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Entries in cognitive impairment (1)

Saturday
Jul232011

an intense week.

*Please note, the names and details of patients and staff have been changed to ensure anonymity.  I have attempted to stay true to the nature of the stories in as much as their identities can be concealed. 

"Do you have a therapist?" my friend Charlie asked me when I finished explaining the ugly contents of my day.

I don't... currently.  After a hectic spring and early summer, I lost contact with the woman I had been paying to listen to my problems.  (This quip is not meant to minimize, I am actually a huge fan of therapy.  I think almost everyone should be in therapy--no matter how sane you think you are.)  I am considering finding one out this way, though.

More than the previous two, this week has been a roller-coaster in my family medicine rotation.  I feel pretty lucky in terms of placement.  Despite the fact that I am in a Catholic health system, I have quite a few liberal attendings that defy my very ignorant pre-conceived notions.  I'll be honest, when I saw I had been placed within this particular health system I immediately thought of my political leanings and sexuality--how would they 'deal' with me?  What would they think of the tattoos?  My partner?  The organization of which I am chair?  I basically assumed I was in for it.  So far, I am so happy to report I was very wrong.  The people I have met are as various in their politics leanings as they would be anywhere else.  I guess, much like the rest of the world, health care providers just need a damned job.

In any case, the flow of patients has been pretty slow.  I guess this is quite typical in the summer (which makes plenty of sense, kids are out of school, not as many viruses, etc.).  While the residents are kept busy with charting, I am often left to entertain myself.  Sometimes I do this quite well (especially on days I bring my laptop), and sometimes I find myself searching for stuff to do.  There are other days, however, when I am on my feet constantly; following residents, doing exams, taking histories.  It's great!  My only hesitancy with Family Medicine so far has been the pace.  I am a terrible waster of time and I need to be kept BUSY.  I am assured by both the residents and attendings that July is atypical, and I should be sufficiently exhausted most other months.

I have gotten to the point where I am comfortable enough with the residents to ask to be included in their more interesting cases.  I am trying to expose myself to the battery of problems that can walk through the door of a Family Medicine clinic.  There was one case, however, that I couldn't have created in my worst nightmare.

*Lydia's name popped on to Dr. *Cherski's schedule early Wednesday morning.  It reported that she had a positive pregnancy test.  I was thrilled!  I love preggos and pregnancy!  Dr. Cherski didn't seem thrilled.  He said that Lydia would be coming in with a friend.  I asked if the 'friend' was Lydia's partner. 

"Well, no.  Lydia sometimes has a hard time understanding things," Dr. Cherski said.

"Is she not a native speaker?" I asked, assuming the problem was a language barrier.

"Uh... not exactly."

"Oh... is she, uh, kinda slow?"  I asked.  Sometimes, even though mentally retarded is a clinical term, it sounds much more harsh than 'slow.'

"I think so," said Dr. Cherski.

One of the reasons I like working with Dr. Cherski is that he lets me talk to patients on my own before he joins me in the room.  Too tired to examine my mixed emotions about pregnancy among the cognitively impaired, I gather a piece of paper and a pen for notes and headed into the exam room.

Lydia is 31.  She is fair-skinned and has dark hair and wide, inquisitve eyes.  I shake her hand and introduce myself as Emily, a medical student who is working with Dr. Cherski.  I explain that Dr. Cherski will be in shortly to talk to her a bit more.  Lydia avoids my eyes and looks at her friend, an older woman, sitting in the chair next to the exam table.  Her friend smiles at me, is that sympathy in her eyes?  For me or for Lydia? 

I greet Lydia with a big smile and ask how she's feeling. 

"Um... OK," she says, still not meeting my eyes.

"So, I hear you are pregnant! When did you find out?"

She hands me a slightly tea-tinged, crumpled piece of paper.  Her friend pipes up:

"Well, she got a positive pregnancy test at the Urgent Care here, and then we went to the Pregnancy Help Clinic."

My heart sinks.  I know the clinic they are talking about.  It's not a "help" clinic, it's a Christian counseling center that is purposely located across a major road from Planned Parenthood.  This 'clinic' is better known as a "Crisis Pregnancy Center."  It exists to lie to and intimidate women who are considering abortion.  They set up shop next to clinics that offer abortion or options counseling (that includes abortion) to attract the very same women who would otherwise find their way into clinics that offer a full range of options to women who are pregnant and scared.  There are few things I detest more than CPCs. 

"OK," I breathe, composing myself and attempting to maintain my cool.  "Well, we are running just one more urine test, but let's talk about this pregnancy."

Obviously, prenatal care is pretty complex.  Aside from all the basic tests and questions that we give any woman with a healthy, planned pregnancy, it becomes even more comprehensive when a woman who is quite obviously cognitively impaired comes in with a positive urine test.  Talking to Lydia reminded me of talking to an eleven or twelve year old.  There was something so innocent about her, despite her long sexual history.  I asked Lydia if her partner was going to be involved with the pregnancy.  She hesitated and explained that she wasn't sure who the father was.  I catch the eye of her friend and she looked pained, like she wants to talk to me on her own. 

Then, I asked the question: "Lydia, do you want to pregnant?"

I know there are other ways to ask this question, but I think my way hints that she does have options, even if in my current setting, I can't give them to her.

"Yes!" she says, lighting up at the very thought of this pregnancy. 

"OK, so tell me a little bit about what kind of mom you want to be.  How do you plan on supporting your child?"  These are the same questions we use when we are talking to teenagers about their pregnancies.  Are they ready to be a mom?  Are they ready to be a good mom?  Even if Lydia would never consider abortion (and I would never ask her to), would adoption be better for this child? 

It turns out Lydia hasn't had a job in two years.  According to her friend, she's never been able to hold one for more than a few months.  Invariably, it seems, Lydia gets frustrated at work and ends up yelling at her boss or supervisor, and subsequently, gets fired.  Lydia is also living in her Uncle's unfinished basement with three other people.  She has no contact with her parents, who have, according to her friend, compeltely written her off.  Lydia has had over 40 sexual partners in the past few years.  In fact, she stopped keeping track. 

"I just want something to love me," Lydia admits, "Guys suck.  They never stick around."

True enough, my friend.  Sometimes, when I am taking the history of someone who has been wronged in so many ways, I wish I could look at my face and make sure I am keeping my cool.  This woman has been failed by her family, many partners and the government.  She has been passed-over so many times, she has slipped through the cracks.  Thank God she has this woman, this mom-figure in her life to take care of her, because, clearly, no one else cares.

Of course, though, the plot thickens.  It turns out this friend is one of the possible fathers' mom.  Her son is also cognitively impaired--and in another relationship.  Lydia starts to cry when this is revealed.  To me, it's pretty clear she is terrified of losing this woman, the one person who consistently demonstrates the love of family.  But *Sherry is here to stay.  Sherry loves Lydia and wants her to be safe and healthy.  To her, it doesn't matter that this child could be her biological grandchild, either way, she will be a part of Lydia's life (and possibly, the life that grows inside her). 

Things become even more complex when Dr. Cherski knocks on the exam room door and reveals that our office pregnancy test if negative.  Sherry looks relieved and Lydia looks crestfallen.  To myself and Dr. Cherski, though, not much has changed.  Two positive and two negative pregnancy tests mean very little--except that we will be drawing blood for a Beta HcG (the definitive test).  Now, we are left to talk in 'what ifs?'

Lydia's case is proof of the complexity of reproductive freedoms. 

In some senses, this pregnancy was not a choice for her.  Can someone make a choice if they do not have the cognitive ability to full understand the consequences of their choice?  She openly admits she is happy about the pregnancy, but it is readily apparent that Lydia is not capable of raising this baby on her own (which, in truth, is the only clear possibility in this case).  Lydia was also recently diagnosed with a primary Herpes outbreak.  Primary herpes (HSV-II in her case) is one of the most dangerous infections a pregnant woman can have.  We in health care have an acronym to remember the most-feared infections to watch for in pregnant and intra-partum women:

T-Toxoplasma Gondii

O-Other, this includes: Coxsackie & Parvovirus

R-Rubella

C-CMV

HE-HErpes, Hep B, HIV

S-Syphilis

Aside from her questionable ability to raise a healthy kid and her primary Herpes infection, I worried about the psychosocial toll of pregnancy on Lydia.  Could she handle the questions this would inherently bring on?  Could she balance a job and kids?  Would her family harass her, or worse yet, physically harm her?

When we talked about the Herpes outbreak, Lydia told me she was never going to have sex again.  Now, as someone who understands the joys of sex and the impulsiveness it engenders, I wouldn't believe anyone who told me this--let alone a young woman with a long history of impulsive sexuality.  I laughed and told her I understood why she felt that way.  I told her it was completely normal to feel scared and hurt when diagnosed with an incurable STI, but it was also compeltely normal to want to have sex.  Sex is part of being human and I didn't expect her to remain celibate til death.  She giggled and admitted she loved having sex.

"So let's talk about that," I said, smiling.  "What are some ways we can prevent pregnancy?"

"Well... birth control," she says.

"And another?"

"Abnitence [sic]?"

"Hahah, yes, and another?"

"... there are no others," she says, looking confused.

"Well, we are missing one very important way," I say, feeling a rising wave of concern.

"..."

"Condoms?"  I suggest.

"Oh, those don't work," she says definitively.

Holding my feelings of disbelief back, I ask:

"Why do you think that?"

"Well they break.  And everyone says they prevent AIDS but that's a lie."

My stomach flips.  "No, that definitely not a lie.  Condoms are a wonderful and cheap way to protect yourself from pregnancy and HIV.  They do need to be put on properly, but they are great protection."

She looks down.  I can't help but think she feels stupid.  It breaks my heart.

Lydia leaves about an hour after we start our conversation.  She is coming back next week and I will tell her whether or not she is pregnant.  At that point, we will be having a very long conversation. 

Until then, I will continue to sort out my feelings.