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Chapter 10 Case Studies

        CASE STUDY 1: YOUTH AND SEXUAL HEALTH

        Nita is 21 years old and lives in Toronto, where she attends university and works part-time as a waitress. Her studies keep her busy, and she is doing well. As often as possible she returns to see her family in her community north-east of Montreal. On a recent trip home, she makes an appointment to see a family doctor at the community health centre, which she prefers to the university clinic. She sees the visiting family physician, Dr Pear, at the clinic, where she presents with vaginal discharge and itching, but is otherwise healthy and physically active. She has no fever or urinary symptoms and has normal bowel movements. She lives with her boyfriend and is taking birth control pills as prescribed.

         Scenario 1

        Dr Pear prepares to examine her. It is a busy day in the clinic and he is running behind schedule. He asks if she is sexually active, but does not take a full history. He proceeds to examine her without much interaction and recommends doing a Pap smear. He does not realize that she has regular examinations, is in a stable relationship, and is taking good care of herself. After finishing the examination, he says that the exam is inconclusive and he is not sure what is going on. He suggests that she might have an STI, does not explain other possibilities, and says that the nurse will call her when the results are back. He arranges for the nurse to come in and talk to her about birth control.

         Scenario 2

        Dr Pear greets Nita and asks her a few questions about herself. She tells him how she is doing in university, that she is in a happy and stable relationship, and about her symptoms. Dr Pear explains that he is going to do an examination to see what is going on. He leaves the room so that she can undress and asks her to drape herself so that she will feel more comfortable. He returns and prepares to examine her, going slowly and gently, and explaining what he is doing as he goes along. After finishing the examination, including taking a sample and examining the slide, he tells her that it seems she has bacterial vaginosis. He explains what this is and that it can be easily treated. He gives her a prescription for antibiotics and reminds her that if she has a Status card, she should show it to the pharmacist since her medication is covered.
        Dr Pear asks Nita if she has any questions. He also asks if she has regular health checks and if she has ever had a Pap smear. Nita explains that she has regular examinations and knows the importance of staying healthy, but that she doesn’t really like going to the clinic on campus. Dr Pear lets her know about Anishnawbe Health Toronto, an Aboriginal community health centre.

         Learning Points

        • Do not make assumptions about a young woman’s sexual activity, such as that she has multiple partners or dysfunctional relationships.
        • Always explain what you are doing during procedures and why.
        • Ask about Status as it relates to medication coverage. Be familiar with the medications that are covered by the NIHB, or have a reference readily accessible.
        • Ask open-ended questions, since these often give patients the opportunity to disclose things they are uncomfortable with.
        • Ask the patient if there is anything else you should know or anything else they would like to talk about.

        CASE STUDY 2: ADOLESCENCE AND PREGNANCY—MIDWIFERY CARE

        Tracy is a 16-year-old woman from a semi-remote First Nation community. She is 36 weeks pregnant and attending a prenatal visit with her community midwife. This is her first pregnancy and she has attended all previous visits with her mother and/or Frank, the father of her baby. Tracy is very quiet and makes limited eye contact during these visits. Tracy’s pregnancy has been fairly uneventful. Her weight gain has been 23 pounds. Laboratory values and blood pressure have been within normal limits. A 20-week ultrasound found no abnormalities of fetal anatomy. At her last visit the midwife told her they would be discussing place of birth today. Tracy’s options are to deliver in one of two tertiary care centres in a large city 9 hours away, or at a hospital in a smaller city closer to home. Tracy arrives for her visit with her mother and her midwife notices that they seem to be more serious than usual today.

         Scenario 1

        Her midwife Mandy quickly asks them what is wrong. When there is little response, she asks if Tracy is starting to experience some fears around labour and birth, and quickly goes on to reassure Tracy that they will discuss all the options for coping. Tracy does not make eye contact. After an uncomfortable silence Mandy begins to enquire about fetal movement, changes in vaginal discharge, whether Tracy is taking her prenatal supplement, headaches, etc. Tracy answers with yes or no.
        Mandy explains Tracy’s options for delivery, and asks her whether she has thought about which hospital she would prefer to give birth in. After a moment, Tracy’s mother replies that she will give birth at ______ tertiary care hospital and that she will be escorting Tracy. Tracy’s mother informs Mandy that Tracy is upset because she does not want to leave Frank behind when she flies into the city to give birth. Mandy asks Tracy how she feels about that and she shrugs her shoulders. Mandy proceeds to explain the next steps in setting an appointment with a referral physician and arranging transportation.

         Scenario 2

        Although her midwife Mandy suspects that there may be something bothering Tracy, she begins the appointment by asking about Tracy’s sister and her 1-year-old son, who she helped to deliver. Mandy casually asks whether there are any plans yet for who will be able to attend Tracy’s birth, knowing that the family is very close and Tracy would like more than one person to be there. There are some vague responses. When Mandy asks a question, she speaks directly to Tracy’s mother until Tracy initiates eye contact.
        She goes on to ask about fetal movements and jokes about how active the baby is at 1:00 a.m., saying that the baby is just like her mother. Tracy smiles a little and makes brief eye contact with Mandy, which Mandy sees as an indication that she is ready to speak about today’s concerns. When she feels that Tracy has relaxed, she asks about Frank and how they are doing as a couple. Tracy answers that she is worried about having to choose between bringing her mother or Frank with her to the city to give birth.
        Tracy’s mother then asks when Tracy will be “sent out.” Mandy reviews Tracy’s options for where to give birth and asks them if they have discussed their plans and considerations. Tracy’s mother replies that Tracy will give birth at ________ tertiary hospital and that she will be escorting her. Mandy glances at Tracy to see how she reacts. She reassures them that she will request funding for Frank to be able to accompany them.
        The referral appointment is booked for one week from the current visit.
        The day following Tracy’s scheduled appointment in the city, Tracy calls Mandy to tell her that she has noticed blood in the toilet and that she is still in the community. The midwife arranges to meet Tracy at the clinic to assess her. Frank comes with Tracy to the clinic.

         Scenario 1

        A medivac flight is organized to transport Tracy to the hospital to query early labour. Her mother arrives at the clinic with a suitcase and escorts Tracy. There are vague plans for Frank to travel later with Tracy’s father.

         Scenario 2

        Mandy comments on how Frank and Tracy are treating each other well and how important this is for Tracy and the baby. A medivac flight is organized to transport Tracy to the hospital, to query early labour. Her mother arrives at the clinic with a suitcase and escorts Tracy. There are vague plans for Frank to travel later with Tracy’s father. Mandy asks Tracy and her mother to keep in touch.

         Learning Points

        • Indirect questioning about feelings is often more effective, allowing the underlying story to emerge.
        • Noticing eye contact is an important aspect of reading body language since it is an invitation to communicate. Young people may initially hesitate to make eye contact.
        • When accompanied by her mother or another Elder, a young woman will often defer to her mother or Elder when questions are asked. Politely address the Elder directly in the conversation and respect and recognize her role as decision maker while carefully considering the patient’s perspective.
        • When a mother has to leave her community to give birth it can cause considerable stress in her intimate relationship. This stress can sometimes present as conflicted feelings about being with the partner or complying with guidelines and recommendations for leaving. This is especially difficult for young women in new relationships, and it is important to recognize that they are not deliberately being irresponsible; they are generally willing to be guided by caring adults in making significant decisions in their lives.

        CASE STUDY 3: PREGNANCY AND BIRTH EVACUATION POLICIES

        Marni is 31 years old and 35 weeks pregnant. She was initially seen in the emergency room of the hospital in her community and was referred to a tertiary care centre in the city after being assessed by the family doctor, who was concerned about preterm labour because of clear changes in her cervix. Marni arrives at the tertiary centre escorted by a nurse who reports that she was comfortable and had no contractions during the transfer. She reports that Marni has had no fever, urinary symptoms, nausea, or vomiting and that her bowel movements have been normal. Dr Green, the on-call obstetrician, proceeds with a medical history. Marni is a grand multipara, gravida 5, para 5, delivering at 37 to 38 weeks. She has not had any terminations, miscarriages, or stillbirths and has had 5 live births, all vaginal with short, uncomplicated labours and uneventful deliveries. She had gestational diabetes in her last 2 pregnancies and her antenatal visits for this pregnancy were unremarkable apart from the diabetes, which is being well-controlled with insulin.
        Being away from home, Marni is concerned about her other children and is eager to get back home. Since her contractions have settled down, Marni asks if she can go home. She tells Dr Green that there is a family doctor who comes to her community to deliver babies. She wants to be close to home for the birth so that she can be with her family.

         Scenario 1

        Dr Green explains that given her history, there could be complications. She tells her it is not safe for her to give birth in her community and that she will have to be flown out for delivery. Her husband will be able to accompany her, but not her children. Dr Green sends Marni home to prepare.

         Scenario 2

        Dr Green is worried that given her family concerns, Marni might present very late in her labour so that it would be too late to fly her out. She tells Marni that her reasons for wanting to give birth in her community are good reasons. Dr Green takes some time to explain why she thinks it is important for Marni to deliver in a tertiary centre, explaining the risk of delivering in her community in easy-to-understand language. She also gives her some information about things the hospital can do to support her through the labour and help honour the birth of her baby even though she will be away from her family. She gives her the contact information of the liaison officer.

         Learning Points

        • Consider the reality of living in rural locations, and the complex and multiple considerations a woman must make in leaving her community.
        • Familiarize yourself with the services available in rural areas.
        • Communicate with the mother about the plans she will need to make to leave her community.
        • Appreciate the cultural significance of birth to the family and community.
        • Acknowledge and validate the concerns of your patient; do not dismiss concerns beyond the safety of the unborn baby.
        • Be familiar with the programs and services available at the hospital to better support the inclusion of families.

        CASE STUDY 4: MATURE WOMEN’S HEALTH

        Jaci is a 66-year-old woman from a remote, fly-in community who presents to a nursing station reporting vaginal bleeding as spotting occurring several times per week for multiple weeks. She has no pain, no urinary symptoms, and no fever. She is voiding well and her bowel habits are normal. The nurse assesses her symptoms and medical history and then examines her. Her pelvic examination is unremarkable and her abdomen is benign, with no lumps or pain. The nurse refers Jaci to the doctor who is coming the next week.
        When the doctor arrives she examines Jaci and conducts an endometrial biopsy, which returns positive for abnormal cells and Jaci is referred to a tertiary centre in the south. Because of her age and difficulty speaking English, Jaci is accompanied by her daughter. At the tertiary centre, Jaci meets Dr London, the gynaecologist.

         Scenario 1

        Dr London takes Jaci’s history, running through a check-list of questions. Jaci’s daughter feels rushed, does not understand all the questions, and has difficulty responding, in addition to needing to translate the questions for her mother. When he proceeds to examine Jaci, he does not explain what he is doing or why. Jaci feels exposed and uncomfortable. Her daughter recognizes this, but does not feel comfortable interrupting the examination to tell Dr London this. He finishes the examination, tells Jaci that he needs further imaging and says the nurse will come to make arrangements. Since neither Jaci nor her daughter pose any questions, Dr London assumes that Jaci understands and he leaves the room.
        At their next visit, when Dr London has the results of the ultrasound, he explains that there is a tumour in her uterus and that she will need surgery. He asks the nurse to give Jaci her appointment dates and leaves the room to attend to his next appointment.

         Scenario 2

        Dr London greets Jaci and asks her where she is from, about her family, and how many children she has had. He asks if she travelled far to get to the appointment and if she understands the reason she was sent to see him. He explains that her bleeding symptoms are not normal because she has already experienced her change of life (i.e., menopause), and that the family doctor who comes to her community did a test that showed that the lining in her womb was not well. He explains that it is important to examine her uterus to understand the cause of the bleeding and that he will do this examination for her today. With Jaci’s daughter’s help, Dr London tries to find the word for uterus in Jaci’s language, so that Jaci can better understand what is happening.
        Jaci’s daughter helps her mother prepare for the examination, covering her as instructed by Dr London. He proceeds with the examination and warns her that it might be uncomfortable at times. When conducting the examination, Dr London explains each part of the examination and talks and examines slowly, so that Jaci’s daughter can translate what he is saying. Dr London finishes the examination and leaves the room so that Jaci can get dressed. He then returns and tells Jaci that she will need to have an ultrasound, ensuring that she and her daughter understand why and how this will be arranged.
        At the appointment to discuss the ultrasound results, Dr London sits down across from Jaci and explains that the ultrasound showed some growth in the uterus. Dr London explains that the growth could be serious or not dangerous at all, but it is important to be sure, so he needs to do an operation to take out the uterus. He asks if Jaci understands what he is saying and if she has any questions. Jaci and her daughter both agree that they understand. Jaci asks when she needs to have the operation and how long will she have to stay here. Dr London carefully explains the next steps.

         Learning points

        • Having a uterus is an important part of most women’s sense of identity, including Aboriginal women, even as grandmothers.
        • Be sensitive to shyness, modesty, and high rates of sexual abuse. Being aware of the legacy of the residential school system is particularly important when working with older Aboriginal women.
        • Always drape appropriately, taking a gentle approach and explaining each step of the procedure.
        • Use a professional interpreter if needed and ask if the patient is comfortable with the service. If using a family member to translate, be sure to use accessible language so that they understand what you are saying.
        • Check with your patient regularly to make sure that she understands what you are doing and what is happening with her. Do not assume that silence indicates agreement or understanding.