I Lack Insight

I had a patient on my pediatrics rotation whom I'll never forget.

She came in the middle of the night in DKA. She'd passed out at home and been brought in by EMS with her worried mother in tow. Fifteen years old, she was disheveled, wearing huge sweatpants and a baggy t-shirt.

The intern said I could do the H&P interview, so we politely asked her mother if we could speak to her daughter alone, the mother left, and we sat down to talk to the girl.

At first, the interview was fairly normal. How long have you felt bad? Have you been taking your insulin? Have you been sick recently? How long have you had diabetes? When was the last time you saw your pediatrician?

She told us she'd recently moved, that she was under a lot of stress from switching schools, that she'd maybe forgotten her insulin once or twice, and she'd been a little tired lately.

In adolescent interviews, there is a series of questions for the "sex, drugs, and rock & roll" topics. Under a mnemonic of HEADSS, you ask questions about Home (who lives there, any conflict?), Education (what grade in school, grades)/Employment, Activities (after school, church, sports, music, etc), Drugs (cigarettes/alcohol/illegals), Sexuality (with what gender, how many, what protection), and Suicide (any thoughts of, feelings of depression, access to firearms, etc).

I'd learned the mnemonic, but I thought it was dumb. What teenager was going to tell me about any of these things? I am the man, after all. I persevered because I had to, basically, but inside I felt retarded.

We started into HEADSS with our patient. Home, it turned out, was hectic; mom was always at work, dad was in jail, older brother was out of the house, money was scarce. School was okay, but most of her friends were at her old school. Some of her friends used marijuana, but she denied all drugs. She'd quit sports. She didn't have a boyfriend and wasn't sexually active.

When I asked her, "Have you ever thought about killing yourself?", she didn't even bat an eye. "Well, yes."

I almost fell off the end of the bed where I was perched.

As we probed deeper, we got a history of months of 20+ lb weight loss without effort (documented in the chart from a prior admission; she didn't even care), feelings of guilt, hopelessness, and worthlessness, excessive sadness, tearfulness, extreme worry about her incarcerated father (he'd been in jail over 2 years), grief over a long-deceased grandmother, poor sleep, poor appetite, fatigue, and a desire to be dead. She'd been "forgetting" (ie, refusing to take) her insulin for a while because, as she put it, "what is the point?"

We asked her if she'd tried to talk to anyone. She said her mother said everyone has problems, deal with it; her school counselor and friends told her to pray about it. She'd reached out to several people for help and received none.

We asked her if she had a plan for committing suicide. She told us she thought some of her friends had guns or could get guns; she felt like she could get one to kill herself.

Her DKA resolved in a few days. We had her transferred to an inpatient psych facility to begin treatment for her depression. I don't think I ever forgot to give the HEADSS screening for the rest of pediatrics.

And yet, I didn't think I'd like psych. =-P

Pick Your Scenario

One day, a young woman wanted to sit under a tree. Normally, only the boys sat there, but she didn't think that was fair. After all, it's a free country. So she gathered some friends and went to sit under the tree. The next day, someone had spray-painted the sexist word "C**t" on the tree. The boys responsible for the spray-painting were briefly suspended from school.

Several months later, six different girls were hanging out at school when a boy walked by. He called them sluts and insulted one of the girls in a sexual fashion. One girl hit him in the back of the head, then the six beat and kicked him while he lay on the ground. He had to go to the ER for treatment of his injuries.

Were the women justified?

What if the tables were turned? What if the graffiti had said "D**k" in response to a boy sitting in the girls' spot? What if six boys had attacked a lone girl after she laughed at them and accused one of having a small manhood? Would those six boys be justified in attacking her? Most of us find this scenario more offensive than the first, but I think they're approximately equal.

Is six against one ever fair, no matter what the offending person said about your gender, your sexual orientation, your mother, or your race?

I'm sure you know where I'm going with this. The group called the "Jena 6" did exactly that, attack a lone victim 6:1 (some reports say 5:1) after the victim bragged that one of the attackers had been beaten up by a white man.

If the Wikipedia article is truthful (and I take Wikipedia with a grain of salt), then Jena High School and the town had some racial tension preceding the tree incident (involving three nooses), which got worse in the four months before the assault. The principal recommended expulsion for the noose hangers, but was overridden by the school board, who felt it was a "harmless prank." Perhaps expulsion would have been an appropriate punishment, but some people are calling for felony convictions for commitment of a hate crime for this incident. I'm not sure that this meets criteria for federal conviction, disgusting (and racially-motivated) though this action was.

The sentencing for the six attackers is what troubles most of us. Assault, yes; attempted murder is a bit of a stretch. Conspiracy to commit murder only holds true if they planned the attack, and it sounds spontaneous. Saying that kicking the victim with tennis shoes meets criteria for "assault with a deadly weapon" may be a bit of a stretch, although getting kicked in the head could certainly be deadly enough. The one attacker who has been tried and convicted was only 16 at the time of the crime, yet was tried as an adult. His conviction was overturned on this basis, but he has not been released.

I'm willing to buy possible racism in the prosecutory over-zealousness. It could also be an attitude of "I'm going to crack down on crime so I'll get re-elected", in which case ANY highly publicized violent crime would have been over-prosecuted. Who knows?

What bothers me are statements like this:

JoAnn Scales, who brought her three teenage children on a two-day bus journey from Los Angeles, California, to Jena, made the same point.

"The reason I brought my children is because it could have been one of them" involved in an incident like the one in Jena. (cnn.com)

Um, lady, this could only happen to your children if you teach them that violence is an appropriate response to someone calling you a bad name, and if you teach them that 6:1 (or 5:1) is a fair fight.

I realize Jesse Jackson is an extremist with an agenda, but I disagree with him that "Punishing the teens with probation would have been sufficient" (also cnn.com). These guys committed a violent crime, sent a kid to the hospital, and several of them have prior records. These guys deserve a few months in juvenile detention, if properly convicted.

Therefore, I'm not necessarily all about standing behind these guys. I know our justice system is screwed up, and I'm all for changing it to be more fair. I'm all about charging these guys appropriately, and sentencing them appropriately. If there's no evidence that one of the boys participated, then don't charge him. If they're too young for adult sentencing, then don't try them as adults.

But don't tell me that their crime was "okay" because the victim called them a bad name. "He's an asshole" is not an acceptable defense.

Whoops!

Apparently, somebody called me out on my lack of knowledge about prairie dogs. Shocking, really, as they teach us so much about prairie dogs in medical school. Apparently, my lame attempt at humor went straight over their head. However little I know about prairie dogs, I do know that they can in fact carry the fleas which carry Yersinia pestis; some of the rodents in recent years were infected with monkey pox (they were in captivity) and tularemia (in Texas). Yes, I read Wikipedia. I apologize to any prairie dogs who read this for calling them disgusting disease-ridden vermin, as the correct term is "rodents"; "vermin" may be too discriminatory or prejudicial, and it's definitely not a politically-correct term. My bad!

In Case You Missed It...

...go here to see the complete "12 Medical Specialty Stereotypes" by Michelle at the underwear drawer. As always, she brings the funny.

More Microbiology in the News

http://www.kpho.com/news/14107744/detail.html

Friends, when you are traveling in Arizona or New Mexico (or anywhere, really) where there are prairie dogs, do not play with them. They may look cute, but in reality they are disgusting, disease-mongering vermin who deserve to be shunned. If you insist on playing with these nasty creatures, you may contract the bubonic plague. Yes, the plague, which wiped out most of Europe several hundred years ago. The Black Plague, which is still 50% fatal if you contract the pneumonic form. So, if you play with prairie dogs on vacation, then go home and start feeling "flu-like" symptoms, be sure you tell your doctor where you traveled so you can get the right antibiotics pronto.

In case the above isn't nerdy enough, this article discusses the link between resistance to Yersinia pestis and the HIV virus, which scientists may be able to exploit in future HIV prevention/treatment research.

Yes, this is how I spend my Sunday evenings.

Oh Boy Humberto, Part II

So for the second time in two years, a hurricane turned away from Houston and hit East Texas and Louisiana. Once again, Nature has showed that she hates Louisiana.

Oh Boy Humberto

The Gulf Coast is preparing for Humberto, which formed quickly and is marching in to bitchsmack parts of Texas, including Houston. Hope that those of you in Houston stay dry!