poured out before bed
“Yeah, I guessed that.”
The new attending stares blandly at me, her hand lying flaccid in mine. She sniffs to my greeting smile.
“Here’s a chart. Follow up asthma diagnosis. You should be able to handle that.”
The words sound confident, but her inflection betrays low expectations.
I do love it when the morning begins so auspiciously.
Dr. Sniff is wan when I present the first patient, but can find no fault with my assessment and plan. Yet the feeling during our encounter is one of a general, vague, and poorly localized discomfort. The snide cascades from her being like urine from a drunk, with all the same social inappropriateness. Another attending winks sadly at me from across the room, pulls me aside in a brief free moment to whisper that Dr. Sniff was called in to cover for a colleague today and is less than thrilled about the assignment.
“Mullberry, she’s a ‘burbs-a-trician. She’s always asking her colleagues to cover her shifts here – thinks she’s too good. Please don’t sweat the ‘tude she gives. She’s always like this when she’s in the Inner City Clinic. Your presentation was top-notch. You just keep it up.”
I thank Dr. Slip-a-Word for the heads up and miss Dr. Wonderful with all of my soul as I head off to see a 16 day old infant in for a well child check.
Perusing the chart outside the door, I note that mom, who is my age, has a very rare syndrome associated with moderate cognitive difficulties. I read further to find that she has four children in addition to the newborn I’m to see today, each with a variant of that syndrome. The children are all spaced almost exactly 10 months apart; each has a different and uninvolved father. They live with their mother, grandmother, and aunt – all of whom suffer the same syndrome – in a home in one of the diciest parts of the city. There is a flag in the chart detailing non-compliance with medication regimens and frequent clinic visit no-shows, as well as multiple letters from various attendings explaining the difficulty of the situation – that her noncompliance is not willful, related more to confusion and learning difficulties – and recommending she not be fired from the clinic as it would destroy any opportunity for preventative health maintenance for the entire extended family. There are also reports from CPS visits to the home documenting evaluation, remediation, education and assistance offered over the years.
Monday morning just got even better.
I take a deep breath, knock, and enter.
Mom’s hair is tangled, but drawn up severely into a bright green bandana. Her clothes, like the two older children’s with her, do not match, but they are clean. The children sit quietly, hands in their laps, smiling little timid smiles when I offer high fives and ask their names and ages. The newborn is swaddled tightly in a lacy afghan, lying in a toddler’s booster seat. Mom is shy and a bit unsure of her answers as I take the pregnancy, birth, and perinatal histories and inquire about the feeding and toileting patterns of the newest addition to her family. I calculate the baby’s growth and we talk briefly about normal growth and development. When I ask her how the older children are handling the new little one, there is a long pause.
“You look concerned. Can you tell me what you’re thinking?”
“They a bit jealous, but they alright. They always want mama to theyselves at first, but they’ll get it in a few days,” she says slowly.
“I’m sure they will. I know you’ve done this before so you probably have some great coping strategies, but they tell me the clinic has this really nice pamphlet on sibling responses to newborns. May we go over it together so I can learn about it too? I bet you can teach me things the pamphlet can’t!”
For the first time mom smiles.
“Why sure, I’d go over that with you.”
We sit and discuss the pamphlet together, and mom’s giggles and stories of her older children make me laugh too. The once shy woman is now patting my forearm, regaling me with tales of her sweetly mischievous children and asking questions about everything from tantrums to colds to vegetables to vaccines.
When the springs of family lore and health questions dry up, I ask how mom is feeling now that baby’s been home a few weeks.
She is quiet for a spell again.
“Well, I think I got a lil’ baby blues, but I’m alright.”
“What do you mean by baby blues?”
“Oh, jus’ weepy. I cry for no reason at all sometimes. My mama jus’ laugh at me and take the baby so I can nap.”
I assess her mood, her home support, her prior postpartum experiences, ask respectfully about other symptoms of depression, about any suicidal or homicidal ideation. I am glad that her story is not currently consistent with post-partum depression, and I talk to her about the signs and symptoms of this condition, encourage her to let us know if she feels things are getting worse. She seems relieved to have explored the issue.
Now I come to those important child safety questions – safe sleep, home smoke and carbon monoxide detectors, and car seats. On the last issue, mom points to the toddler’s booster seat into which her newborn is loosely strapped.
“See there. I always keep my babies safe in the car. I only got two of these so I only take two my babies with me driving. I never hold ’em on my lap no more.” She smiles proudly.
Oh SNAP, I say in my head, a little shot of adrenaline entering the periphery.
“OK, that’s really great you put them in seats,” I say out loud. “Is this the seat you use for the baby?”
“OK. You totally have the right idea about keeping all your little ones in seats. This seat is great for your toddlers. But this seat is a bit too big for the baby. See how loose the straps are? They don’t really hold her in place very firmly. They need to be just loose enough for a finger to fit beneath.”
Her look spells doubt and a tinge of embarrassment.
“I been using this for all my babies and they been fine.”
“Have you been in any car accidents before?”
“Well, no, but I’m a good driver and my babies never slipped out.”
“I’m sure you’re a great driver. But not everyone is – someone else on the road could make a mistake to get in an accident with you. Then your baby would almost certainly slip out of this seat and could be hurt.”
Mom stares at her baby. She begins to look that type of sullen that can lead to stubborn. I quickly try a different tact.
“You’ve worked so hard to be a good mom to your kids, I can tell. You’ve done so well, but everyone needs a little help sometimes – everyone. Can we help you make driving in the car safer for the baby? We can give you a new baby car seat and show you how to use it. Do you think that would be helpful for your family?”
Finally, mom looks up. She nods, wringing her hands a little, but smiles sheepishly.
“Sometimes I do need a lil’ help…but I’m not stupid. I do my best to be the best mom.”
“Oh absolutely, I know you do. May I show you a new car seat? We can learn about how to adjust it together. And I’ll get Gina, who will show you how to put it in the car correctly.”
“I’d like that.”
I then ask for permission to examine the baby, noting her syndromic appearance and a few abnormalities consistent with that syndrome, but nothing unexpected or highly concerning. As I complete the exam I confirm the social and family history I read in the chart. I thank her for her time, and excuse myself, promising to return with the doctor shortly.
I write an order for car seat education, begin the process to check out a seat, then seek out an attending with which to staff.
Despite my quickly fervent prayers, the only available attending is – you guessed it – Dr. Sniff. As I begin presenting the patient, she lives up to the name I’ve given her. She sighs and rolls her eyes throughout.
“Why do we even bother? This woman has no place raising children. She has no place having children. She is irresponsible and unfit. What a waste of our time.”
Now, I do agree that this is a difficult case. This is a woman whose inherited disease should give her reproductive pause, and whose cognitive disabilities make childrearing – especially of children with special needs – a special challenge. Admittedly, her greatest concern (or her perhaps her greatest area of understanding) does not appear to be birth control as she has spent the majority of the last 5 years pregnant, boasting two pair of Irish twins. She consumes a disproportionate amount of time and healthcare dollars, not to mention social services work. But it is my job to do my best with the resources at my disposal to do right by her innocent children. And although I may be distressed by the situation, it is not my place to discuss my opinions with my attending or anyone else involved in her care, for that matter.
It is most definitely not the place of my attending to use a student as her social issues sounding board.
I blink, but let the silence stretch as I wait for her to comment on my assessment and plan, to offer feedback. She’s too busy shaking her head and, well, sniffing.
“I’ll re-examine the baby. But I can’t stand the mom. You do the counseling. You’re a 3rd year student, you should be able to handle that.” The second time she’s said that, the first time it’s sounded somewhat sincere.
I stop in the back for a carseat and follow her to the exam room. As we enter, I think about our roles. For once, I’m glad to be the student – too bright-eyed to be daunted, too fresh to be jaded – and I hope to stay that way long after I’m board certified in whatever it is I decide to be when I grow up.
Note: I will not be publishing any comments which represent a speech from atop those hot-button soapboxes marked “Welfare” or “Medical Ethics” or “Reproductive Rights,” etc. This is but a place for simple story telling, not for political or social argument.