Your child is in the hospital, and you're blanketed by guilt - vital signs - column

I have this very distinct memory from the first month I ever worked in an emergency room. I was a third-year medical student, and I had no idea what kind of doctor I wanted to be. A father and son had come into the emergency room together, and the triage nurse had scribbled ''sp/MVA'' on their form. A triage nurse is the person who reviews the patients coming into an emergency room and makes the rapid decisions: absolutely urgent (bleeding to death in front of you), reasonably urgent (in some pain), not so urgent (headache for the last three days). And sp/MVA, for those of you who didn't guess it immediately, means status post motor vehicle accident. So this father and son had been driving along in their car, and the car in front of them had stopped short, and they had banged into it. The father had been thrown against the steering wheel. The son, who was about ten, had hit his head on the windshield. They were both shaken and bruised, but neither was badly hurt. The father was refusing to let any doctors examine him until he had made sure that his son was all right.

The pediatrician examined the boy, checking out his head and then his whole body for any bruises or evidence of injury. He wrote down everything he saw, knowing that his medical notes could well be part of a court case or an insurance settlement. He asked a series of questions about the accident. Finally, gently, he asked the boy, ''Were you wearing a safety belt?''

''No,'' said the boy. And suddenly, the father, who had been reasonably calm, grabbed my arm and began asking me over and over, ''Is he going to be all right? You can tell me, is he O.K.? Is anything wrong with him? Is he going to be all right?'' His voice escalated toward hysteria.

It was my first exposure to acute parental guilt. Now that I'm doing a residency i pediatrics, I see parental guilt of one kind or another almost every day. Now that I have a child of my own, I've felt twinges of it myself. Maybe because I do have a child, I recognized it right away when I heard it coming from that father. What he was saying was this: By asking about the seat belt, you're reminding me that it's all my fault that my son is hurt, and I can't stand it.

An issue that you don't have to deal with in pediatrics (or at least not all that much) is the issue of so-called self-inflicted diseases. I'm not talking about suicide attempts here, but about the sequelae of such habits as drinking and smoking. In adult medicine, you spend a lot of time taking care of lung disease and heart disease in long-term smokers, taking care of debilitated people with drinking problems and liver disease. In pediatrics you don't. You may take care of a two-year-old who swallowed the contents of a bottle of aspirin, or a six-year-old who fell out of a tree, but some doctors find these kinds of things easier to cope with. The whole idea of self-inflicted disease as a separate category is largely fallacious; many if not most diseases are the products of the life the patient has lived. If you live in a certain place, eat certain foods, have a certain number and type of sexual contacts, work at a certain job, handle stress in a certain way -- then you're at risk for certain diseases. Still, in pediatrics, we have the luxury of viewing most of our patients as innocent victims.

And usually their parents also see them as innocent victims, andthat means they look around for the guilty party. Who left that two-year-old unsupervised, who left the aspirin bottle within reach, why didn't it have a childproof cap? Who let that six- year-old climb the tree, why wasn't anyone standing by to catch her if she fell?

There are times when, as a pediatrician, you can try to alleviate parental guilt. When I worked in the newborn intensive care unit, I often found myself sitting down for meetings with parents of very sick newborns. I would try to explain: This is what's wrong with your baby, this is what we're doing about it, this is what we think will happen next. And always in that first meeting I'd find occasion to say, it isn't your fault that your child is sick. It isn't your fault that your child was born early, not your fault that he developed an infection, not your fault that her heart isn't properly formed. And then, after I'd said this, people would ask me specific questions: My father said the baby was premature because I worked too hard right before he was born. Is that true? Is it because we had sex while I was pregnant? You know, I had a cold a week ago and I took some cough medicine -- could that have affected my baby's heart?

Almost everyone had some secret fear, some carefully worked out chain of causation. Almost all the parents were blaming themselves. And an astonishingly large number had had relatives or friends accuse them. So I would say, over and over, as many times as seemed to be necessary, no, it isn't your fault.

But what about when it is? What about that unsupervised two-year-old, that bottle of aspirin with the easy-open cap? There are times when my job isn't simply to reassure. There are times when I'm required to worry about child abuse or neglect, to question parents closely about exactly how some accident happened, why it wasn't prevented.