Monthly Archives: November 2011

Teen Pregnancy

“We Were Hoping”

–Patricia J. Harman

At 4:00 p.m. Dee Telemann is fifteen minutes late for her 3:45 appointment. It gives me a chance to return a few phone calls. It’s a familiar last name, Telemann. She’s probably the daughter of my patient, Sara, who lives on a farm out on Snake Run.

At 4:45, an hour overdue, the patient arrives with a boyfriend. Dee sits on the edge of the exam table, a petite blond with the smooth tan skin and high cheekbones of a lot of Appalachian women. She’s dressed in jeans and a low-cut white blouse. Her young man slouches in the gray guest chair in a T-shirt with some kind of motorcycle logo on it. He wears tight, worn jeans, a creased baseball cap, and run-down cowboy boots.

“Hi, Dee, I’m Patsy Harman, nurse-midwife and GYN practitioner.” I reach out my hand and note the girl’s firm grip.

“This is my boyfriend, Jerry,” Dee says proudly. “My fiance.”

Jerry nods and meets my eyes. He’s a small guy, but muscular, about five feet nine with light brown hair curling over his shoulders.

I glance at the birth date on the patient’s chart. She’s sixteen. He could be eighteen. Because she was late, I’d been prepared to start off the encounter with a lecture about the importance of coming to appointments on time, but curiously I skip it. “So Dee, what brings you here today? Are you having difficulties?”

“Oh, no real problems. . . . We’re just pregnant. We did three home tests.” Her face glows and she looks at Jerry for confirmation. He grins but then quickly pulls a shade over his joy.

“So, is this a good thing that you’re pregnant? A happy thing?” From the look that has just passed between the two lovers, it’s obvious.

“Oh, yeah, we were hoping it would happen. The only problem is, we don’t have any money or a medical card. I was hoping you would take care of me until I can get one. I wish you could deliver our baby too, but the receptionist said you don’t anymore.”

“Do your parents have health insurance?”

“I don’t know, but if they do, it wouldn’t cover me. I quit school.”

I want to ask why she dropped out. She seems smart enough, but I stick to the subject. There will be time for that later. “Have you applied for medical assistance?”

“Not yet. We need my mom’s signature or a health care provider to verify that I’m pregnant. I was thinking that could be you. . . . We need a due date too, on the form.” She stops. They all stare at me.

“Does your Mom know you’re pregnant?”

“Not yet. We wanted to wait until Jerry gets his first paycheck from Taco Bell so she’ll see we can be responsible. She doesn’t even know I came to see you.”

Sara Telemann, married, thirty-four, a rural postal carrier, has eight children. I delivered the last one. Will she be happy when she finds out the news? Does she expect her daughter to get pregnant early and often? Or will she be angry seeing Dee repeat the old pattern? I glance over the new OB intake form. The girl is low risk. Like most teenagers, she hasn’t been around long enough to have many medical problems. After a quick physical and a review of the OB packet, I take them all down the hall to the ultrasound room. Standing in the dark, I point out the tiny fetus on the monitor. It’s just eight weeks, but it has arms and legs and there’s a flicker of a fetal heartbeat. Dee has tears in her eyes, and Jerry reaches over to touch her bare foot. I give them a picture of the baby.

In the end, I sign the papers for the medical card and tell the young woman to call the welfare office first thing in the morning. “And I want you to tell your mom about the pregnancy before your next appointment. Legally I can take care of you as an ‘emancipated minor,’ but I would prefer it to be out in the open.” I don’t say, “Because if your mom comes to see me, you may meet one day in the waiting room.”

Dee and Jerry will be good parents. Maybe they’ll be parents of eight like Sara. Their children will be responsible, well behaved, and loving like Sara’s and get pregnant at sixteen or seventeen and have more babies. They’ll work at Taco Bell or Wal-Mart or Select Tech, the telemarketing place downtown. Maybe one or two will stay on the farm or go to community college for nursing or computers.

Standing at the checkout desk, I watch the young couple leave with arms wrapped around each other. They have everything against them—youth, poverty, and lack of education—but they love each other and seem so solid. I think of a mountain covered with trees.

Midwife Harman explores issues about caring for patients who have different values and goals than we do. How do you remain nonjudgmental and respect your patient’s values and goals, which may be different from our own? Have you seen examples where this is done well or poorly? Share those without divulging the identities of those involved. Midwife Harman refers to an emancipated minor. Most states allow providers to provide care to teens without parental permission. What is the value of this law? Have you seen your providers use it? What are the challenges in rural areas? Midwife Harman shares one.

Advertisements

Mashkikiwinini

Thanking Sylvester for His Unconditional Smile

–Arne Vainio

Sometimes teaching comes when you aren’t looking for it or even have the

time to think about it. Recently, one of my partners at Min-No-Aya-Win Human

Services Clinic on the Fond du Lac Ojibwe Reservation in Cloquet, Minnesota,

was off, and I saw one of her patients. Behind and rushed (as usual), I went over

Sylvester’s records enough to know he had metastatic cancer, but his records

were sketchy and I didn’t know much beyond that. Before I went in, one of the

nurses commented that she thought he was in denial about his prognosis. That’s

the expectation I had as I walked into Sylvester’s room and introduced myself. I

expected to see a man desperately holding out for a cure and a miracle. Instead,

I met a smiling man who welcomed me into the room. His eyes were bright and

clear, his smile sincere and real. In spite of that, he was pale, gaunt, and clearly

sick. He had dark circles under his eyes and his words came in short, labored

sentences. His belly was huge, even under his baggy shirt. He was short of breath

just sitting on the exam table.

 

“I would like to know if my cancer is worse. Last year I was told I had five

months to live. This year I’m going to plant tomatoes.” He had no illusions about

his cancer and his prognosis; he knew this was a bad cancer and was spreading.

In the room, I went through his records again and found a CT scan report

from six months earlier from a different medical system. The report stated “interval

worsening” since his last study, with spread of cancer to multiple areas

of his liver, into his abdominal wall muscles, and into the mesenteric area. His

cancer was a GIST (gastrointestinal stromal tumor), which is a rare cancer. It

can either be slow growing or aggressive. Unfortunately, his was very bad and

spreading rapidly. The fact that he had already asked not to be resuscitated was

in his records. There wasn’t much to do at this point except to make sure he was

comfortable and didn’t suffer.

 

He lifted his shirt and I could see the massive tumor under the

skin on the entire right side of his belly. It was tented up at an unnatural angle

and as hard as wood. As I felt around the edges of the tumor, I could feel that

it went deep inside his abdomen and I could feel other smaller tumors.

Sometimes diseases that involve the liver cause ascites, fluid collecting inside

the abdominal cavity. I could not identify this on exam but was hoping for it,

as draining it could help his breathing. A chest X-ray showed part of one of his

ribs eaten away and a mass inside his chest. He accepted this without complaint.

Through all of this, he was smiling and planning his garden.

Dr. Vainio reflects on the lessons that come from our patients. Clinics are busy and we often see patients on a tight schedule. It is easy to be moving so fast that we don’t take the time to get to know patients and learn about their lives and hopes. What lessons did Sylvester have to teach Dr. Vainio? What can we do to help patients end their lives as peacefully and painlessly as possible? Why was Sylvester focusing on his garden and tomatoes?

 

 

LIFEprayerDEATH

–Kathleen Farah

“I prayed for you”

she said.

“I prayed every day you would have a healthy baby.”

I did.

She sat across the aisle from me at church you know,

Exchanged greetings of peace and watched my pregnant belly grow.

We prayed.

Tall in my white coat I stood before her in shivering snowflake gown.

My eyes and hands observed the tumor her right arm birthed had grown.

I sighed.

Too few weeks later I kneel beside her in her home hospice bed.

“I pray for you”

I silently said.

Words and tears are blocked by “professional boundaries” in my head.

I silently cried.

“I pray you have a peaceful death.”

She did.

Dr. Farah explores professional boundaries, prayer and expressing emotions with patients. As we have explored in other posts (Onime) dual relationships are common in rural areas. Our patients are our friends, and expect to be. We may see them at church and at the grocery store. Close relationships increase compassion, but may also bias us in our care for patients. Being close to a patient may make us more compassionate in giving bad news, but may make it harder to help a patient make decisions about their care because we have our own opinions and hopes as their friend.   What have you seen on your rural rotations?

Dr. Farah also explores expressing emotions with patients. Crying with and for a patient is not a bad thing as long as we can step back and be in our doctor role when we need to be. The ability to move from one role to another is often called compartmentalizing. This allows us to switch between roles. For example, in a crisis, I need to put my feelings aside so I can think clearly and make decisions about what to do. Feeling sadness or happiness for and with patients is also quite human and shows that we care. Grieving the loss of a patient we were close to is normal and healthy.  As a physician we are privileged to walk through the best and worst of times with patients. It is important to learn how to distance ourselves from some of the intense emotions, otherwise the roller-coaster ride of highs and lows is exhausting and draining. However, not taking the time to feel the feelings at all can lead to cynicism and burnout.

If you don’t have what you want…

–Joseph Gibes

Dr. Gibes periodically does home visits to Amish patients in Wisconsin.  He tells a story about performing a circumcision on an infant.  You can see him read this on <YOU TUBE>

I gently lifted the little patient from the bassinet and laid him on the board, molded to cradle a newborn baby, and secured his legs with the Velcro straps. He struggled and fussed for a few seconds, but then settled back down, oblivious to his fate. I put on the gloves and started the procedure. Elim [his father] gently held a pacifier with a little sugar water on its tip in his son’s mouth, which was enough to keep him quiet. I tried to keep up a little conversation with the farmer as I worked.

“Cold, isn’t it?”

“Yes,” he replied. “I think it gets even colder here than it did in Pennsylvania.”

“What kind of stove is that you have?”

“Kerosene.”

While we spoke I worked quickly. Two clamps on. Probe to reduce adhesions. Third clamp on, to mark the extent of the foreskin to be removed. Then apply the Mogen clamp and close it. The patient remained stoically quiet through the whole thing. The procedure was all over except for the actual cutting. I reached to the sterile field for the scalpel. I couldn’t see it in the dim light. I pushed the instruments around, looked under the gauze: no scalpel. Trying to sound calm, I asked Elim, “Is there anything else in the kit?”

The farmer obliged by reaching in and feeling around. “Nope,” he said.

It suddenly seemed to be getting warmer in the little room, and I started to sweat. The nurse and I had checked and double-checked, and I had checked again, to be sure that everything was there, and we had missed the most important instrument.

The scalpel.

It was a twenty-five minute drive from the clinic and hospital. A little apologetically, I asked the farmer, “Do you have any kind of knife I could borrow?”

If he thought this a strange request, his face did not betray it. He stepped out of the room and said something in their own language to Rebekah [his wife]. A moment later he returned, bearing in his hand the instrument his wife had found, an eight-inch steak knife. “Will this do?”

Given the situation, I wasn’t sure I was going to get anything better. Fortunately, this part of the procedure required neither a sterile instrument nor finesse. “Sure,” I said, trying to sound nonchalant, trying to sound as if doing a circumcision with an eight-inch steak knife was a routine occurrence.

The knife was quite dull, and I had to saw at it a bit to get the job done. The patient lay there placidly, Elim looked on placidly, and I tried to look placid. I left the clamp on for another minute and a half to minimize any bleeding. When I removed the clamp, there he was, as good as if I had used the finest sterile precision surgical instrument in the world…

Once outside, I started to berate myself in earnest. I can’t BELIEVE I was so stupid to forget a scalpel! They must think I’m an idiot! Nevertheless, I attempted to keep up an air of nonchalance as I walked to my car. I opened the door and collapsed into the seat. The mental strain of maintaining a matter-of-fact exterior and trying not to appear completely inept had exhausted me.

I sat and stared out the window for a moment, and as I did, in the midst of my self-reproach, a phrase suddenly popped into my head, a phrase I had heard from a missionary doctor while I was a resident working in a bush hospital in Kenya: “If you don’t have what you want, you gotta want what you have.”

Well, that certainly was true in this situation. And as I stopped berating myself long enough to realize what had just happened, I started to smile. I couldn’t help it, as I thought about it: the absurdity of the situation, the complete stupidity in forgetting the scalpel, me sawing away with a kitchen utensil; and the farmer and his wife so gracious and thankful. The smile became a good belly laugh, and I laughed and laughed until tears rolled down my cheeks.

I was still laughing as I drove down the long driveway. Only in rural practice! I thought how I was going to tell everyone back in my own world about the day’s events: “Y’ know, I’m probably the only doctor in the world to perform a circumcision with an eight-inch steak knife. . . .”

(Excerpted and used with permission, published in The Country Doctor Revisited, KSU, 2010)

Medicine demands we think outside the box and find creative solutions. Iit may be very concrete—identifying physical substitutions or it may be more abstract, making emotional or metal links. To secure the scalpel, Dr. Gibes had a 25 minute drive. He deemed that to be impossible. He made do. He reflects that that is often true in international settings. It can be rewarding to see how folks in low resource countries make do with what they have. Listening to fetal heart tones with a cone constructed from cardboard, feeding infants from a cup or by dipping one’s finger in the milk and then dripping it into the infant’s mouth, washing and drying gloves as the way to deal with limited supplies. Such expansion of your normal experience is often humbling  and  gratifying. You realize what you take for granted in our life and you can pat yourself on the back for your problem solving. And sometimes it results in a good belly laugh.

Helping patients change to healthier behaviors often demands creative mental and emotional gymnastics. Instead of lecturing a patient about what they should do, it often works better to help them explore the pros and cons to making a change. If we use motivational interviewing techniques we ask questions that help patients see the ambiguity in their thinking—what benefits do you get from your cigarettes? What else in your life provides that benefit? Which cigarette is the least meaningful to you during your day?

Do you like walking, what do you like about walking? How could you manage to do a little more? Such questioning demands that the provider follow the patient’s lead and explore the same old thing in a new way. That way we might bring obstacles and resistance into the sunlight as well as assets. Uncovering new angles or feelings might facilitate and empower the patient to try again to change. It may be more time efficient to give a lecture, but we already know that our lectures rarely change a patient’s behavior.

Think about a situation where you saw one of your preceptors bring creative thinking to patient care or when you did so yourself. What did you learn? Was there an “ah-ha” moment for the patient?