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The Exterminator

This article is part 2 of 2 in the column A Pediatrician's Perspective

I am no longer surprised. The presentations are varied. ‘‘I think I have wax in my ear.’’ ‘‘He keeps tugging at his ear.’’ ‘‘I hear a buzzing in my ear.’’ Sometimes it’s the shocked look one of my new pediatric residents gives to me, stating, ‘‘I think I see a bug in his ear.’’ By the end of the third year of their residency, regrettably, this surprised reaction fades as cases of ‘‘cockroach ear’’ become commonplace.

In the past 10 years of practicing pediatrics in a large academic center, I have become the ‘‘go-to guy’’ for the inglorious role of ear roach removal. The first time was as a first-year pediatric resident examining an unsuspecting 5-year-old boy for his health maintenance visit. As my untrained hands pulled back his pinna and placed the otoscope speculum into his ear canal, I was astonished to see what I thought was a bug inside his ear. My attending identified the insect with an unsurprised glance and casually mentioned to me that ‘‘we see this all the time’’ as he instructed me on his method of choice for removal, irrigation. As the insect flowed out of the ear canal onto the paper towel that I was holding underneath, I glanced at the boy’s mother and was met with a despondent expression. It might have been her face that made me feel obligated to become proficient in this technique.

Over time I have developed various removal techniques through trial and error, literature searches, and anecdotal reports. The goal is to cautiously remove the pest so as not to tear its body in half as it clings to the walls of a child’s ear canal. I have used water irrigation. I have used lidocaine, which serves the dual purpose of numbing the ear canal while simultaneously killing the cockroach. I have used alligator clamps, small angled metal pliers used to grip the body and pull slowly. Depending on the age of the child, his or her demeanor, the level of discomfort, and the viability of the insect, I generally start with irrigation and use the alligator clamps as a last resort to avoid dismembering the insect within the confines of the ear canal.

As I sit on the examining room table with the child, I study his face to try and predict his reaction. Most children are trustworthy, unaware of their predicament. Some children become withdrawn, some fearful. I talk to the child the whole time, complimenting his bravery as other signs of his home situation come into focus. The dirty socks. The plaque-laden teeth. The preoccupied look on his parents’ faces as they seemingly contemplate larger questions, such as how to make ends meet.

I have learned to wait until after the bug has been removed to inform the family what the foreign object actually is. I sometimes tell white lies so as not to contribute to the humiliation and powerlessness I have often seen when families learn that a cockroach was living inside their child. ‘‘I’m removing some ear wax,’’ I’ll tell a mother as I quickly hide the bug from her unsuspecting eyes. ‘‘This could happen to one of my children as well.’’ Or the tragic factual statement that can take the sting out of the situation—‘‘this happens all the time.’’

As a pediatrician working in one of the most indigent areas in Philadelphia, I regularly see poverty’s unrelenting toll on the children and families we serve. Malnutrition (both overweight and underweight), lead poisoning, teen parenthood, constant stress, interpersonal violence, covert racism, and disparities in education that writer Jonathan Kozol has termed, ‘‘The Apartheid of American Schooling.’’1 Sometimes I feel I have grown almost immune to the social context for my work. But the visceral impact of staring into an unsuspecting child’s ear and seeing the backside of a cockroach staring back at me is something I will never get used to.

It’s not the bug itself. I have had to get used to dealing with the insect. It is the circumstances that lead an insect to find a home inside a place designed to protect the delicate inner ear that I find so disturbing. Does the family live in a home infested by these insects? Is the child so sleep-deprived from a chaotic home life that he didn’t awaken as the roach climbed into his ear? Is it a level of tolerance that has developed in a child, used to the pains and discomforts of hunger and stress, that enables an insect to avoid the typical defenses a child from more comfortable means might employ? Relative to the stresses of day-to-day life, is a bug in your ear just a minor annoyance? I think it must be a combination of all these factors.

In the midst of debate over large issues related to quality and access in health care, the tiny legs of another arthropod bring me back to the realities of this day, this child, and this family’s circumstances. The cockroach in this child’s otic canal becomes a symbol of the obstacles that he will surely face in life.

I cannot personally exterminate poverty, injustice, and health disparities. These issues will take many socially conscious individuals and courageous politicians who are unafraid of grappling with lobbyists and special interests. But I can continue to do everything I can, for every family I care for. I can continue to be the go-to guy for removing another insect from a child’s ear while trying to maintain the precarious dignity of the child’s family.

REFERENCE
1. Kozol J. The Shame of the Nation: The Restoration of Apartheid Schooling in America. New York, NY: Three Rivers Press; 2005.

This article first appeared in Academic Pediatrics (2010).


Daniel R. Taylor is an Associate Professor of Pediatrics at Drexel University College of Medicine and general pediatrician at St. Christopher’s Hospital for Children. Dr. Taylor is also course director of Community Pediatrics and Child Advocacy at St. Christopher’s Hospital for Children and is the Medical Director of the medical legal partnership at St. Chris.

Dr. Taylor is the founder of the Children’s Advocacy Project of Philadelphia (Cap4Kids) which is an on-line resource directory for providers, child advocates and families to find resources in their community to help address various social determinants of health that can affect the health, safety, and long-term outcomes of the children we serve.

Dr. Taylor’s passion is children and their families especially those that are underserved, living on the fringes, and those most vulnerable. His impact on this population ripples throughout the pediatric community nationwide.


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