Shared Delusions
Alberto Palacios Boix MD
It was two days before Christmas Eve when he was admitted to the pediatric ward, shaken by fever and bacteremia. He was a shy child, very attached to his mother, whom he constantly looked up to for protection. The mother, a now unemployed nurse, had resided in Little Rock since June, shortly after her divorce from a Memphis psychiatrist, whom we notified of the admission.
The man was curt on the phone and perhaps worried: this was Travis' third admission in a few weeks. First, for a thrush and then for an accident at home; he had burned both hands on an iron. His mother attributed it to his natural curiosity with some kind of neuropathy and suspected congenital immunodeficiency, for which she had apparently initiated an investigation at Nashville Children's Hospital that had been cut short by the move.
My medical assistant and I moved him to the emergency cubicle to check him, obtain cultures and administer the first doses of intravenous antibiotics. Upon stripping him of his pajamas, we discovered a series of small abscesses on his arms, legs, and buttocks, which raised our concern about the possibility of Chronic Granulomatous Disease or some other deficiency compromising his innate immunity.
– These kids are usually very delicate, Nathan, - the head nurse told me, - you need to consult with Infectious Diseases and do genetic testing right away.
– You read my mind, Stella. Please call them and we'll draw blood for DNA and immunoblot testing.
Working with a diligent team makes things easier, and Stella, eight years older than me and a veteran of the service, was irreplaceable. She is a plump mother of seven from humble beginnings who emigrated from Oxford, Mississippi, due to a lack of incentives for specialists of color. Her energetic tone is like that of a mother to the residents and students, who revere her. This time, I felt she was jumpy around the patient and his mother, which is unusual for her, as she is always helpful and attentive to family members.
In the first forty-eight hours we saw a substantial improvement. The discharge from the boils had grown Escherichia coli sensitive to the drugs we decided to apply at the outset, so that the fever subsided, and the boy seemed to regain his spirits. The danger had passed, but the initial tests yielded no results that could help us discern the cause of such an acute immunodeficiency.
Against all expectations, on the third day, having left the patient with no evidence of infection, according to the nurses who tucked him in during the afternoon shift, he woke up with abrasions in his groin, pain in both hips and superficial infection by another coliform germ. The mother was grief-stricken, accusing the paramedic team of lack of supervision and the doctors of indolence in such a delicate case.
I decided to organize a consensus meeting at noon. Present were Dr. McNamara, chief of Pediatric Infectious Diseases, an Immunology expert brought in from Children's of Memphis, the nurses and the bulk of the Pediatrics attending from both wards.
Maddy, my best fourth-year resident, gave an impeccable presentation of the case, suggesting that a neutrophil motility deficiency – a syndrome reported only a decade earlier – might explain the child's complications. The lab people disagreed, because they had done extensive testing on the entire range of white blood cells that had shown normality so far.
In a gesture of harmony, I suggested adding a third antibiotic and tightening surveillance for opportunistic infections. Stella, who usually participates in these discussions and encourages her staff to ask questions, remained very quiet during the meeting. When she finished and thanked my colleagues and subordinates for their commitment, I approached her to question her. She seemed more unforthcoming than usual; I might even say angry.
– We miss your opinions, Stella. Is something wrong? Everything all right at home?
The trust that unites us for five years of daily work allows me these liberties and she, always kind, does not resent it. On the contrary, she often confides in me details of her life, the economic difficulties she is going through and the demands she imposes on her children so that they do not follow in the footsteps of their father, who died of liver carcinoma (after an inveterate alcoholism) not long ago.
– I’m fine, buddy, but there is something that confuses me a lot about this kid. He spends his hours reading next to his mother, who does not leave his side and, frequently, it is she who expresses his symptoms and discomfort to my nurses. I understand that she also belongs to the guild, but....
– Don't overthink it, - I interrupted her gently, taking her by the arm, - it's natural. If you were in her place...
– Forgive me, Nathan, if I were in their shoes, I would have let others do their job without interference a long time ago.
– What do you mean?
– When Shaneeza or Cindy go to check on him or help bathe him, the mother adamantly objects. She says only she is authorized to see him naked and attend to him. There's something sinister about that overprotectiveness, Nathan. I don't know...
–Dr. Grinberg? - a voice behind me prevented me from answering Stella, who stepped aside to greet the man in a dark suit with a sober accent who was asking for me. - It's me, tell me. How can I help you?
He stretched out a firm hand and introduced himself with some boast as Travis' father; Dr. Martin Lightman, a psychiatrist and psychoanalyst. I led him to my office, leaving the conversation with Stella pending, to investigate the boy's background, and contrast it with the medical history his mother had given us.
Outside it was snowing heavily and the sky was hidden behind a thick blanket of clouds. My office overlooks the pond that flanks the north wing of the hospital, and the view of the leafless trees and frozen creek provided the backdrop for our conversation. The hospital was nearly empty that Christmas; as my secretary was away on vacations, I brewed two cups of espresso and held one out to Dr. Lightman, who accepted it gratefully as he shed his coat and gloves. I turned on the oil heater and pulled it close between us, its glow giving me an inkling that it would be a long and lurid talk.
The psychiatrist told me that he himself did not understand the repetition of his son's symptoms, whom he admitted having abandoned in the hands of a “symbiotizing” (his term) mother who did not let him grow up. He argued that this had been the main reason for the divorce, although he said it while gesturing at his wedding ring, which gave him away in another sense. His late arrival at the hospital, without visiting his son before looking for me, gave reason to suppose that he was not a very present father.
I was disappointed by the interview. Perhaps the father did not know who his son was, or he was overlapping the mother in an attempt to get rid of the medical and economic problems that these infections caused him. He was very insistent on ruling out a “congenital lowering of defenses”, to which I responded that we were doing our best to pinpoint the diagnosis as soon as possible. I dismissed him at the edge of Travis’ bed, under the conspicuous gaze of his ex-wife, who seemed to be protecting her son from a monster.
Finally, after Boxing Day evening, which we usually celebrate with my English in-laws, I received a call from Stella at home. Although my wife knows her and they have mutual respect for each other, we have an unspoken agreement not to disturb on days off; that’s what on-duty residents are for.
– Stella, this is unusual, what is going on?
– I'd better tell you in person, Nathan, and excuse me for interrupting your break. Do you have a time to meet me at the pavilion?
The car ride was complicated because the dirty snow had accumulated on the streets and we were suffering from a public servants’ strike, but my friend’s tone was dramatic enough not to postpone our confrontation.
I arrived in fifteen minutes and parked my car next to a rotting pile of garbage in front of the hospital. It had stopped snowing, but the air was thick, and it was hard to walk because of the slippery sidewalk. Stella had coffee and donuts ready on the table in our meeting room. Cindy and a newly hired orderly, Jason, were chatting quietly when I walked in to greet them. I tried to hide my annoyance at the haste of this meeting.
– It’s the mother, Dr. Grinberg, as I suspected all along. Stella usually addresses me more formally when we are in front of the paramedics, perhaps to preserve our privacy and the respect of others.
– What do you mean, Chief? I don’t understand.
– It is she who inflicted these wounds on her son. First by injecting him with her urine, then by smearing excrement on the abrasions she herself inflicted...
–Do you have proof of this? It's a very serious accusation, you know that don't you? - I warned them, now addressing the three of them, who looked at me without blinking.
– We haven't just seen it, Nathan – the tone softened, back to our friendship. – These two boys filmed it last night with their cell phones. We had known for days that she was hurting him, and I asked them to pay attention in the early morning hours. Yesterday we caught her in the act, and I wanted to warn you because the police are on their way.
I felt humiliated and deceived, but I restrained myself. The situation compelled us to act. While Travis’ mother was being kept separated from Travis at the head nurse’s station, I made calls to Tennessee hospitals. This time I was not surprised by the response. The Memphis and Nashville ERs had alerted to the case, a Münchhausen Syndrome by proximity that the father had refused to accept and had covered up by helping the mother flee the state. The FBI had been notified a few months ago but had not considered it a priority and the report was held up in bureaucratic red tape, which had prevented the boy from being rescued.
– Thank God you have them in custody, – the administrator of Nashville General Hospital, where the culprit had been removed for mistreatment two years earlier, said before hanging up.
Federal agents showed up later to take over the case. By then, the social worker had set the precedent and our health administration was mobilizing to provide a crib for the little boy, who kept sobbing and asking to be returned to his mother.
From my window I watched the ex-nurse being loaded into the squad car. She was standing tall among the FBI detectives, resolute, as if she had nothing to confess, perhaps smiling in the blizzard. After all, mother knows best.
* All names and locations mentioned in this column are fictitious.
