Don’t Forget to Dig Deeper

“I am Dr O by the way. I don’t think I had the time to introduce myself. And you must be Liz?”

I turned around to the male sitting in the corner, mostly focused on his phone. “Hi, how are you related? I usually like to know who is in the room.”

He replied, “I’m dad. But you have to ask her everything; I don’t know anything about her business.” He paused then continued, “you look young to be the ‘real doctor’.  Is this the part where you talk to us then go talk to real boss?”

“No, its not. I am both the ‘real’ doctor and ‘boss”, I replied, “Nice to meet you.  I’ll start speaking with your daughter, but at some point, I may need you to give us some privacy. We like to speak to teens alone, just to make sure we are getting all the information to help take care of them and also answer any confidential questions they may have they have confidentially. Would that be ok? “

“Yeah, Sure,” he said. “You gotta do what you got to do. Just let me know when to head out.”

I turned back to my patient who tried to smile but seemed uncomfortable. “What brings you in today?”

She said, “For about a week now, It’s been hurting down there every time I pee and my back started hurting 2 days ago. I did some intensive exercise a few days ago and I think that’s why my back hurts but not sure why the pain with urinating has lasted this long.”

As I listened, my eyes darted between her and father to see if he was involved in the conversation. Once I realized father disconnected, I focused on my patient. 

Suddenly, she briefly looked at her dad and seeing he wasn’t paying attention to us, motioned to me with her head and eyes to send father out. 

I wasn’t a novice around patients, especially teens. I have learned over the years that by paying attention to facial expressions, you can get a lot of information without words.

I turned to her father and said, “do you mind if..?”  I hardly completed my sentence, he interjected, “where is the lobby? I’ll go wait there. I don’t need to be all up in her business.”

Great, thanks. I motioned with my hands, “take a left here and then another left and you’ll be right there.”

I shut the door, pulled up a chair and sat directly facing Liz. I knew she probably had a lot to talk about so I wanted to be at her eye level; not only to listen but to let her know I was interested in helping.  

She jumped right into it. After an uninterrupted verbal spill (with intermittent sobbing) of about 5-8 minutes, in which she included how the absence of her mother in her life has left her confused as a teen; the discomfort of discussing her menstrual cycle with her father; morbid fear of being a disappointment to her father if he learns she has been having sex; and a compounding concern that her vaginal and back pain might be related to having sex, she ended by saying “I’ve had this pain for a week and didn’t know where to start and I wouldn’t have told my dad to bring me but I could barely walk today due to the pain.”

She paused, wiped her tears, like she was done. Done with talking and crying. But, just when I tried to speak, she started again. 

“Oh! And before you ask, my mom was killed a few years ago by a stray bullet. My brother and I live alone with my father. Heworks a lot so we don’t see him often. I’ve basically been figuring this whole teen stuff out. At least I’ve found comfort in the arms of my 15 year old boyfriend. We are each other’s firsts and only partners so we don’t like condoms or anything like that. We’ve been having sex for about 1 year now. I have that contraceptive implant in my arm that was placed for my painful periods before mom was killed. Dad hasn’t taken me to get it checked out but I heard it can also prevent pregnancy so I’m good.”

“By the way, do you guys have any tampons? My periods have been all over the place, just weird. I used my last tampon yesterday and since I didn’t have an extra one to change into, I just slept with it and took it off this morning.” 

I waited to make sure she was actually done. I may have waited too long but I was also trying to collect my thoughts too. I was slightly consumed by all the information and emotions flowing from this young teen who seemed to be going through a lot. Wondering where to start from, I said, “We don’t have tampons here, but we have pads. I’ll grab you some pads to get started. “

I dashed out of the room and grabbed some pads and urine collection cups from the nurse.

“The bathroom is right there. Go pee into these cups, change into your pad. I’ll give you a few minutes to get that done and I’ll be back. We sure have a lot to talk about.” 

Few minutes later, she walked slowly back into the room with the filled urine cups.

“I feel much cleaner,” she said with a smile, “but it still hurts to pee.”

I replied, “we will run some tests on your  urine to tell us if you have a urinary tract infection and the other will tell us if you have a Sexually transmitted Infection (STI).”

“I better not have an STI or someone has some explaining to do,” she muttered under her breath

Now let me grab a nurse to chaperone for me while I examine you and then we can discuss all you told me about.

Ok! your exam is reassuring. Your back pain seems to be in a location with mostly muscles.

After a long discussion that included a description of menstrual cycle and periods; sex education and proper protection,; evaluation of her past traum and current sadness related to her mother’s death, I noticed she was understandably overwhelmed. 

I said, “Liz, we will probably not be able to get through everything you need to know about being a teen in the ED today but I will refer you to a Teen specialist who will have more time to discuss with you. But here are 5 things I want you to know for now:

• Try not to have your tampons in more than 8 hours. You can get a bad infection that can really make you sick. Here are some more pads.
• Pain when you pee might be a urine infection and if it stays untreated  for a long time, It may affect your kidneys. 
• You need to use protection ALL the time. And I mean condoms. The implant does NOT protect you from sexually transmitted infections (STIs). I understand you and your partner have sex with each other alone, we still highly recommend All-time protection.
• I’ll need you to keep a chart of your periods. I don’t expect it to be as irregular as you describe. But the teen specialist will use this to know how to help
• I think you will need someone to talk to, to help with grief of your mother’s death. 

She blurted out, “I didn’t know all this before but I can deal with these 5 for now.” And I do need to talk about my mom. No one really asks how I’ve been coping with that. Dad is struggling but he doesn’t seem to speak about it.”

“Wait, are you going to tell my dad all we talked about?”, she stared at me, shocked.

“Some of them” I replied, “but not the part about sex but I’ll encourage you to share that with him at some point. It helps with communication.”

For now, you just have a UTI and need antibiotics for that.