Terminally Ill

by Melissa Yi

  Tori nodded, unfazed. “That is a problem. Most studies focus on the fit elderly, because the frail can’t participate in studies as easily. I did find one observational study of over 2000 patients where they measured fitness by ability to walk 6 metres in under 8 seconds. For the fast walkers, lowering blood pressure did decrease mortality. Lowering blood pressure made no difference in mortality for the slow walkers, and actually increased the mortality for those unable to complete the walking test. So they suggested we could risk stratify our patients in the office with a walking test.”

  Stan laughed. “That’s one good thing about FMC. They have to walk 20 feet just to get to the elevator on the first floor, and then 100 feet from the elevator to our clinic, so we know they’d either benefit from therapy, or that it would make no difference!”

  I had to work that through more slowly, but he was right. If our elderly patients couldn’t walk down the hall, they wouldn’t make it to our rickety fourth-floor clinic. But then I thought of the exception to the rule. “What about patients in wheelchairs? I wonder how we could measure frailty for them.”

  Stan cackled. “At least you don’t have to worry as much about orthostatic hypotension.”

  I smiled a little. It’s true, orthostatic hypotension is usually low blood pressure when you stand up. But I thought out loud, “We could measure blood pressure lying and sitting up, but it would be hard to lift a patient out of the wheelchair and on and off one of our examining tables.”

  Dr. Callendar cleared his throat. “Interesting discussion. Perhaps we should bring this up at our FMC monthly meeting. Thank you for the very informative presentation, Dr. Yamamoto.”

  She inclined her head in acknowledgement. Then we checked our appointment schedule and scattered into the examining rooms for our patients.

  First up on my patient list, Kameron Rosenberg. I won’t lie, I was pretty excited to see that she was only 13 years old. Between palliative care and the FMC, a 60-year-old seemed positively sprightly. So a teenager was practically fetal as well as a welcome change of pace.

  I threw open the door, half-expecting Cameron Diaz, who has that tall, blonde model/surfer vibe. Instead, Kameron Rosenberg was short, plump, and pasty, with brown hair that looked more hacked off than cut. A few spare tires of fat around her middle bulged between her too-small black T-shirt and cheap black leggings. Her narrow brown eyes immediately catalogued my age, height, weight, race, and the way I came in and closed the door while she tapped her dusty black combat boot on the floor.

  This girl’s celebrity lookalike was the original Kelly Osborne, twice as sulky, but with equal eyeliner.

  I ignored the bad vibes and said, “Hi, I’m Dr. Sze. It looks like this is your first visit. I’m going to have a lot of paperwork to fill out. We’ve only got half an hour.” I opened the chart to the first page and poised over the problem list. “Now. Do you have any medical problems, like asthma?” I’d already figured out that if you ask for a medical history, a lot of young people say, No, nothing, but a minute later, they’re like, It’s just the blue puffer I’m on.

  “No. Nothing like that. I just want to go on the pill.”

  Man. I gave her a pained look and tried to explain. “Usually, for a first visit, we get an hour so I can take an in-depth history and do a physical exam. Going on the pill needs a whole other work-up.”

  “I don’t care. That’s what I want.”

  “I understand that, but what you want and what I can do for you in 25 minutes doesn’t exactly match up. It’s like that judge who said something like, ‘My freedom to swing my fist must be limited by the proximity of your chin.’” She glared at me. I was getting nowheresville. So I sighed and said, “I’ll do what I can. Are you sexually active?”

  Her bottom lip pushed out, making her look her age or younger. “No. I just want to go on the pill.”

  “You mean you’re not sexually active right now, but you want to get contraception in case you become sexually active later?”

  “No! I don’t want anything except the pill. Are you going to write me a prescription or what?”

  I paused and gazed at her until she fidgeted in her chair. Then I said levelly, “I already told you I’m not going to just write you a prescription. I’m not a vending machine. Could you please answer my questions?”

  She crossed her arms and leaned forward in her chair to burst into my face, “I already did! God! I’m not having sex! I’ve never had sex, okay? What are you, some kind of pervert?”

  I released my breath and ignored the last bit. “But you are planning to have sex in the future?”

  “I’m not planning anything. I want something just in case, okay?”

  Actually, I didn’t think it was 100 percent okay. A sexually active 13-year-old is a little young but not one for the record books. A 13-year-old virgin who wanted to go on the pill…I needed to know more. Just for my own background. “If you don’t think you’re going to have sex for a while, even for years, you might want to consider another birth control method, like condoms and contraceptive foam, instead of taking a pill every day. In general, I don’t recommend that you take extra hormones if you don’t need them. And you have to use a backup method for the first month anyway, so the pill isn’t something you can just take and magically prevent pregnancy.”

  She threw up her hands. “I know that! I don’t know why you’re making such a big deal out of this. Lots of girls in my class are on the pill, and their doctors didn’t give them the third degree.”

  I was starting to miss my little old ladies with ten thousand medications. They might have trouble climbing up on the examining table, but at least they were much more polite. “I’m not trying to be a jerk. I have to ask you questions because not all pills are created equal, and people want pills for different reasons. For example, if you want a lighter cycle, I might pick one pill, but if you’re worried about your skin, I’d pick another.”

  “What’s wrong with my skin?”

  “Nothing,” I said automatically, even though she had a few zits on her chin.

  She fake-coughed something that sounded an awful lot like “Liar.”

  Was I this annoying as a teenager? Probably not. I wanted everyone to like me, from boys to friends to teachers and other grown-ups. My parents would have clouted me on the ear for looking at them the wrong way, let alone insulting a doctor. Either “kids nowadays” had really lost it, or this one in particular was a prime specimen for why one Quebec couple had lobbied for the right to name their child Lucifer. (They lost, by the way.)

  I looked into her eyes, trying to ignore the eyeliner and the accompanying look that could not only kill, but slice and dice you first. “Let’s move on. When was your last period?”

  She shrugged and swung her legs, scraping her boots on the floor.

  “Do you remember?”

  She shrugged bent her leg so that she could pick at a hole in her leggings, on the inner thigh. Just above her knee, but still. Ew.

  “Kameron, you’re the one who came to me. I need information so I can do my job. You don’t talk to me, I can’t do my job properly. If you want to go to another doctor, you can.”

  Her head snapped up. “Are you kidding? I waited a year on a waiting list, then two months to get an appointment with you.”

  There is one advantage to family doctors becoming rarer than hen’s teeth, and that is that even ornery teenagers get the message. A little. I inclined my head and waited.

  “Look. I told you. If you give me a few boxes of pills, I’ll go away and leave you alone. That’s all I want.”

  I looked at her.

  “You’re not a real doctor, right? You just want to get this over with. Well, so do I.” When I continued staring at her in disbelief, she misunderstood my silence and said, “You get free pills from drug reps, right? That’s what I heard.”

  “Listen. Kameron. I have to do my job. That means getting the information from you. So just answer the question and lose the insults. What
was the first day of your last menstrual period?” I asked, slowly and clearly, since sometimes people accuse me of muttering.

  She sniffed and lifted her chin in the air like she’d heard me, but she didn’t want to answer.

  “Do you know when was the last time you got one? Even just a ballpark, like two or three weeks ago?”

  She bent her head to pick at a thread at the legging hole. She dragged it loose and tried to saw it in half with the nails of her index finger and thumb. Finally, she muttered to the floor, “Didn’t.”

  “What?”

  She lifted her head. “I didn’t have my period.”

  I paused. “You mean, you don’t have it right now?”

  She shook her head.

  “Well, when was the last time? Or the first time?” Maybe I needed to backtrack a little. “How old were you when you got your first menstrual period? It doesn’t matter if you’re not regular.”

  She looked like she wanted to either give me the finger or cut my head off. Or both. “I told you. I don’t do that.”

  “Wait a minute. You’re not menstruating yet?”

  She gritted her teeth like it was my fault.

  I backpedaled some more. “Look. You’re only thirteen. It’s no big deal if you haven’t had your period yet.” I was twelve when I got mine, which I figured was still about average. “Was that what you really came about? You’re worried that you don’t have your period yet?”

  “No.” She spat out the word like it was a poisoned pellet. “Like I keep saying. I came for the pill.”

  “But you don’t need the pill right away if you’re a virgin, you’re not ovulating, and you’re not having sex. And usually, we don’t give out the pill to make you start your period.”

  Her eyes drilled into mine before they flickered for the first time. She said, “I just want the pill.”

  I shook my head. “I like you being proactive, but I’m not comfortable with all this.”

  “I want it for protection! I told you that!”

  “Birth control. Is that what you mean?” I had to get very clear now. I held her eyes with mine. “Protection doesn’t mean the same thing to everyone. You know it doesn’t protect against diseases like HIV, hepatitis, or herpes, right?”

  Her eyes flickered again, but she said, “Yeah, well, at least it’d stop me from having a kid. I wouldn’t be here for acne.” Her lip curled.

  “Okay, You’re here for birth control because you’re afraid of getting pregnant before you start your period. That’s what you’re telling me?”

  “Yes.”

  “But you’re not having sex yet.”

  “So what? You and I both know I could walk out of here and have sex any second.”

  “True, but the best birth control method of all is abstinence, which you’re already doing, and the pill works by stopping ovulation, which your body hasn’t started yet,” I said.

  She stood up, her body vibrating with tension. “So you’re not going to help me?”

  I stood up, too. “I didn’t say that. Let me review this with my supervisor. I just need to check your blood pressure and stuff like that. Could you sit on the bed?” Her pressure was 140 over 90. Yikes. That was like the cut-off for an adult.

  “Just a second. Could you try and sit quietly?” I repeated it, repositioning my stethoscope on her medial elbow and pumping the pressure up in the cuff. Ideally, she’d rest her back against something to bring it down even more. Now it was 129 on 85. Better.

  “You’re squeezing too hard,” she complained. “What’s the matter, anyway?”

  “Sorry. It’s a bit better now,” I said. I quickly listened to her chest and got her to lie on her back so I could press on her belly, simultaneously tossing out any other questions that occurred to me: if she had any bleeding problems or clotting problems in her family, if she drank, if she had liver disease, or high blood pressure.

  Of course, by that point, everything was no, no, no, no, no. She seared me with a look of scorn when I belatedly remembered to ask about breast cancer.

  “We don’t have time for the pelvic exam, chlamydia, and gonorrhea swabs today,” I said. Actually, I’d already run overtime with her history and physical even before my showdown with Dr. Callendar.

  She scowled and dragged herself up to a sitting position. “I thought you only needed those if you were sexually active.”

  “That’s true, but you’re expecting to become sexually active, aren’t you? I should get a baseline. I have to bring you back for a blood pressure check, anyway.” I left out the news that I couldn’t take her word for it that she was a virgin, and that high blood pressure would disqualify her from the pill altogether. “If I just give you a year’s worth of pills, you won’t come back until they run out, and I won’t see you again for a whole year.”

  She muttered and crossed her arms.

  “I’ll be back in a few minutes.” I shut the door firmly behind me.

  Dr. Callendar made me wait, so I wrote a long note, trying to think of the best way to present this. Thirteen-year-old virgin, pre-menarchal, requesting the oral contraceptive pill, or OCP. Before I started medical school, I thought it was funny that they called it an OCP instead of “the pill,” like I was used to, until I realized that for doctors, nearly everything is a pill, so you’ve got to be more precise.

  By the time Dr. Callendar deigned to listen to my presentation, sighing and checking his own watch all the while, he harrumphed and said, “What you have here, Dr. Sze, is an extremely conscientious young woman.”

  “She’s thirteen,” I said, remembering that I barely felt like a woman when I was 18, which is legal drinking age in Canada.

  “That makes it even more remarkable that she made an appointment with a family doctor on her own, kept the appointment, and is seeking out birth control in advance of need.”

  “You don’t think it’s strange?” I said.

  He offered me a patronizing smile. “Dr. Sze. Not everything has to be a criminal case.”

  I gritted my teeth. His smile widened in response, so I made an effort to grin, even though it probably looked more like an anatomy room’s skeleton’s hollow orifice than Dr. Huot’s angelic twinkle. “That’s not what I said.” Something felt off about this girl, and not just the attitude. When I did psychiatry in medical school, one psychiatrist compared his therapy to operating with a scalpel, and I understood immediately. He dissected with his words. He probed their stories, cutting toward the truth and consistency and discarding what was unnecessary or harmful. I was no surgeon or psychiatrist, but to use that same analogy, I’d barely unveiled my scalpel around Kameron Rosenberg. How could I explain that to Dr. Callendar, who not only possessed no poetry in his soul, but would probably burn poetry books if he could get away with it? “So you would give her the pills.”

  “I might ask her if she’d considered the patch, because then she wouldn’t have to remember to take it every day, but it’s a little more expensive and releases more estrogen into the body than the OCP. Then she’d have to remember to change the patch twice a week. The Nuva ring is better, because she’d only have to change it once a month. In the end, if she chooses to go on the OCP before she starts having intercourse, not only would I give her the pills, I would award her with a gold star for being such a responsible young woman.”

  “Even if her first blood pressure reading was a little high?”

  “To be expected. The second was nearly in normal range.”

  “Well, then.” I stood up. I was on my own here, that was clear.

  Omar slid into my recently-vacated chair, mouth already open to present his case, but Dr. Callendar had some parting words of wisdom for me. “I hope you’re not letting your personal views interfere with her medical care.”

  What was he talking about? I gave him a strange look. “You think I’m against birth control?”

  “Are you?” He leaned back in his chair and watched me like I was a panda at the zoo, brought all the way from China
for his personal entertainment.

  I was on the pill myself, as we spoke. But that was none of his business. It took me a second to speak semi-civilly. “No. I just didn’t think it was indicated in a virgin who hasn’t had her period yet.”

  He waggled a finger at me. “That’s because you haven’t worked with teenagers enough yet, Dr. Sze. They are a seething cauldron of hormones. One moment, they are as innocent as lambs. The next, they are...not.”

  Omar had been clicking on his phone while Dr. Callendar spoke. He held up the screen and said, “One doctor says that you shouldn’t give oral contraceptive pills until after menarche, because the hormones can interfere with the closure of the epiphyseal plates.”

  “Give me that,” said Dr. C. He scrolled through the screen, eyebrows knitted, while Omar shot me a tiny grin. I smiled back until Dr. Callendar’s head jerked up again. “Dr. Hassan, you must learn to finish reading your articles before you quote them. Both Dr. Vanessa Cullins, Medical Director of Planned Parenthood, and Dr. Michael Policar, former Medical Director of Planned Parenthood, respond that it is appropriate to give contraception to a teenager before menarche if she is having intercourse or about to have intercourse. There is no evidence that the low dose of estrogen in today’s oral contraceptive pills limit a patient’s height by causing the epiphyseal plates to close prematurely. Now, perhaps in Oman, you can get away with such shoddy reading, but you’re in Canada now, and as long as you’re under my tutelage, I expect you to read the entire article before you make a comment. Do you understand?”

  “Certainly,” said Omar, in a neutral voice, but his left eyelid dropped in a tiny wink at me.

  I left the room, almost smiling. Dr. Callendar might be the worst SOB in the FMC, but at least Omar was showing me how to play him. I turned left out of the conference room, heading for the soiled utility room that doubles as our pharmacy. I crouched and slid open the bottom panel under the sink. I’d forgotten to ask Dr. Callendar what kind of pill I should prescribe, but as I suspected, we had only one kind of birth control pill to offer anyway.