A darkened radiology reporting room was the unexpected circumstance that led to my encounter with a case that I’ll never forget.
I was a senior registrar in paediatric emergency medicine and I’d arranged to sit in on a Monday morning X-ray reporting session. I wanted to get more confident at spotting subtle fractures and the tell-tale signs of disease on x-rays and my friendly paediatric radiology colleague was a mine of information. With strong black coffee in hand, we’d go through the X-rays and scans of patients who had been seen in the emergency department over the weekend.
In the high-pressure environment of a busy NHS emergency department, experienced doctors spend an average of just eight seconds reviewing their patient’s X-ray films. Whilst the vast majority of X-ray abnormalities are picked up, subtle changes are sometimes missed, so films are reviewed and reported in the cold light of day by an X-ray specialist – and that was what I had joined my colleague to do that morning.
A young teenager* had been seen in the emergency department the previous Friday evening with a stab wound to his shoulder. The story given by the boy was that he had been sitting on his own in a local park when he had been accosted by a group of older boys that were unknown to him. They had asked him what he was doing there, whereupon one of them had drawn a knife. Before he managed to escape, he was stabbed in the chest.
We scrolled through the images one last time to check that nothing had been missed… and then we both saw it at the same time.
A passer-by had called for emergency services and with his t-shirt soaked in blood, the boy was brought by blue-light ambulance to the children’s A&E. On first assessment it looked like the knife had caused a superficial injury to the left shoulder but the wound was perilously close to the chest cavity and the attending doctor organised a CT scan of the boy’s chest to ensure that the blade had not punctured the lung. Thankfully the scan showed no lung injury. His wound was sutured closed and he was admitted for observation overnight on the children’s ward. The case was discussed with police and children’s social workers and the following day he was allowed home to recover.
Two days later in the reporting room, the radiologist and I sat and looked though computer-generated X-ray cross-sections of the boy’s torso. There were plenty of dressings to be seen around the left shoulder wound but otherwise everything looked reassuringly normal – dark lungs full of air, a bright white spinal column and light grey heart muscle filled with blood. We scrolled through the images one last time to check that nothing had been missed… and then we both saw it at the same time.
There was something very unusual in the boy’s stomach. Nestled beneath the left half of the diaphragm, only a part of the stomach was visible but in it was the unmistakable contour of a foreign object around five centimetres in diameter – something that would probably have been swallowed within an hour of the scan being taken.
This was a typical scenario of ‘body stuffing’ which occurs when people about to be apprehended by others swallow or conceal packets of drugs inside the body in order to avoid detection. It can be extremely dangerous – if the drugs are not packaged properly, they can be absorbed by the body in huge dosages, with sometimes fatal consequences.
Our patient had had two lucky escapes from potentially fatal threats to his life. Unfortunately, other children have not been so lucky. Serious youth violence is constantly in the news, with young lives ruined on a regular basis.
The boy was recalled urgently to hospital. His vital signs were checked and found to be normal and there were no signs of intoxication. Repeat x-rays unsurprisingly showed no foreign bodies, which usually take less than 24 hours to pass through the digestive tract. He denied swallowing anything despite the evidence from the CT scan and was discharged home to be followed up by the social work team.
Our patient had had two lucky escapes from potentially fatal threats to his life. Unfortunately, other children have not been so lucky. Serious youth violence is constantly in the news, with young lives ruined on a regular basis. Lazy commentators jump to criticise poor parenting or denounce these children as feckless youth – yet cannot offer any solutions to this growing problem. For paediatricians wanting to reduce this burden of death and despair, we must look beyond the confines of healthcare and be prepared to challenge our political system.
Vulnerable young people have been exploited by organised criminals since Dickensian times but it’s a travesty that the conditions that enable such brutal exploitation are still functioning so well today. The UK government’s policy of austerity has been devastating for the services that should be providing opportunities to vulnerable children. Social workers tasked with supporting young people in the same circumstances as our patient are overworked and have precious few options to help them. Schools struggle to help disruptive children and too many end up being permanently excluded. Pupil referral units, Youth offending teams and probation officers have all experienced a lack of government funding.
Too many health professionals shy away from being involved in politics, but we are missing a great opportunity to create change.
In contrast, the economic climate for organised crime is buoyant. The government’s policy of prohibition of drugs – the Misuse of Drugs Act is 50 years old this year – has artificially created an illicit drugs market which is worth approximately £10bn in the UK today: money that funds and sustains networks of powerful and brutal organised criminals. With so many people living precariously, with little hope and no political agency, it’s no surprise that many end up perceiving opportunity inside these criminal networks.
Prohibition of drugs and austerity are the political pathologies that caused our patient to come to harm and it is the political arena in which we need to act.
Too many health professionals shy away from being involved in politics, but we are missing a great opportunity to create change. We care, we have integrity, we are trusted by the public, but most importantly we bear witness to the reality of people’s lives. We owe it to our patients to speak out.
Alex Armitage trained in paediatric emergency medicine in England and now works as a consultant paediatrician in Shetland. He was a parliamentary candidate in the most recent general election and actively campaigns on many issues including drugs policy reform, migration and climate change.
- *. Names and other information that could identify someone have been changed.