So I have had this idea brewing in my head for my next blog, but have been unsure of exactly how to get it started and I decided (finally) to get it started with a story. Well, several stories actually.
(I sh@# you not, these are actual clinic encounters that I had. Even Stephen King could not make crap up this good.)
I have this 22 year old Vietnamese female with a complaint of left ear pain. She is accompanied in the exam room by her two sisters and her mother. After a brief exam it is apparent that she has a cerumen impaction. (Gobs of ear wax stuck in the canal for those who don’t know.) The treatment for this is pretty standard. You get the ear wax out and presto chango, the ear stops hurting and the patient can hear again. In my clinic we use a lavage technique, basically irrigating with water until the plug-o-wax pops out of the ear. So I explained what I wanted to do with the ear, how it will feel and how she should expect to feel afterward. After some quick Vietnamese banter between the five of us (I don’t speak Vietnamese, but I did nod my head yes a lot while they spoke); myself, the patient, the two sisters, and the mother all agreed that this would be the most appropriate next step. I got a medical assistant going on the lavage and continued to see my other patients. After a little while the medical assistant tracked me down and let me know that the ball-o-wax was not coming out completely and the patient is stating that it is starting to hurt. Ok, no big deal. So I go and have a look at the ear. Sure enough a good portion of the lump-o-wax had broken free, but some still remained adhered to the canal wall. I spoke with the patient about this and laid out two options. Option one is to get her to go home and start using Debrox, an ear wax softening agent, and return in one week so we can finish the job. Option two is for us to continue working on the ear in the office. I then asked “Would you like us to continue to work on the ear today?” The answer was an immediate “NO!” The problem was that this 22 year old patient that I was looking at never said a thing. So I asked again “Do you want us to continue to try and flush out the ear?” “NO!” (Again with the ventriloquism.) As it turns out this adult patient was not answering me at all, it was her mama that was fielding all questions. This got me going a little so I informed the mama bear that her cub is not a cub at all, and that I needed my patient (a grown woman) to answer my questions. This got the little Vietnamese lady freakin pissed off to the extreme. I don’t understand Vietnamese, but I sure as hell know when I am being cussed out in any language. I had to spend 20 minutes arguing with mama bear about her daughter being an adult and that adults make their own medical decisions. What a monumental waste of my time.
I am given the chart of a patient that wants to renew her birth control pills after being off of them for several months. She is of child bearing years and is not sure when she had her last pap. Ok, no big deal. Knock out the pap and prescribe her some birth control. We put patients in a normal exam room to do a basic physical and history before the pap. Once ready for the pap we will move them into the OB/GYN suite. I walk into the exam room to do the initial consultation and what do I find? The patient and her 5 year old little girl. So cute, she brought her baby girl with her to the doctor’s office. This is a good opportunity to help foster a positive outlook for this child regarding coming to the doctor’s office. Maybe she won’t be so scared the next time she is sick and has to come in. I play nice with the little girl for a few minutes and then start to talk with mom. She has had abnormal paps in the past, but can’t recall what was done about it. According to her she had some kind of “other” tests. So I let her know that we need to do a full pap and pelvic exam in order to prescribe the birth control medicines. “I know” she tells me. I step out and let the medical assistant know to set the mom up for a pap. The medical assistant finds me and informs me that mom is ready. I grab a chaperone and head into the room. Mom is on the table, legs in stirrups, tray is ready, and… what the…. baby girl is sitting on the stool. Not just any stool, my stool. The stool I use to perform the pap. The stool that is nestled between her mama’s legs, and she is staring right up at her mama’s va-jay-jay. I immediately step out of the room and give the medical assistant a “WTF is the kid doing in there?” Her response, “We don’t have anybody to watch her.” Got to be kidding, right. No, not kidding. I pull myself together, go in and remove the child from the stool. I let her stand up at mama’s head, and begin my normal pap routine. The kid is staring at me the whole time. Not too big a deal during the pap, I am more focused on the cervix than the child. The manual exam, a whole different story. As I am palpating the vaginal cavity this little girl is all wide eyed mean mugging me. I kept thinking “This little girl is going to be like way traumatized by all of this. She will never want to come to the doctor.” I swear, I would have rather been giving my own mother a pap than be in that room at that time. I could not wait to get out of there. I mean why the hell did this lady come to the clinic knowing she was going to need a pap with her 5 year old daughter? Messed up in my book.
I use these two stories to illustrate a point about what it’s like to be directly responsible for a person’s health. Sometimes it’s not the patient that presents the biggest challenges, it’s the family. As Physician Assistants you will soon realize that the most strife comes not from your patients, but from the family that they drag in with them. Let me tell you, nothing is more pathetic than having a 32 year old man in your exam room with his mother there “In case he forgets something”. Like a 32 year old man won’t be able to remember that his throat has been hurting for 4 days and he has been running a temperature. Truth be told, when this is the case, the mom won’t shut her pie-hole long enough for the guy to say anything. This is not exclusive to moms. Sometimes you just get a family member that wants to answer all the questions that you are asking your patient. They are answering the questions that I ask as if they are the one that has been sick. Stuff like how many bowel movements do you have in a day? Are they soft or firm? You know, the kinds of questions that help you understand how the patient is doing so you can start to narrow your differential diagnosis. The things you want to hear directly from your patient. When I run into this situation I do one of two things. I let the mouth piece know that I need the patient to answer in order to truly help, or I ask some very random off the wall question that I know damn well they can’t answer. If it’s a mom with her adult son, I will ask something like, “How long do your morning erections last?” That shuts the mom up real quick.
Here is something else that is awesome. You examine your patient, get the plan together, go over last minute instructions and the family member is like “Since I got you here, what should I do about blankity blank?” Or they will ask something like “Can you take a quick look in/at my whatchamacallit?” Oh yea, it’s like a two-for-one special at K-Mart. Treat the patient and the sick family members, all for the low cost of one office visit.
At times you are going to go into the exam room and so many people are going to be in there that you won’t even know who the actual patient is. You will actually have to ask who is being seen today. You might have three kids up on the table, one crawling under the table, and another zipping around on your stool. Talk about distracting. God forbid you get three or four XXL folks in the same room. Nothing makes an exam room shrink faster than filling it with bigger patients. Not only is there like no room to maneuver around, the air gets all thick and stale. It just flat out reeks at times. I’m just going to say it; big people tend to have more body odor than thin people. You pack them all in the small room with no ventilation and it gets raunchy real quick like. All you can do is think about getting the hell out of there as fast as possible.
The take home message is this; when working as a Physician Assistant dealing with the family of your patient can be the most difficult part of the job. Plan out in advance how you are going to handle individual situations, and stick with it. Whatever you do, do not let the little girl be in the room when you give her mom a pap. You will be scarred for life, I sure as hell have been.