Tuesday, October 28, 2008

Where Civil Liberties and Personal Responsibility Meet

Every Emergency Department (ED) has its regular patients. We colloquially call them “frequent flyers.” They can certainly tax an already overburdened ED. Interestingly, in a 2001 article in Annals of Emergency Medicine, researchers in Oakland reported that a 46-year-old man had rung up more than 1,000 ED visits in less than 3 years. He was not just coming to the ED daily; he was coming on each shift. Interestingly, ED nurses either treated him with antipathy or sympathy. Interventions failed to change his behavior.

We had a “frequent flyer” who was an enigma. She first started to frequent our ED when she was 14-years old. Her initial complaints were vague and we would find that neither she nor her mother would follow our recommendations for treatment. Then, at age 14 she became pregnant. The hospital assured she got good prenatal care and that she was enrolled in Medicaid.

LaTonya was the victim of poverty and probably mild mental retardation. Soon, both she and her newborn were regular ED visitors. I remember, on many occasions, examining her baby girl while LaTonya sat next to the bed with a blank stare on her face. I would explain the diagnosis and proposed treatment and then she would pick up the baby and be prepared to leave. Sometimes, LaTonya’s mom would come along and would chide LaTonya for not following the doctor’s directions. Sometimes, LaTonya would show up to the ED with her child without reason. The triage nurse would ask LaTonya what was wrong with the child only to have LaTonya say, “I don’t know. My momma told me to bring her in.” Over the next 3-4 years LaTonya delivered another 3 children. By this point LaTonya was almost 200 pounds, but only 5 foot or so in height. She was obviously an easy target for the neighborhood boys. Love is blind, and has no sense of smell.

By now, LaTonya and one, or all, of her 4 children were regular fixtures in the ED. Once, one of the nurses thought she could make a difference. She decided to try and find out who the various fathers of LaTonya’s 4 children were and try and get child support for LaTonya. As you might imagine, LaTonya did not have a clue as to who fathered her children. Any attempt at DNA testing would have to include all males in the neighborhood as they all, at one time or another, had a poke at LaTonya. One day, after examining two of LaTonya’s kids with upper respiratory infections, I explained the simple treatment only to be met with a blank stare. At that point I developed a whole new respect for veterinarians. Their patients cannot talk.

Finally, at age 19 LaTonya was pregnant for a fifth time. The nurses again set out on a mission—helping LaTonya get her tubes tied. LaTonya didn’t want any more children (so, she said). When she came in to deliver her fifth child, all anticipated an end to her fertility. But, after she delivered, her scheduled post-partum tubal was cancelled. It seemed that LaTonya had missed several prenatal appointments and never signed the sterilization consent (they must sign at least 60 days before the procedure). She left the hospital with her 5th child and her fallopian tubes intact. Attempts to get LaTonya to take birth control pills were unsuccessful. She forgot, lost them, didn’t get the prescription filled, and similar excuses. By now, LaTonya, her 5 children, her mother and 2 adult brothers all lived in the same house—all receiving government subsidy and not a soul working.

At age 20, LaTonya was again pregnant for the sixth time. A local OB/GYN offered to do the post-partum tubal for free, but anesthesia would not and the whole plan died on the vine. Eventually, LaTonya and her family moved and she quit coming. Over the years she and her 5 children had well over 500 ED visits and nary an admission.

This begs the question. If government (meaning we, the people) is going to support a family for their entire life, does government have the right to deny benefits when health care and social recommendations are not followed? We would not transplant a liver in a patient who is still drinking. Yet, we will allow uncontrolled procreation in a patient who probably does not have the mental capacity to determine whether unprotected sex is in her or society’s best interest. The sad thing is that we are victims of our environment. The only life that LaTonya’s children will ever know is one of poverty and entitlements. Redistribution of wealth is not the answer. Personal responsibility, integrity, and a good work ethic is the answer. My grandparents survived the great depression and 2 world wars. They never depended on the government for anything. What will the millennium generation (the current generation who believes they deserve entitlements) add to society? However, wherever LaTonya is—I wish her well.

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