CPS

It's been a busy week at the clinic, and it's nice to finally sit down and catch up. Yesterday was the Hopi High graduation, which is essentially a weekend-long, reservation-wide party. With the exception of a few alcohol-related incidents overnight, post-event days are generally pretty slow times at the health center. The docs catch up on charting, midlevel staffers try to get through their work in time to take off early, the reception clerks gossip about, well, everything, and the med student updates his travel blog.

That said, this week felt like a particularly heavy one, and I think that's probably due to just one patient. We had a preteen come in to the ER a few days ago with a mild stomach bug--something that we see a half a dozen times a day. But as I was breezing through the exam, the child's grandmother quietly hinted that she was concerned about the child's safety.

A child living with a grandparent is nothing new around here. Many times, it's so that the child can stay connected with the reservation while the parents go to work in bigger cities. Other times, it's because drugs or alcohol have rendered the parents (generally temporarily) unable to care for their children. And as much as we tend to associate alcoholism with the reservation, it's a problem in many communities, especially low income ones.

But this situation was a bit different. The child still lived at home with (for privacy's sake) his or her mother and stepfather. They had been drinking that day, and asked the paternal grandmother to pick up the child. The father is incarcerated, but his mother is still in the picture.

I'm bringing this story up not necessarily to outline the particulars of this child's home life, but to talk about how hard it is to report child abuse.

It's not hard in a logistical sense. There's an 800 number that doctors can call, and Child Protective Services (CPS) takes over from there. I'm talking about getting over the hurdle to dial that number. We all know that health care providers have an ethical and legal obligation to report abuse. And in an academic sense, it's a no brainer. I've sat through dozens of lectures on spotting the signs of child abuse, and we all diligently take our notes and react with a bit of scorn when we we learn that CPS is alerted far less than they should be. At the time, I couldn't understand why that was. Abused child: call CPS. Easy as that. But as I found myself in that same situation, the nuances became a lot clearer.

The first hurdle was just taking the time to listen. I was working in the ER, it was a busy afternoon, and this was a straightforward illness. But something was a bit off. The child seemed a bit more upset than I would have expected in that situation, and there were some faint signs of depression (which manifests itself in different ways with children). Even though there weren't any major red flags, there was enough going on to make me want to ask more.

That brings us to the second hurdle. The grandmother was wonderful. She was calm and caring, and clearly wanted to help her grandchild, but she really didn’t know where to begin. 

Figuring out what people aren’t saying is a huge part of primary care. In my very limited medical experience, I’ve come across dozens of patients with “muscle pain," “stomach troubles,” or the like. They really just want to talk about STDs or erectile dysfunction, but they don't know how to bring it up. And you can’t really blame them. No one really likes to talk about this stuff (insider's tip: not even doctors), but having that conversation is a critical part of medical care.

This is exactly what was going on with the grandmother. If you really parse it out, she probably wasn't all that concerned about the stomach bug. But she know that something was off, and she wanted help. During our conversation, she didn’t outline the situation like I did at the beginning of this post. She made passing hints at subjects that barely approached child abuse. But over the course of probably 30 or 40 minutes, she became more comfortable talking about the situation, and I was able to start piecing it together. But the picture that she painted wasn’t particularly damning in itself. Granted, it's a pretty shitty situation when parents drink too much and have to ask the grandmother to pick up their child, but it's pretty mild compared to what CPS is used to dealing with. That said, there was probably more to the story that the grandmother didn’t know, and that the child was too ill to tell us. 

 
By that point, I had heard enough to know that food poisoning wasn't really the chief complaint. But did we have to call CPS?  Did we have to call them now? How do I call them?  Since this was my first time dealing with these issues, I didn’t have any answers. And to compound the problem, I was the only person in the busy ER who had time to really sit down and talk with the grandmother about this. I couldn’t just watch what the more experienced attending physician did, since no one else knew what was going on.

I mentioned to the grandmother that we may want to get social work involved, which is essentially how doctors say, "I don't really know what to do here." I knew that I was in over my head, and it was time to call in some back up.  Unfortunately, the social workers are only at the health center during business hours, and it was already about 6 pm.  Damn.

Getting CPS involved in a child’s life is not an inconsequential decision, and I wasn’t really sure if there was enough to run with. Whether the child was being abused or not, getting CPS involved would irreversibly change this child’s life.  I didn't want to make that leap inappropriately.

When the conversation with the grandmother reached a natural stopping point, I said a few comforting words and thanked her for bringing up the concerns. I told her that I would take care of things from here, but I didn’t really know what that meant.

I walked out of the exam room, and discussed the patient with the doctor who was overseeing the ER that day. I said that the conversation with the grandmother raised some red flags, but it didn’t really reveal anything concrete. One of the ER nurses (who are the real badasses of the hospital) overheard the conversation, and said that if there’s any concern, we should call. Period. We’re health professionals, not investigators or law enforcers. If we have any suspicions, we need to call the pros, and let them sort out the details. 

 
I liked how she framed the situation. Calling CPS isn’t the final judgment; it’s just bringing in more resources. From that perspective, calling them was clearly the right choice. I had some suspicions and the grandmother was clearly concerned. It was time to call. 

Thankfully, the nurse knew the phone number, and how to proceed from there. She coached me through writing the report and getting the authorities involved. But more importantly, she helped me shift how I viewed calling CPS. I will probably--hopefully--only come across outright child abuse a few times in my career, but I will undoubtedly see suspicious activity on many more occasions. That’s when I need to call. This is too important of an issue, and that hurdle needs to be as low as possible.

Sorry to end the week on a down note. I'll get back to rectal exams soon enough.

Cowboys and Indians

Well, I think it's safe to say that I've learned more in the last two days out here than I have during pretty much the rest of medical school.

It was a reasonably calm day at the health center, and I wasn't actually going to put up a new post. I spent the morning checking out sore throats in urgent care, and I spent the afternoon doing sports physicals and follow-ups in the clinic. I was back home and in my basketball shorts by 5:00.

Around 5:15, the phone rang. It was my housemate, telling me that I should really see something at the hospital. I threw my clothes back on, and ran over.

The day prior, we had admitted a patient to our small (four bed) inpatient unit. For his privacy, I'll keep it vague, but he was relatively healthy, and the hospital stay was expected to be a routine affair. But the next day, he was having difficulty breathing, and his illness had taken a turn for the worse. By the time I made it back to the hospital, the amount of oxygen in his blood was dangerously low. We were going to have to intubate him and let a breathing machine take over.

As you might imagine, intubating someone is no trivial task. And to complicate things, these aren't emergency room doctors or surgeons who do this every day. These are your friendly neighborhood family physicians. But in an isolated environment, primary care takes on a whole new meaning. These doctors are, quite simply, why this person is still alive.

Since this isn't a university hospital, I wasn't looking over 35 shoulders to get a peek at what was going on. I was squeezing the ventilation bag, giving medications, and talking with his family.  It was an incredible experience.

Once the patient stabilized, we needed to get him to a higher level of care. And out here, that means a helicopter ride to Flagstaff. So we called in a chopper, and gave a report to the flight paramedics. They transferred him over to their monitors, and fired up the bird.

Just another day at the office.

Already?

Well, that didn't take long.  I almost made it though my entire first day without partaking in one of the finer aspects of medicine.

I am, of course, talking about the rectal exam.

I was packing up my bag after about 12 hours at the clinic, when I heard someone mention across the hall, "Let's just see if there's any rectal bleeding before we send her home."  Ah!  So close!

I instinctively knew to reach for the rubber gloves, since graduating from medical school renders doctors completely unable to perform this delicate task.  When you want the best, only a medical student will suffice.

I can't really complain, though, since I was the finger, and not the butt.  And it really was an otherwise wonderful day. It's good to be back.

Reservation required

And...we’re back.

It’s time again for some more stories of awkward cultural encounters, scattered rantings, and questionable food decisions.  But for this trip, I got the diarrhea out of the way before I even left home.  My last rotation was pediatrics, and apparently it’s an absolute given that every medical student who wanders through the pediatrics department picks something up from those cute, lovable little cesspools.  For me, it was GI.  Of course.  I managed to stay healthy for five and a half weeks of the six week rotation, but right after the final, I knew something was wrong.  I spent the next 24 hours unsure if I should sit on the toilet or kneel in front of it.  One of those weekends.

But that’s not the story for today.  I’m back on the Hopi reservation, and I couldn’t be happier about spending some more time up here. The high desert is sparsely beautiful, the clinic is a lot of fun to work at, and a little peace and quiet probably isn't the worst thing for me after a year of clinical rotations and brewery management.

I've been looking forward to this trip for months, but I got a somewhat concerning email last week from the person that oversees the student trailer on the reservation.

Myles,
Welcome back to Hopi.  Be forewarned that the washing machine in the student trailer died and does not work.  The dryer is still present.  Please bring water to drink and cook with. At this time there is NO internet at the trailer.
There are Kachina dances on Mother’s day weekend if you want to come early.
See you soon.

But I wasn't going to let that get in the way of a perfectly good trip. It's like camping, and besides, I was looking forward to unplugging for a bit.

That said, I didn't pause for even a second when one of the doctors up here offered me his guest bedroom.  Um...yes, please.  The water I can handle, but no internet? That could have been rough.

The drive up to the reservation was as beautiful as I remembered. High desert is surprisingly green, and the barren southwest landscapes alternate with pine forests for the entire drive.

The towns are also a lot of fun to drive through.  Sleepy, serene, rural Arizona.  I had to keep reminding myself that it wasn't Sunday, since the sidewalks were quiet, and nothing really seemed to be open.

And speaking of nothing being open.  It's getting harder and harder to find a local restaurant along the highway.  But there were a lot of gun shops.  More than I remembered from the last time I made the drive.

There you go, scattered rantings.  It's good to be back.

As you drive up to the Hopi reservation, the tops of the mesas suddenly begin to take shape.  You realize that the jagged outlines aren't boulders or cliff faces.  They're ancient buildings.

And from there, it wasn't long before I pulled up into my home for the next six weeks.  This is the view from the back yard.

It's perfect.