stories

25 y/o G2P1 (second pregnancy, one child already delivered) presents to triage at 38 wks with no prenatal care in labor with a baby found to be double footling breech (both feet down instead of head down).  Baby is born by emergency c-section, and mom decides to give him up for adoption.  I talk her through the possibilities of open vs. closed, available agencies.  I hold her hand as she cries over her selfless decision, over the baby she holds and gives away.  I rejoice quietly with her as she picks a family from the profiles the agency showed her, a family with another little boy, a brother for her baby.  I marvel silently at the strength she shows.

21 y/o G1P1 seen in clinic for routine gyn care.  Oh, by the way, my last period was more than a month ago, a bit late now, unusual for me.  We chat around the Pap and pelvic exam about the Gardasil vaccine and contraceptive options, her life living with her mother to save money to stay at home with her two-year-old, her questions about this or that health-related topic.  Near the end before signing the orders for some vaccines and prescribing her birth control choice, I check a pregnancy test just to be sure.  Positive.  I go back in to tell her, and she bursts into tears.  I sit back down, wondering inside at the irony that there are people who would cry tears of joy for this positive test that only brings pain and chaos to my patient and her life.  We chat about options, me recalling my last difficult conversation with a patient in a similar situation who I now see for regular prenatal care since she never went for that abortion she had initially planned.  I give this patient information about resources related with all her options - parenting, adoption, abortion - advising her of the support available for her should she choose to parent or form an adoption plan.  I wish again that I had easy answers about my role in this counseling, my patient's decision, or at least an easy spiel of what to say and how to say it instead of the ambivalent wading through beliefs and values, situations and specifics, reactions logical and emotional.  We agree to meet up again in two weeks to talk about her final decision.

 55 y/o woman with known history of alcohol abuse comes in with alcoholic hepatitis.  She is then intubated for hepatic encephalopathy with failing liver and eventually kidneys, too, as she develops hepatorenal syndrome.  Unexpectedly, she survives her extubation planned for when her family can be there and moves slowly towards comfort measures as she is now alert enough to make her own health care decisions.  I visit her the weekend before she moves to inpatient hospice to check on how she is feeling and end up sitting at her bedside giving her sips of the dozen or two juice bottles beside her bed and spoonfuls of cool sherbet that make her dry mouth less uncomfortable as her failing liver's inability to make protein to keep the fluid in her blood vessels slowly allows her to become more swollen otherwise and more dry inside the vessels.  I lotion her dry, jaundiced hands and arms, recalling the elderly nursing home residents for whom I did this routinely for five summers through college.  I wonder about how she must feel, relatively young and knowing that her drinking caused this poisoned liver, the dry itchy skin, the slow dying.  Vicarious regrets fill me, and I mourn for what her life could have been.

27 y/o woman with family history of blood clots comes in with chest pain and shortness of breath.  She is mildly anxious (never having been to the ER as a patient before), tachycardic (fast heart rate), tachypnic (fast respiratory rate), but pulse ox is normal.  She tells the ER physician of her family history and risk factors for blood clots - the birth control pills she started herself on for acne, the long trip out to Indiana and Minnesota to see friends and family on her one-week vacation from residency a week and a half ago.  She is found to have a pulmonary embolism (blood clot) in her lungs and is placed on blood thinners for the next six months.  After the blood thinner level comes up appropriately and her pain is controlled, she goes home to stay with her parents for a few days to recuperate.

A routine case - one I have seen two or three times already this year in various transmutations - except that this time six weeks ago the patient was me.  It has been frustrating and educational to be on this side of medicine for a change, getting regular blood work, waiting for phone calls from my own doctor for dosage changes on medications based on the labs, filling prescriptions at the pharmacy and bemoaning how expensive medications are (and I have good insurance!).  I also identify more now with the fear of being in pain before the diagnosis is made, the lack of control over a body that no longer acts as it normally does (short of breath with walking, pain when lying down flat to sleep - now all resolved, thank God).  And I am grateful for the family and friends (despite being in this place for only seven months) that support me during the time when I felt sick as well as now when I now feel normal but still have to do the follow up things (blood work, making up the week of work I missed, occasional checkups).

trafficking, shame, and freedom

Human trafficking is an issue that has come up recently in efforts to raise awareness - yes, even here in rural southeastern Pennsylvania.  A quick search of related websites indicates probably 27-30 million people under modern-day slavery, forced to work or be a child soldier or a prostitute often in a place where they don't speak the language.  It's an ugly issue, one nearly overwhelming with the myriad of stories of abuse and rape and shattered lives.  And yet it is one where I as a person in medicine have the possibility of playing an important role in recognizing victims.  Look beneath the surface, the presenters urge.  Look for the signs that might indicate a powerless person with no control over their employment, income, place to stay.  And the corollary:  Be willing to help.

It reminds me somewhat of child abuse.  Physicians are always obligated to report suspected child abuse, even if they are not sure.  The investigation is out of our hands, but the error must always be on the side of protecting a helpless victim.  This feels similar - the obligation to help, to know what resources are available - with the added complication that this is sometimes an adult, so how do I offer help in a recognizable form to someone used to betrayal?

Perhaps the most important step starts with the step illustrated by this Ten Shekel Shirt song, "Fragile:" http://tenshekelshirt.com/.  "It's Not Your Fault."  The people who came and spoke at my church about their work among former victims of trafficking told stories of seeing new life come when women began to find forgiveness for themselves.  Often their own way of seeing themselves kept them in captivity.  But they have found a way out of that crippling shame through Jesus, and it transforms their lives.

Shame is not limited to victims of human trafficking, however.  It is found as well in the physician addict who secretly shoots up opiates scavenged from the ER sharps box.  It is found in the young man with hallucinations who can't seem to escape the clamor of voices inside his head.  It is found in the survivor of domestic violence who goes back once again to the abuser, hoping against hope that this time will be different.  It is found in my own heart with my struggles and failures.

I read a book once that spoke of shame, saying, "Shame enters in and makes its crippling home deep within our hearts.  Shame is what makes us look away, so we avoid eye contact with strangers and friends…  We know we are not all that we long to be, all that God longs for us to be, but instead of coming up for grace-filled air and asking God what he thinks of us, shame keeps us pinned down and gasping, believing that we deserve to suffocate... Shame causes us to hide.  We are afraid of being truly seen, and so we hide our truest selves and offer only what we believe is wanted."

I think of that image often as I interact with the hurting people that cross my path, their regrets and disappointments combining nearly to suffocate them.  I think of it today, Ash Wednesday, as I think about the vast heart difference between shame and repentance (which is the season of preparation for Easter that Ash Wednesday initiates).  One leads to that crippling sense of suffocation; the other leads to walking head up and eyes on Him in freedom and life.  As the Anglican liturgy says, 

"Praise to you, O Christ, King of eternal glory.

The Lord is a great God, O that today you would listen to his voice.

Harden not your hearts." cf. Psalm 95.3, 8 

"Remember that you are dust, and to dust you shall return.  Turn away from sin and be faithful to Christ," the priest reminds as he puts the black powder of the ashes of last year's Palm Sunday fronds on our foreheads.  It is a reminder of our fragility and our mortality, a truth I see daily in my work.  But more, it is a reminder that out of death we, like all in slavery - physical or spiritual, are called to life, out of binding shame to joy overflowing, out of sin through repentance to holiness and wholeness.  Harden not your hearts...