It would have been easy for newFNP to just blow off the attitude of the almost thirteen-year old obese boy who begrudgingly attended his well child visit with his mom today. Eyes steadfastly examining a single spot in the floor, his 213-pound frame turned away from his mom and from newFNP, he initially refused to respond to newFNP's questions or to his mom's exasperated pleas for the responses.
Tuesday, March 18, 2008
"You see, Doctora?" she lamented. "This is how he always is."
NewFNP cares for this boy, his two younger brothers, his mom - who has diabetes - and his grandma who also has diabetes and who has had two strokes. His mom cares for herself, her mother and her four children as best she can. One older boy is on house arrest. As newFNP flipped back to the last physical, she saw in her handwriting: father incarcerated.
NewFNP knew that this attitude was about that. She asked the patient if his dad was still in jail - he is. She asked him if that was why he was upset. It was. She asked the patient's mom to leave them alone, not quite certain how to broach the subject of the kid's attitude and his father's incarceration. These topics are difficult for newFNP - she often feel like the emotional equivalent of a bull in a china shop when she has to discuss them.
True to that expectation, newFNP's start was rocky. She asked her patient, whose emotional pain was weighing heavily in the room, to please look at her. He refused. She told him that it would mean a lot to her if he could just look at her. He made a micro-movement toward her, decided against it and again faced the floor and told her no.
NewFNP said, and in writing this she knows that it is harsh, "OK, so you just want to sit here and be a jerk?" He said yes. This affirmation opened the door for newFNP to ask him who has told him that he is a jerk.
And the floodgates opened. NewFNP is not sure what she would have done if they had not but it doesn't take a psychic to know that this kid has had a lot of negativity directed towards him. 'Jerk' may have been tame compared to other names he has been called.
NewFNP spent the next twenty minutes listening to this devastated kid cry about how he misses his dad. It was absolutely heartbreaking. He doesn't want to go to school because his dad used to take him. He doesn't want to go to the park because he sees all the other kids with their dads. When someone picks on him at home, no one is there to defend him like his dad used to. He is about to turn thirteen and all he wants for his birthday is to visit his father in prison. He is concerned that he will be deported and that he won't see him again. His uncle is mean to him, tells him bad words and to "calm the fuck down." His aunt yells at him. His mom is frustrated with him.
NewFNP was, frankly, not sure what to do. Obviously, this kid is at high risk for school failure, perhaps for criminal behavior given that his brother and father both modeled it for him. NewFNP knows that he is also at high risk for diabetes, that he already has fatty liver infiltration and she assumes that part of this overeating has an emotional component. She made an executive decision to blow off the medical concerns for today - at least in part - and to focus more on his emotional decompensation.
She told him that he has already seen too much and suffered too much for his young life, acknowledged that life has dealt him an unfair hand, allowed him to grieve his loss and his loneliness. She talked to him about his potential, about making good decisions and about how he is loved. She told him that she saw a sweet person inside who wanted love and caretaking.
She just let him cry and tell his story as, in the world according to newFNP, telling one's story is an important therapeutic process.
At the end of the visit, newFNP listened to the kid's heart. She let him listen to it - it was the first time he smiled during the visit. She asked his permission to check his blood and ordered a cholesterol, a comprehensive metabolic panel and an A1c - just in case. She told him that she would see him in two weeks. The nutritionist referral will have to wait until then.
NewFNP left him in the room and spent a few minutes with his mom. She asked her to tell him every day that she loved him. She asked him to tell her bullying brother to lay the fuck off. She told his mom that she was very worried about this sensitive and hurting boy.
NewFNP was e-mailing a pal from public health school to ask about mentoring programs for this kid when she heard him call her name. She turned around and he gave her a big hug and thanked her.
Even though newFNP thought how she was utterly powerless to change this kid's life during her encounter with him today, she simultaneously felt so grateful for the opportunity to say kind words to a troubled adolescent. She needed that. Clinic has been so overwhelmingly thankless lately that she had been questioning whether or not she could stay.
Even though newFNP didn't do much medicine with this guy, she definitely did some nursing. And some social work. And it felt really, really good.