• 11 APR 12
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    Crime or Care: The Limit of Coercion

    Crime or Care: The Limit of Coercion

    Dr. Jan Bruckner wonders if health care professionals should coerce people out of harm’s way and urge them to be good citizens and productive members of society? What is the limit of good health care and who should make that decision?

    For the uninitiated, Strawberry Mansion might invoke an image of a magic castle, an elegant manor house, or luxurious living. People who know Philly have other ideas about this neighborhood. When I got the referral on Patient B, any illusion of elegance melted away. The referral described a 21 year old male with “5 GSW” (gunshot wounds) to both legs. His history said that he had been shot in the stomach when he was 18 years old and I would later learn that he fathered a son, spent 2 years in jail, and had been released home 2 weeks when he had been shot point-blank in both legs. I had an address but I knew that no street sign would guide me to this street and no house numbers would identify the house. When I called the night before to arrange my visit, I requested that someone meet at the house and that someone guard my car during the session. Patient B grunted approval to these conditions. As I turned into the street I saw a large young man lounging on the marble steps of a row house. He raised his chin at me so I pulled up to the curb. He tiled his head towards the door so I let myself in.

    I entered into a living room with circa-1960’s décor. A large black velvet wall hanging pictured the heads of John F. Kennedy, Robert Kennedy and Martin Luther King. An elderly woman sat on a sofa by a TV with her arms crossed. I identified myself and she responded, “How do I get these people out of my house?” I asked about my patient and she waved her hand towards the stairs.

    On the second floor in the back bedroom, Patient B lay on the bed watching music videos. I identified myself and asked him to turn off the TV so I could do my physical therapy evaluation. He ignored me. I explained that I needed to hear his heart beat and lungs sounds and that I could not get a good assessment over the loud music. He ignored me. I told him that he had the right to refuse physical therapy so I collected my coat and my bag and started for the door.

    “Yo! Where ya’ goin’?”

    “You don’t seem to be interested in having a physical therapy assessment so I’m leaving.”

    “Ain’t you s’posed t’ get me walkin’? Ain’t you s’posed to get me strong agin? Ain’t you…?”

    “And what are you supposed to do? Do you know that I am not getting paid for this visit? It says here MA-AP- Medical assistance applied. You have no health insurance. If you don’t want to cooperate, that’s your prerogative but I’ve got to work with people who want to work with me. Turn off the music and let me do my job or I’m out of here.”

    He turned off the music and I did the physical therapy evaluation. At the end of the session he asked me if he would be able to walk again. I said that it depends.

    “On what?”

    “On where you want to walk. According to my records, last time they patched up your wounds, you fathered a child and went to jail. You’ve been out of jail 2 weeks and you’re shot up again. Maybe the safest place for you is here in your Mom-Mom’s bed. May be that’s safer for me, too.”

    Wound vacs pumped breaking the silence.

    “Where ya’ wan’ me t’ walk?”

    “Some place that doesn’t get you shot and back on my patient load.”

    He laughed. “OK, what will it take?”

    “Truthfully, it will take a year of your life, a million dollars, every trick I know and more pain than you can ever imagine.”

    Wound vacs pumped.

    A still, small voice asked, “Ya comin’ back?”

    “It depends…”

    “Come back.”

    I came back and slowly over the next few weeks we found a way to communicate and to trust each other. He learned to move around and get himself out of bed. I jimmy-rigged a system using his high-topped sneakers, some clothesline, and his father’s leather belt that stabilized his legs enough to enable him to walk to the bathroom and negotiate the stairs with crutches.

    When he could walk independently 60’ and do the 14 steps from the first floor to the second, I said that the home care physical therapy goals had been met and I had to discharge him. He asked me what would happen after home care. I said that it depends. Where was he planning to walk? He said that he’d like to be a barber. His father was in jail and he didn’t want to be the father to his son that his father had been to him. He wanted his son to be proud of him. I told him that I would get him into an in-patient rehab program to get him to the next level of rehab but that he better become a barber because I had no intension of teaching him to walk again. I told him that I knew where he lived and he laughed.

    I never found out if he became a barber but he never came back on my patient load. Was it fair that I made him promise to get an honest job as a condition of getting into an in-patient rehab program? Is it the responsibility of the health care system to do more than just teach someone to walk, heal wounds, and stabilize a medical condition? Should health care professionals also exert a certain amount of pressure on an individual to lead a healthier lifestyle? Should health care professionals coerce people out of harm’s way and urge them to be good citizens and productive members of society? What is the limit of good health care and who should make that decision?

    Dr. Jan Bruckner lives in Philadelphia, Pennsylvania. She has a PhD in bioanthropology from Indiana University, is an expert physiotherapist and the author of the “The gait workbook: a practical guide to clinical gait analysis”. Jan speaks American English, Français, Italian, Spanish, Haitian Creole and Philly gangsta.


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