her, it’s coloured zinc cream.  “Have I still got some on me?”

“Just a little bit.  You look like you’ve been through a mincer.”

“You silly sausage!” her Mum says.  With that, she lets out a little yelp, puling her hand to her mouth, like she’s broken a self-imposed bad-joke ban.

“Is the diazepam helping?” I ask.

“I think so,” Lauren says, her falling closed, “I can’t feel the spasm anymore.”

“Can’t feel anything anymore,” whispers her Mum.  The hand returns to its rightful spot.

“So what happened?”

“Well, I was finishing the race, the fifteen hundred metres.”  Lauren stops to take a breath.  And I was coming up the straight,” she continues, her arms starting to pump, “and I felt pain down my side, all down here…”  She touches her right loin, the only part not covered in red.  “The pain just kept building, and building and building.  Until I collapsed.”

“DNF,” says her Mum.

“Right,” I say.  They both stare at me.  “Which is code for?”

“Did not finish,” says Lauren, yawning slightly.

“Bummer.”

“Yeah, bummer.  But it’s all good now.”

“I’ll bet.”  She looks at me and giggles.  “Let’s have a look at your side.”

* * * * *

I lean Lauren forward.   “Tell me where it’s sore.”

“Yeah, right there,” she says.  I notice her singlet, a synthetic thing – probably made of recycled plastic bags.

“Fancy looking singlets they get you guys in these days, aren’t they?”

“Nah, that’s not from school, that’s indoor-cricket.”

“Right.”  I look across at Mum, still smiling proudly.

“So what time did this happen?”

“About one-thirty.  Just after high jump.”

“Right.  Was that your only other event?”  Both of them laugh.  I stand back, waiting.  For the gold.

“Ummm,” says Lauren, scratching her head and grinning.  More red flakes fall.  “No, there were others.”

“Go on.”  Lauren looks at her Mum, who smiles politely.  Like it’s shrink wrapped on.

“The one hundred, the two hundred, the four hundred.”  She stops and thinks for a moment.  “The high jump, the long jump, the eight hundred.”  She looks across at her Mum.

“The discus,” she continues.  They both think for a moment more.  I expect Mum to pull out a list.

“Shot put,” Lauren says.

“And then the fifteen hundred.”

They look at me, like it’s my turn.

“Is that it?”

“Well, then this happened, she couldn’t go on.”

“No, I guess not.”  They frown with disappointment.  “I’m joking.”   Their eyes light back up.  Even Lauren’s.  “I think we know how you got the muscle strain.”

“How?” says Lauren.  I look at her, and after a couple of seconds, she laughs.

“Have you been hydrating today?”

“Yeah.  I had an apple and some chips.”

“You had an apple and chips?”  I hear the disbelief in my voice, but I can’t help myself.  “Deep fried chips or crisps.  Chips?”  She nods.  “When did you have time for chips?

“Just before high jump.”

“And then you did the fifteen hundred metres.”

“Yep.”

“Doesn’t anyone else at your school do sports?

“Yeah.”

“Are you the only one in your house, then?”

“No,” she says, laughing, “I just like sports.”

“You like sports?  Really?”  She breaks into a full Valium-giggle.  “What else do you do?”

“Cricket, and footy umpiring.”

“She wants to play football with Melbourne Uni,” says her Mum, suddenly officious, “but we’ve said she’s got to leave it to umpiring at the moment.”  I look at this slight girl, swimming around in an oversized tank top, her wiry frame falling against the bed, flakes of red peeling off.

“You want to play footy against fully grown women at university?”  She nods.  “I mean, these aren’t just fully grown women.  These are the ones who like to play football.”

“You should see the size of some of them,” says her Mum.

“I really don’t want to.  I see the size of you.  You’re fifteen.  Why would you want to play against them?”

“I like sports,” she says plainly.

All I can do is nod.


* * * * *

I walk into the office, where Eric looks up.

“This girl had a muscle strain after running the one hundred, the two hundred, the four hundred, the eight hundred, the high jump, long jump, discus and shot put.  She did it during the fifteen hundred.”

“She strained a muscle?”

“Yep.”

“Geez, that’s bad luck.  Some people are just unlucky, aren’t they?”

“It was just after she had a steak and chips.”

He stands up, looking through the window and into her cubicle.

“How big is she?”

“Fifty kilos.”

“Shot put?”

“Yeah, she was born to do it.  And she wants to play footy against Melbourne Unis women’s side.”

“Jesus!” he says, “they’ll kill her!”  He sits back down.  “I played touch-footy against a mixed team that included some of those women.”   He shakes his head with sorrow.  “They didn’t understand the concept of touch.”

I look around the office, and see the nurse heading our way.

“How’s she doing with the diazepam?” he asks.

“She’s flying,” I reply.  “I think it’s the only thing that will stop her from training tonight.

We both stand and look through the window, this mother helping her daughter with her stretches.

“Did you tell her to do that?” he asks.

“Absolutely,” I reply.  “If she ever expects to win, she’s got to get back out there and throw herself into it.  Kid’s these days, I don’t know.”

“Did she win any of the events?”

“Nup.  Best she did was a third in the shot put.”  He looks at me and frowns.  “I know, the girl who came fourth is also in the waiting room.”  He looks at me, daring that its true.  “The worst thing, though, is that this girl was winning the fifteen hundred.”

“Oh no!” he cries, “gutted!”  We sit back down, and the nurse walks past, watching Eric as we do.  I catch her, and she blushes.

Eric returns to his notes, oblivious to this interchange.  I do too.  We both write for a couple of minutes.

“How many instruments does she play?”

“Sorry?”

“How many musical instruments does she play?”

I smile.  “I haven’t asked yet,” I say, getting up, “I’ll go and find out.”

I walk out through the door.  “I’ll be back in an hour,” I yell, as it closes behind, leaving Eric and the nurse in the office alone.

* * * * *

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Giving Birth

By Mark Nethercote, May 7, 2010 10:39 am

Sean turns to me, his eyes having lit up.
“Oh, you’re a doctor are you?”

“Yep.”  I exhale, my breath almost making mist.  It’s a frigid summer’s night, and we find ourselves outside, at a barbeque at dusk, drinking chilled beer.

“What’s the weirdest story you’ve been told as a doctor?”

“Oh,” I say, beginning to think.  A couple of tales – inappropriate for dinner conversation – run through my head.  I stop myself.

“The stories I hear are never as good as what I see.”

“Really?”

“Yeah.”

“Okay,” says Sean, “then try this one on then.”

I sit back, as a smirk comes to Sean’s mouth.

“So it all happened on the day of my daughter’s birth, right.”

“Oh,” Amanda says from across the table, “are you sure?  People are eating.  It’s not exactly…”

“…Perfect,” I say.  “Suddenly I’m interested.”

Sean looks at me and smiles, pleased at the approval.  “Amanda was in labour, right, and had been for a few hours.  She’s going through the contractions, they’re building…”  He pauses for effect.  “…And then it started happening.  I started getting pain myself.  You know, down there.”  He points at his pants, until I nod my understanding.

“Got it.”

“And I didn’t want to tell her, right?  You know?  I mean – guys are renowned for being pussies with pain, right?  Like they can’t hack pain, can they?”  I nod.

He leans forward, rubbing his hands together.

“So she’s starting to get more pain, the contractions are winding up, and like – almost like a sympathetic-type thing – so is my pain.  The pain in my dick is getting worse and worse.”

“And he starts acting really strange,” chimes in Amanda.  “I’m in labour, and I’m asking him to rub my back, and he’s doing it, but he’s staring into space.  Like a zombie.  He staring straight ahead, not hearing me, generally being fucking unsupportive.”

“Yeah, because I’m trying not to pass out,” he says defensively.

“Anyway,” she says.

“Anyway,” he continues, shaking his head, “so we head in to St. Vincents, and the baby’s born at 1.33pm.”

“Piece of cake,” I say.

“Yeah, piece of cake,” he repeats quickly, eager to continue, “and meantime, I’m sitting there, with my new daughter.  Just sitting there in agony.  In agony.”  I look across at Amanda.  She rolls her eyes.  “And I say, ‘Darl, I’ve got to go to hospital.’ ”

“You have to go to hospital?”

“Yep.”

“Where?”

“St Vincent’s Public.”

“So you’re in birthing suite at St V’s Private, and you walked next door to Emergency at St. V’s Public?”

“I don’t walk.  I get an ambulance.”

“Over the road.”

“Exactly.  With a kidney stone.”

“Ooh, they hurt,” I say.

“No shit!”

“No, really,” I say to Amanda, “I don’t know where I heard this, but I remember someone telling me that the two types of pain that are as intense as birth pain, are a heart attack and a kidney stone.

“No shit!” he laughs, slapping his leg, and pointing at his wife.  “I told you I was giving birth over there.  Through the eye of my dick!”


Amanda rolls her eyes again, conceding the point.

“So then what happened?” I ask.

Sean leans forward, elbows resting on his knees, like he’s ready to share game-plan tactics.

“They let me out, doped up to the eyes.”  He throws his arms up in disbelief.  “And I had to go home.”

“You didn’t go back to see your daughter?”

“Nope,” says Amanda.

“I couldn’t,” he pleads to the entire table.  “I was in agony.  I caught a cab home, and went to bed.

He takes a deep breath before continuing.

“And in the night, I woke up, busting for a piss.  I walked out to the toilet, and when I pissed…”   He shakes his head, looking away, like a digger unable to complete a story of a war atrocity.  “Eventually, I wake up, on the toilet floor, God know’s how long later.  Bleeding.”

“Bleeding?”

“From my head.  I passed out from the pain, fell against the mirror, smashed it, and cut my head.”

He sits back, like the story is finished.

“And?”

“And what?”

“Then what happened?”

He pauses for a moment, averting my eyes.  “You know,  I…well…that when I called my mum,” he says sheepishly.

The table erupts.

“Had you pulled your pants up?”

“Not sure.”

“Fair enough.  Had you cut yourself badly?”

“Nah, it was okay.  Mum fixed it.”  He takes a swig of his beer.  “Although, I swear,” he says, tapping his finger on the table, “if I’d had a knife with me as I was passing that stone, I would have cut off my dick if I knew it would stop the pain.”  He shakes his head, again taking a big swig.  “I’ll tell you, with that pain amount of pain, my dick had shrived to this big,” he says, holding his thumb and forefinger a centimetre apart, “but it felt like a metre of pain.”

He sits back again, taking a deep breath and letting it out.  He takes another drink, unconsciously rearranging his trousers.

“So when did you see your daughter again?”

“The next day, the day after we both gave birth,” he continues, without missing a beat.

Everyone sits there, staring off in their own thoughts, some people shaking their heads slightly, no one quite sure what to say.

“I think that’s the weirdest story I’ve ever been told, Sean,” I say finally, breaking the silence.

“Nah, that’s not weird, mate.  That’s just funny.”

* * * * *

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Growth Charts 101

By Mark Nethercote, May 4, 2010 5:29 pm

A 12-month old boy presented to a Paediatric Clinic with concerns regarding his growth.  Prior to arrival, the chart below was faxed through.

The following pattern is pathognomonic of a single disease process.  It is a spot diagnosis, but often missed by inexperienced clinicians:


The disease phenomenon is known as Shrinkingheaditis, eponymously named after Alfred Shrinkinghead, the great 19th Century English physician, who never owned a computer, most likely because they were yet to be invented.  All the same, he found buttons of any description very confusing.

To the untrained eye, the changes above may be missed.  Yet, if you examine the growth chart closely, you will find that the last three dots are below the two prior to that – an unusual finding for a skull, as it is made of bone.

Don’t despair if you miss it at first;  these changes are very subtle.  If you are having difficulty, you may need to squint, or even stare through it, like you would with one of those 3D drawings everyone loved in the 1990s.  Several readers have suggested swapping between internet browsers to appreciate the changes, which are often missed if only viewed through Internet Explorer.

This is a very serious condition.  Thankfully, this disease is reversible, and was discovered just in time.  Had Shrinkingheaditis continued for another few weeks, then the case would have become fulminant, the curve represented a parabola, and the child imploded and become a black hole.

Which would have been very embarrassing indeed.

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