Tuesday, April 24, 2007

The mysterious noise – An [auditory] patient encounter

[Disclaimer/warning: This is a long entry. Sorry. Scroll down for easier-to-read, bite-sized excerpts...]

I had never heard a noise quite like it before.

I was outside the waiting room in the parking lot of of of Swaziland’s many Public Health Units (PHUs), and it came from inside.

I could tell that the mysterious noise was the whine of a crying child, probably around two years of age.

The age estimate was based on the easy-to-recognize monotone quality of the cry, the type that betrays the fact that the child is actually not too terribly upset, but does not wish to admit it. Such lack of intonation is uncommon in a much younger baby, who typically cries sincerely, if not passionately, for want of something. The really young ones hit several tonal variations and several impressive notes. They throw in frequent crescendos. If truly peeved off, they sometimes will even naturally soften into a decrescendo before really blasting off.

Quite an intense, operatic communication style, especially for such a small creature.

But, as we all know, babies eventually develop personality and learn that they can pretend that they sincerely need something, and adults scurry here and there to find out what it is.

During my first year of pediatrics training, I used to fall for that.

Then, in a moment of on-call late night clarity, I realized that these mimickers had what card players call a “tell”, basically an unwitting giveaway that one is bluffing.

If you identify the tell, your opponent is busted.

For me, this was one of the primary epiphanies of my medical training (#7, actually). The other six are:
(1) It is easier to say “I don’t know” than to make an educated guess and be wrong.
(2) It is easier to sleep in really baggy scrubs than the more stylish, “fitted” ones.
(3) Circumcisions do not hurt newborns [that much] if they are sucking on a pacifier dipped in sugar water.
(4) If you learn who to ask for help and when, it is possible to practice very good medicine under most any circumstance.
(5) San Francisco does actually have a reasonable barbeque place—Big Nate’s—that delivers to most area hospitals.
(6) Kids pee, poop and reason with an unpredictable (in)discretion.

Though I do not want to give up too many trade secrets willy-nilly (for surely someday I can sell them), those were freebies. I will even elaborate on the seventh:
(7) When a 1½-2 year-old wants to put on a demonstration of being upset, they tend to choose a note, often in a minor key (D and E flat are favorites) and they stick with it, interrupting the din only to breathe.

Oh, another thing. A fake cry is usually slightly nasal, for it takes less effort and breath than making a proper, back-of-the-throat, cry.

Go ahead. Try it.

In any case, I heard this noise when walking into the crowded PHU waiting room

The purpose of our visit was PMTCT.

PMTCT stands for “prevention of maternal to child transmission [of HIV],” and, if used successfully as a public health strategy, can put me out of a job.

Though I would like nothing more than to end my pediatric HIV career early, there is no danger of that happening any time too soon, as a pitiful ~10% of HIV+ pregnant mothers receive PMTCT drugs in Sub-Saharan Africa.

Back to the main topic of this story: the ~2 year-old’s cry.

It was a D flat, more or less, mostly originating from the nostrils.

I had heard plenty of nose-heavy D flats, but this particular cry had something unique about it.

It was in staccato, as if the nearly two-year old were operating a low-frequency jack-hammer.

If that is hard to imagine, and you have been to an African bus station/combi stop, it was similar to the sound of an eager driver rhythmically abusing his horn to declare either “all aboard” or “get the hell out of my way”. (I was wandering around Mbabane’s bus ramp the other day in a futile search for a watch battery, and should probably dedicate an entire entry to that entropic parking lot, for it is rife with bloggable imagery and chaos.)

In any case, I initially thought the jack-hammering-horn-like-mystery noise might be the result of a mother firmly patting the back of a baby throwing a fake temper tantrum, but non-abusive back-patting should not knock the air from a toddler’s lungs.

My expectations mounted as I finally stepped in the door of the waiting area.

After my eyes adjusted to the indoor half-light, I scanned the room. Mothers and babies were everywhere. Babies were breastfeeding, a sleeping, and having diapers changed, mothers were breastfeeding, dozing, and changing diapers, and a handful of children, siblings I suppose, were jockeying for attention from their respective breastfeeding, dosing, diaper-swapping mothers.

When I at last tracked the cyptic honking sound, I was disappointed in myself.

I should have known.

Babies here, when are not eating, are with rare exception attached firmly to their mothers backs. This is especially the case in space-limited waiting rooms, in the interest of crowd-control.

When I was a pediatric resident, I completed an outpatient rotation in one of San Fransico’s more frou-frou private hospitals. Intrigued by the no-holds-barred buy-loads-of-stuff-for-my-baby culture of my patients’ parents, I did some research into the locally-marketed consumer goods for new mothers (and fathers).

One of the items I investigated was baby-carrying devices.

There are several models, ranging from ~USD$30-3 trillion. One can fancily strap a baby to his/her front, back, or side. The baby can face forward or backward. There are frills galore and several fashions, fabrics, patterns and colors to choose from. The “Baby Bjorn” seemed to be a West coast favorite. (It is a Swedish brand with a tradition of high quality baby-carrying since 1961.)

In Swaziland, the popular choice for the purpose of lugging babies is an old blanket or bath towel tied in a knot.

No doubt the Baby Bjorn comes with an instruction booklet, so here is one for the Swazi version: Imagine getting out of the shower and wrapping a towel around the waist, except wrap it a bit higher while bending forward, clothed, with a baby laying prone on the back. Ensure that the fabric is snug around the tike’s bum, and tie a simple but firm square knot in front.

The babies love it. If they do not, retie.

The baby making the mystery noise was tied in the manner described above, with a textbook wrap and knot.

Still, he cried.

I believe that he had just had his blood drawn, or maybe he had peed himself. Whatever the case, he had gotten over it but was still milking his audience for more attention.

Now for the punch line.

In an courageous but ineffective attempt to quiet the noisy strapped-in baby, the mom was actually jumping up and down.

Not just bending the knees, but really hopping. Approximately a 5cm vertical, I would say.

Each time she hit the floor, it knocked the air out of the child’s lungs.

Come to think of it, the impact itself may explain why the child continued to half-heartedly protest.

Or, maybe he liked it, and didn’t want her to stop.

In any case, for those of you wishing to invest in a device to carry a infant or toddler, if you can afford an up-scale high-tech San Francisco Pacific Heights Swedish model, feel free to invest.

If they have one with a suspension system, spend the extra dough.

Then, when your two-year old is pretending to cry, you can hop about all you want.



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