The Kiss of the Bat

Bat bites are difficult to see and may not be felt.

- CDC, Div. of Public Affairs

The chief concern was “bat bite.” There was no mystery in those words. The mystery began when the concern was personified, as in, “A bat bit my daughter.” That’s medicine. 

 My patient was eleven years old, her red hair woven neatly into braids. There was a prancing unicorn on her long-sleeved tee. She was a tween: eleven, but an older self hovered nearby to replace her at any moment. She thought before she answered “yes” or “no.” When I asked what she was studying in school, she replied, “Amerigo Vespucci.” She didn’t swing her legs from the stretcher; she kept them folded at the ankles, and completely still.

Her mother was immaculate in a white sweater, wheat-colored hair swept back in a bun. The patient’s sister, a six-year-old, wore sparkly sneakers and a designer jacket. She snuck peeks at me over the top of her tablet. 

“So,” I said, taking my seat next to the girls’ mother. “Nina was bitten by a bat?” 

The woman knitted her eyebrows. “I think so. But we’re not really sure.”  

I nodded. In the emergency department, there is often uncertainty about what has taken place. Lighting and visibility are never perfect. Things happen so quickly they are never fully seen or understood. Emotion complicates recollection.

Here is the story Nina’s mother told me: a bat had been found dead in a corner of the family’s barn. This wasn’t just any barn, but a renovated barn, with a built-in stage, where the girls liked to put on plays with kids who lived nearby. The night before the bat was found, they put on Hansel and Gretel, but Nina didn’t participate. “Why not?” I asked. “We always do Hansel and Gretel,” said Nina, rolling her eyes.

 “So, did you see the bat while you were watching the play?” I asked Nina’s mother.

 “Not exactly,” she said. “But as I think back, I remember it being there.”

 “How so? Did you hear it? Feel it?”

“I just remember a sort of shadow. We were lying on our bellies in the barn watching the play, and I had a blanket around me, but Nina didn’t. And there was this shadow.”

“I’m never cold,” said Nina. Then she added, “I don’t need a blanket.”

“And I think, because she was wearing her PJ’s, which are short, and she had no blanket, the bat must have bitten her.” When Nina’s mother said short, she wrinkled her nose. She was, I thought, bothered by their shortness.

“Did you feel something bite you?” I asked Nina.

“No.” She shook her head.

“But it did bite her,” said her mother. “At least I think it did, because it left a mark.” And she gestured for the girl to show me.

Nina stood up slowly, resentfully it seemed, and pulled her purple leggings up over one knee, revealing two little marks in the square of flesh behind it. The marks could have been anything: eczema, two bug bites, parallel scratches. But whatever they were, they were undeniably present. The skin had been, in the language of medicine, compromised. 

Nina’s mother pointed a perfect beige fingernail at her daughter’s wound, then went completely pale and put her head between her legs in a crash-landing position. “I’m sorry,” she said, hyperventilating from the depths below the chair. “It’s just so scary. I’m so afraid she’ll get rabies.”

“I saw the bat,” the six-year-old piped up.

I turned to look at the little girl. 

Nina rolled her eyes. “Corliss, you didn’t see anything.” She pulled her pants leg back down and returned to the stretcher.

“I did,” said Corliss, the six-year-old. “From the stage.”

Her mother, with difficulty, righted herself. “With a pillowcase over your head?” She turned to me to clarify, still very pale. “Corliss was a gingerbread person.”

“The eyes were cut out,” Corliss countered. “I could see. I saw the bat fly into the barn. It flew all around the room, and flew right past Nina, and bit her on the leg.”

“Really?” I asked. It seemed unlikely that she’d seen all this in the dark of the barn, from under her pillowcase, mid-performance.

“Yes.” Corliss leaned forward, her dark eyes burning, obviously feeling the weight of her testimony. 

“So why didn’t you tell anyone?” the mother demanded.

“Because I didn’t want to stop the play!” Corliss picked up her tablet again.

Just then, Nina’s father walked into the room. He was clearly coming from work, in a business suit and shiny black shoes. I introduced myself.

“Hi Doctor,” he said. “Nothing bit her, right? Tell me we can go home.”

Postexposure prophylaxis should be considered when direct contact between a human and a bat has occurred, unless the exposed person can be certain a bite, scratch, or mucous membrane exposure did not occur.

- CDC, Div. of High-Consequence Pathogens and Pathology

There are many types of uncertainty in medicine. First, there is scientific uncertainty. There are limits to what is known about the human body. Second, there is diagnostic uncertainty, because no test is perfect, and there are many conditions for which there is no test. But the richest uncertainty, to me, is the uncertainty in the stories my patients tell. This is where the art of medicine lies, and to tell the truth, where the pleasure in medicine lies, too. I enjoy the mystery, the what really happened?

ER stories are representations of events that are deeply personal, that happened to the patient at a place and time outside the examination room. As physicians, we pass these stories on to one another scrupulously, as though they were the pure truth. In fact, they are only an approximation, re-constructed through layers of emotion, held together by the patient’s own assumptions about the world, and dragged through the fog of human memory. I don’t know if the bat was at the play. I don’t know what Corliss saw. Nina had two little marks behind her knee, and I don’t know how she got them. I’ll never know.

Some days we are early explorers, like Amerigo Vespucci, unsure of where the world ends. 

I presented all that was certain to the family. A bat doesn’t need to bite you to give you rabies. It can infect you just by brushing up against your mucous membranes. If it’s possible a bat has brushed up against Nina, she should be given the rabies vaccine and immune globulin. 

The man in the suit sat down next to his wife. He was irritated; he looked tired in the bright lights and palpable din of the ER. “What the hell is a mucous membrane exposure?” 

Both girls giggled at his language.

“It means the bat’s saliva has touched your eyes, nose, or mouth,” I said. 

“A kiss,” said Corliss, batting her eyelashes. “It’s the bat kissing you!”

“Shut up,” said Nina. Now she looked angry.

“Ugh,” said the mom. “That’s awful.” She looked green. Was it the word kiss? Or the word bat? Or simply not knowing what would happen next to this girl on the verge of adolescence?

“Let’s test the bat,” proposed the father.

The mom shook her head. “Rufus tore it apart,” she says. “There’s really nothing to test.”

The father cursed the family dog. Then he said, “So let’s just do it. Let’s get the medicine so we can get out of here.”

“Do what?” said Nina, suddenly panicked. “Am I getting a shot?”

“I knew it,” said her mother. “You think it bit her.” Tears slid down her face.

So much ink is spilled over the pain of childbirth, it has come to symbolize the primary pain of motherhood. But the real pain is in the love of the child. The more you love, the more you are afraid to lose them. Every moment of sickness, or its potential, rips through your heart like a screeching animal. The bat is never just a bat. It is the unknown, the thing that lies in wait.

I picture that night, the dark, the barn, the children on stage, and the one who abstained, lying on the floor, a latent girl, red hair in plaits or maybe loose, and shorts too short. She is watching, waiting for her own time. 

A strange creature that nobody will ever truly know flies through the air. 

All I had was medicine, and that’s what I used. I don’t know if I saved her from rabies, or just from our fear of it, or from nothing at all. But I do know the vaccine and several shots of immunoglobulin made everyone feel better. Everyone except Nina, who was furious. I’m sorry for that. I hope that one day she’ll understand, because she’ll be a mother or a doctor. Medicine was all we had. It was a modest bulwark, a token really; a doctor’s last stand against the kiss of the bat.

-Rachel Kowalsky

Rachel Kowalsky is a Guatemalan and Ashkenazi pediatric emergency medicine physician from New York. She loves to explore hospital stories and use her writing to bear witness to the many stories she has seen unfold there. Her work has been published, or is forthcoming, in Orca Literary Magazine, JMWW, JAMA, and the anthologies “Real Life of a Pediatrician” and “Perspectives.” You can read more about her at https://www.linkedin.com/in/rachel-kowalsky-863a0a9b/ or find her on Twitter @rachel_kowalsky