"Stories of lost love, promiscuity, and
infidelity are common in the ER."
A story by Alexandra Godfrey, who practices emergency medicine at St. Joseph's Mercy Hospital in Ypsilanti, Michigan:
The girl with the STD wants a baby with the boy next door. The girl has the chubby cheeks of a 10-year-old and the idealism of a teenager. The boy wears his Tigers cap back to front and his jeans halfway off his waist, revealing his Snoop Doggy Dogg boxers. They come to the ER complaining of cough and congestion, but their real concern is VD. She has a malodorous vaginal discharge, and he has dysuria. The pair contrived this ruse to deceive the not-listening-but-listening audience in the ER waiting room."Love the way you lie," Journal of the American Academy of Physician Assistants>>
Away from triage, I place boyfriend and girlfriend in separate rooms. I want to hear both sides of the story.
I see the boy first. Cocky and talkative, he tells me that he has a new girlfriend who insists he checks out before she checks in. His new girl wants a guy with a clean bill of health and needs lab results to prove it. The girl with him is his ex, but she is unaware of her obsolete status. As he tells me his story, he casts a wary glance at the room next door. This look betrays him. He feels the pressure. He used crafty promises of eternal togetherness to persuade his ex to come with him to the ER. Soon she will know the truth. The boy who proclaimed himself her lifelong lover is a pretender who fears both slighted girls and the pain of STD cultures. He wants her cultures to negate the need for his: if she is clean, then he is too. Looking at me as if I am a brother, he tries to engage me: "Girl, are you picking it up as I am laying it down?"
I nod my understanding but tell him I still need cultures. This swiftly ends the friendship. The boy looks disappointed, then gives me a disingenuous look. He tries a different tack, flirting with me in an attempt perhaps to skew my thinking or at least distract me from the task at hand. He does not know that as a clinician, I am focused on his progression rather than regression. I carefully explain to him the rationale for cultures. I wonder when and where this kid will draw the line. I am gentle with the culture, but still he flinches and howls. The boy who yearns to be a playah is a child inside after all.
Next, I see the girl. The ex who does not know she is an ex loves the boy who plans to leave her for another chick. The girl is naïve and vulnerable. Her eyes brim with tears as she tells me about their heavenly future: "He's my guy; we're trying for a baby," she says with a dreamy smile. The tales of the Snoop Doggy Dogg boy have captured her heart. She loves the way he lies.
The girl is nervous about the pelvic exam. I use simple language to take her step by step through the procedure. The nurse holds her hand and guides her breathing. At 17 years old, she is having her first pelvic. The girl does it for the boy. She does it for her future. I wonder if deep inside she wants to cry. I question if my silence makes me the boy's accomplice. Bound by HIPAA, I am caught in the deception. This girl needs the wisdom of a mother, not the empty pinky promises of a smooth-talking kid. I wonder how she will manage labor. Does she know the demands of raising a child? I doubt it. Her dreams center on monogamy, young love, and the sincerity of the boy next door. Looking at her cervix, I suspect Trichomonas. I send cultures; then I prescribe metronidazole along with the usual ceftriaxone/azithromycin mix: an antibiotic cocktail that in the ER hints at a relationship on the rocks.
I counsel both partners about STD prophylaxis and management. I discuss contraception and pregnancy, giving the girl further information about women's health and multivitamins. The handout does not include a section on broken dreams, the cost of raising a child, or the lies a man might tell. I thought perhaps it should.
Stories of lost love, promiscuity, and infidelity are common in the ER. Some understand immediately the implications of their infection. I watch as faces fill with anger, dismay, or horror. I see trust shattered, dreams evaporate, and partners split. Sometimes I encounter questions that stem from naïveté and hope—contaminated toilet seats, distant partners, and unwashed hands offered as likely culprits. I tell the truth. I relate textbook facts. I say them gently. My remit as a PA is to educate, not to betray. Bound by privacy rules, I cannot tell the girl about the confessions of the boy. All I can do is help her see the truth behind the lies. When she leaves the ER, I am left pondering some ethical questions: Is it acceptable to sacrifice the best interests of one patient to the confidentiality rights of another? Is there a moral difference between lying and deceiving? Is it ethical for a clinician not to tell the truth?