KIDS routinely inform me that the tooth fairy gives them ‘at least’ 5 dollars. Maybe even $20 for their very first. Not only is the tooth fairy boundlessly generous, she is also inconsistent. Children of divorced parents report getting$10 at Mom’s house and a Star Wars action figure at Dad’s. But ultimately, I tell myself, those 10-bucks-a-tooth kids will develop character flaws, aimlessness, obesity (it buys a lot of junk food), and a pill-cabinet full of medications like Xazaxa.

As a child I remember awakening, newly toothless, to find some change under my pillow. Exactly how much I can’t recall, although I’m certain it was a sub-dollar amount. But what can a youngster of today buy for 50 cents? Certainly not a comic book, or even a chocolate bar – the staples of my youthful tooth-related bounty. So, I eventually settled on giving my own children a buck. Inflation was just a cover story, though. My real reason for choosing this amount was to build character. A dollar seemed large enough to say ‘you and your teeth are loved’ while simultaneously being small enough to prevent my kids from growing up soft. In 2011, the average American tooth fairy payout was $2.60, so I happily remained a few standard deviations below the norm. When we accidently dislodge a permanent tooth in the operating room, we call a lawyer. When we knock out a aby tooth, though, we cheerfully pass around a specimen cup for tooth-fairy contributions. Ditto for when we perform a planned, preintubation loose-toothectomy. A dollar bill is also my donation in these situations. A few years ago, I discovered something wonderful: gold! Sometime in the 2000’s, the US mint began making gold-colored dollar coins. One has Sacajawea, others have past presidents. It’s actually just ‘manganese brass cladding’ that makes them look so pretty – but don’t tell the children. My kids now receive a shiny, apparently-gold coin that can be spent or saved, according to their current financial goals. I feel great about this arrangement and – judging from their early-morning gap-toothed expressions of wonder and excitement – so do my kids. Bank tellers, on the other hand, are clearly annoyed. When attempting to exchange a$5 bill for five gold-colored dollars, my success rate is less than 50 percent. The teller usually suggests that I try the bank across the street. A bank, it should be said, that did not take the bail-out money.

***

The story of how I discovered gold is poignant. I was going through a preoperative history and physical with a 6-year-old boy. Urethral stricture, I think it was. Or maybe hernia.

“Any loose teeth?”

The boy shook his head no. “One just fell out last night.”

“Wow,” I remarked, trying to sound suitably impressed. “Did the tooth fairy leave anything?”

“Yes! A gold dollar!”

With a national debt that can only be written using scientific notation and the concomitant surge in gold prices, a quick mental calculation suggested that his tooth might be worth upwards of $500. This struck me as quite a lot – even though I harbored suspicions that these parents were frivolous$10-per-tooth-ers. His father caught my uncertain expression and said, “It’s a regular dollar coin, but it’s gold-colored.”

“What a great idea,” I said. “Where did you find that? Can you get them at the bank?”

At this point, there was a long pause. I realized my mistake. Finally, the father said, “I don’t know where the tooth fairy found them – maybe she makes them herself, or maybe she found a buried treasure….”

***

Anesthesiology is rife with mistakes waiting to happen. A moment of inattention, poor communication, or a syringe swap. Misjudging the shortness of a chin, the severity of a chronic illness, or the tally of blood-soaked sponges. But really, few mistakes compare to killing a dream. This is the story of how, with a single stupid comment, I almost destroyed a child’s belief in the tooth fairy. Although I console myself that his quick-thinking father smoothed over my mistake, I still feel terrible about the incident.

Although we adults consider the tooth fairy to be demonstrably silly, young children do not; their thought processes differ qualitatively from our own. Call it ‘magical thinking’ or ‘preoperational’, these mystical beliefs may seem to be nothing more than childish naïveté and idealism. But there is another side to the story. Children’s ability to insulate themselves in fantasy while hospitalized can also be utterly pragmatic.

To be blunt, my young patient just doesn’t get it. He doesn’t know why he’s in a hospital, what a hospital is, what an operation is, who all these people are, or what will happen to him before, during, or after ‘surgery’. Frightened, powerless, and confronted with great gaps in understanding, he has only one weapon: belief. He believes that whatever happens in the hospital today, by tonight he’ll be home eating dessert and watching TV just like normal.

For adults, the idea of a favorable surgical outcome is not just a belief, but rather an intellectual concept that can be anticipated, understood, rationalized, and discussed. To an anxious young boy who has not yet reached this stage of developmental maturity though, the idea that ‘everything will be OK’ is really just as plausible as the tooth fairy. As anesthesiologists, we have the responsibility safeguard our patients’ beliefs, just as we do our patients themselves.