Wednesday, June 2, 2010

The Stressful Life

So you think you have a stressful life?

I walked into Room 14 and introduced myself to my next patient--a peroxide-blonde, twenty-something female anxiously sitting in her cot, her tattoos peeking out from both the collar area and the short-sleeves of her hospital gown.

"Hello, Marissa," I said, "I'm Dr. Jim and I'll be taking care of you today. What happened that brought you to our ER?"

Her answer was brief and, quite honestly, unexpected. "My boyfriend and my husband are both being jerks to me." It turned out that she had been "completely stressed out lately" from the shabby treatment from the men in her life. As a result, she was having episodes of heart palpitations, episodic runs of shallow, rapid breathing, and being "jittery all the time."

"In fact," she said, interrupting my history-taking, "I need a cigarette real bad. Like, right now."

I shook my head "no" to her request, explaining that my ER patients are not allowed to leave our department to go outside and smoke. "If you really need to, though," I said, "you are free to sign out against medical advice, go out and smoke all you want, and then sign back in to be seen. Unfortunately, you might be waiting a while."

As I expected, she decided not to sign out AMA and go have a smoke, but not before rolling her eyes at me. That's okay, though. Little did Marissa know, but I got an A+ in "Rebuffing Eye Rolls, 101." Hell, I could teach that class, even.

We continued on with our discussion. "I think I might be having a heart-attack from the stress," she said, sincerely trying to explain the full scope of her symptoms. "I never was like this until my husband threatened to leave me, and now I am stressing-out all the time. Even my boyfriend notices it." There was no flicker of self-awareness, although I was expecting at any time for her to jump up and down and recognize the root of her problems. Without my help. I was hopeful that saying the words out loud might make the obvious evident to her.

No such luck. Marissa needed to hear her it spelled out from her friendly ER doctor.

"Well, Marissa," I asked, "do you think that maybe you are creating a lot of your stress by trying to have a relationship with two men at the same time? Emotionally, that is a lot of energy you are giving away." My shoulders shuddered as I had a sudden thought of just how much physical energy Marissa might be giving away, too.

"Um," she said, "I don't think so. I think most of the stress is coming from trying to get pregnant." She looked at me to gauge my response.

I took the bait. "You're trying to get pregnant?" I asked, trying to mask my surprise. "By which guy--your husband or your boyfriend?"

"Well," Marissa said, "that's part of the problem. I don't know who I want to have a baby with yet. My husband is good-looking, but my boyfriend is a little smarter, I think." She took a slight pause before continuing. "Do you think I should go for some good-looking kids or some smart ones?"

I looked around her treatment room closely, straining my eyes to find the hidden camera that was obviously recording my reaction for one of those candid camera shows. I couldn't find a little peep hole, though. Unfortunately, this was a real patient-physician encounter.

"And," Marissa continued, "it's not just who should I have a baby with that is stressing me out. My boss just increased my hours to thirty-five a week. I used to do twenty-five hours before. I don't know if I can handle ten more hours a week."

Again, I took the bait. "What do you do that is so stressful, Marissa?" "I'm a bartender," she said, puffing out her chest with pride. "Do you have any idea how stressful a job that is?" I assured her that I didn't. "Yeah, well, it's not only about mixing and serving drinks. I have to listen to people go on and on and on about all their problems. Like their problems are more important than mine. Most of the time, I just smile and nod my head while I'm tuning them out."

I smiled at Marissa and nodded my head.

I had had enough of Marissa's complaining for this visit. It was time to move on to her physical exam and testing. And, hopefully, figure out what we could do to help her.

"Marissa," I said, after completing a stone-cold normal exam and reviewing her normal EKG, "I have several worries about you, the most important being that you are carrying on relationships with two men. I worry for your safety right there. Are you protecting yourself?" She looked at me funny. "Are you sexually active with both of them?" I asked her more plainly. "Well, yeah," she said, like the answer should have been obvious to me. I, however, didn't want to assume anything.

"Then you need to make sure you take care of yourself and protect yourself, okay?" She nodded yes. "Otherwise, I'm afraid, your symptoms all seem to be related to stress. The treatment for that," I continued, "is simple--reduce the stress. I don't know how you are going to go about this, but you need to simplify your life, make some decisions about work and your relationships, and start carrying those decisions through."

"But," she said, "I don't know if I should stick with my husband or my boyfriend. What would you do?" I looked at her, at the sincere plea from her confused eyes, and realized that she was not going to be able to make the decision on her own.

In my mind, I knew exactly what I would do. First and foremost, I would have Marissa throw out her cigarettes. Then, I would have her avoid both men for a month and see where that would leave her. Finally, I would have her immerse herself in her work, since her pride was quite evident when she spoke about her bartending work. Unless, of course, the bartending environment was contributing to her problems (which, I suspect, it probably was).

As gently as I could, I shared some of my thoughts with her. I explained to her that she was exhibiting "psychosomatic symptoms," where her body was physically exhibiting symptoms from her mental stress. Pure, unadulterated anxiety. Marissa, I thought, could benefit from a professional counselor to guide her through some of her decisions. And by staying in close contact with her family doctor, too.

"I'll tell you what, Marissa," I said, "I'm going to have one of our case managers come talk to you. They'll review your counseling options with you and, hopefully, a counselor will be able to help you make some decisions that will be in your best interests. Does that sound okay?"

She nodded her head "yes." "And," she added, "can I have something to help with my nerves over the next few days?" It was my turn to nod my head "yes." What I was providing was, really, only a band-aid to her problems, though. With her unique complaints, she needed to sort her head out.

I wonder if Marissa ever pursued counseling or not. Part of me suspects that she probably blew it off, thinking her time was more valuable than driving somewhere for an hour appointment. But a small part of me still wants to keep the faith in her...that, with a little guidance, she would begin to make more responsible decisions.

Sometimes, the stories and complaints we hear in the medical field are nothing short of mind-boggling. We only wish we were making some of this stuff up. Imagine, being torn between having a baby with your husband or your boyfriend. Makes me wonder if the baby turned out cute or smart.

Maybe both.

In the meantime, I'll just keep things low-stress on my end, plugging away as a father, as a husband, and as an ER doc...how about you?

As always, big thanks for reading. I hope you all had a great holiday weekend. See you on Friday, June 4. Until then...

23 comments:

leslie said...

I had a patient request Valium once so she could deal with the stress of her husband beating her. When I tried to suggest that perhaps the real solution was to get out of the abusive relationship, she rejected it out of hand.

Hudson said...

I really enjoy your stories. Cases like this and Leslie's make me really sad. I know that a lot of people end up in situations where they 'can't see the forest for the trees' but it still makes me shake my head every time I hear it.

c said...

Yes, I have stress. I'll have two squares of dark chocolate and go to bed.

Really? Seriously? Gah!

Capt. Schmoe said...

A true emergency. Marissa needs immediate surgery, a procedure to sew her knees together. If she doesn't grow up soon, that might have to be a permanent procedure.

I wonder if surgically joining the knees would be covered under Obama care?

Thanks for the post.

AtYourCervix said...

Like being an abusive relationship, it takes many, many incidences of a provider offering support for a woman to get out of the bad relationship.

If I recall correctly, a woman will leave her abuser on average of 7-12 times before she finally leaves (if she ever does). I would imagine the same concept would occur in a situation like Marissa's -- unfortunately rooted in poor self esteem and trying to find some source of identity and happiness in her life.

Keep offering the support/social service consult/counseling idea. Eventually, she will be receptive to it, and will follow through.

And hopefully, she won't end up seeing me on L&D with the "who's the baby daddy?" storyline.

Kate said...

The clients I work with at my counseling job sound like this sometimes. And I hate it when a co-worker puts them down. Some of them simply have never learned that having more than one man in your life might be a problem. That's all they've seen and lived. It's my job to help them learn something new.

I'm glad you were gentle with her.

Katie said...

Yesterday my mom was searching for a birthday card for my dad. "Happy birthday, son; happy birthday, boyfriend; happy birthday, son-in-law; happy birthday, father; happy birthday, father-in-law... where are the happy birthday, husband cards? Oh, hidden over here in the corner because no one is married anymore."

Your story just left me shaking me head. How on earth do you keep a straight face?

Plugging away here in my stressful summer life... you have no idea how stressful it is to find jeans that fit. :-)

<>< Katie

Cal said...

Assuming this love triangle was not accepted by all parts (it sounds like it was not, hence the stress), I think once you find yourself wanting a baby and not being sure who you want that baby with, it is time to take a break and have a long moment of introspection.

Rogue Medic said...

My husband is good-looking, but my boyfriend is a little smarter, I think.

Well, the boyfriend didn't marry her, but he is apparently at risk of an unplanned pregnancy, so smarter is a very relative term. The boyfriend is probably a coworker, regular at the bar, or a neighbor - perhaps the palatial estate next door.

That baby will sure lead to a decrease in stress. What would be the purpose of becoming pregnant with such an unstable life?

"But," she said, "I don't know if I should stick with my husband or my boyfriend. What would you do?"

Assuming a switch in genders to account for my sexual orientation, I still would not be in this situation.

Leslie said...

Jim, you never cease to astonish me, in a good way.

In this case, I am both astonished by your patient, and by your amazing amount of compassion.

Hopefully, I won't need to go to the ER for a long, long time, but if I do...I hope I get a doctor like you. Even a doctor with half your compassion would be great.

Your patients are very lucky to have you.

terri c said...

What a sad, sad story. I imagine there are some psych issues there, and I hope she can get some help to sort herself out. I don't see that happening too often but I can hope. At least at present she is not using alcohol to cope with her stress, at least it doesn't sound like it.

MLee said...

Capt Schmoe, lol, the problem with sewing her knees together is that she could still bend over:) (sorry couldn't resist that one)

SeaSpray said...
This comment has been removed by the author.
SeaSpray said...

Well done Jim!

I cracked up at wondering if being on camera.

I hope she got the counseling too.

At first I didn't feel any empathy for her and thought I just went from really dumb to even dumber in the ER blogs ..but then I began to feel for her. She sincerely couldn't see the forest for the trees.

Interesting how the answer to our problems can be crystal clear to others and for us it's like trying to navigate through an opaque world at times.

WarmSocks said...

That is so incredibly sad.

Anonymous said...

Dr Jim,

Your compassion was genuine....not often seen in ER docs. Yes, sad tale, on many levels, but all too true! Hear similar tales of woe unfold in the ED daily. We have entire populations with no coping skills...no life skills, no common sense. Series of bad choices (one after the other) and they have no clue.NONE!

Had a young, 20 something, come in for an abscess on her labia due to shaving- (? MRSA) for the 3rd time! Crying and upset this had happened (again). Told her she needed to stop shaving. "What am I supposed TO DO?" Like vaginal hair was the most disgusting thing she could ever imagine.Stop shaving! She couldn't fathom that thought.

I just knew she was going to continue to shave, so, I struck a balance and told her to trim with beard trimmer (not shave) if she MUST have trimmed vaginal area. Or, she could continue to get abscesses. Eeew! Duh? She never put 2 and 2 together...I hope I don't see her again!

"Like their problems are more important than mine. Most of the time, I just smile and nod my head while I'm tuning them out."
I smiled at Marissa and nodded my head." OMG- LOL! Saw that one coming from her very first mention of her being a bartender but laughed all the same!

Yeah, my life is as boring as watching paint dry... in comparison, to some of these ER folks. I'll keep plugging away at being a mom, wife and ER nurse. Not exactly no stress but I'm not creating my own problems...with bad life choices.

Summer stress- buying a new bathing suit-UUGGHH!

Thanks-911RN

SeaSpray said...

911 RN said "We have entire populations with no coping skills...no life skills, no common sense. Series of bad choices (one after the other) and they have no clue.NONE!"

I agree ..but I am wondering why. ??

My first thought is that parents aren't investing the time into their children. And in some areas ..it's generational now. But I am curious to know the opinions of others regarding this. Anyone have an opinion on blatantly stupid or misinformed or lack of coping skills, etc?

I know off track a little ..just find it perplexing.

911RN said...

Seaspray...your first premise is correct (to me)- parenting and how folks were raised.

I had a lone Hispanic mother come into ED with 5 children, all under age 8,with a newborn in a carrier! All her children were well behaved, respectful and patient despite having to wait in an ER. I never even heard the baby cry!!! I complimented her parenting skills and her children. It was obvious this good behavior was expected and taught in and outside the home.Mom was outnumbered (for sure) but had absolute control.

This group was followed by two seemingly educated, concerned parents with a hellion 2 year old with a chin laceration. He ran the room, was disrespectful, out of control and it was tolerated.The child ruled- not the parents.His behavior was obviously tolerated in and outside the home!No boundaries had been given to this child. If you never learn boundaries, right/wrong or are never held accountable for your behavior-you never develop positive coping, life skills as an adult.

Generational issues are another whole issue.Entire generation of the breathing "entitled." Don't work, have no money, no insurance, no education and no plans for any of the above. BUT, they CAN get pregnant and get Medicaid when they need it. Drugs, alcohol and abuse of prescription drugs can add another whole element to their lives.Their series of bad choices just snowball (like Dr Jim's Marissa decisions). Why would she EVEN consider bringing a baby into the mess she calls a life. She is not ready to raise a child- doesn't even have her own self together!If she does- she will raise one just like herself. How is she going to discipline a child-cannot even discipline herself!Parenting is tough stuff. Thus, the pattern repeats itself.

I, too, (like Dr Jim) am hopeful she pursued counseling but remain skeptical. She did go to ED for help (good sign) but came for pills- not so good.Not an effective coping mechanism to deal with just blatant poor choices that are crystal clear to the rest of us.

The amount of young people and CHILDREN on multiple, powerful mood controllers would make your head spin....medications for depression, anxiety, ADD, ADHD,Bipolar,antipsychotics etc. It defies logic and boils down to- no coping skills, no life skills. We have turned into a "pill for everything" society.Instead, of working on the problems- cover it up with a pill.

Addictions develop and the snowball grows larger.She will turn into a 'seeker' with whatever pill helps her cope.

Seaspray- you're right- perplexing question and one, for which, there are no easy answers. Difficult to teach effective coping skills to folks in their 20's if they haven't utilized any up to that point! Can be done but requires lots of work and effort on their behalf. Have to want it and be willing to DO the work to create positive change.

Those are my seasoned, RN observations from the ER ....the front battle ground of encountering misinformed and sad cases daily!

Thanks for reading-sorry so long.

Karen said...

The poor, poor girl.

SeaSpray said...

I agree wholeheartedly with you. And I appreciate your comments.

Responsible parents have to put effort into their children. We all fall short on bad days or when too tired ..but it's consistency that is key.

Developing a relationship, gaining their trust and respect so that when you are at odds and it will happen ..the strong foundation you built within them will be ever present and deep down they will know their parents love them.

It's not the material things you give them ..it's the effort and love ..even the discipline and boundaries.

I always say that we shouldn't ever punish our children ..but discipline them ..as in disciple ..*teach* them.

I love the example you gave with the woman w/5 children.

Also ..growing up ..it was *expected* that people would have good manners and values.

It seems there is a breakdown in society as with the school shootings and other violence. Violence since beginning of time ..but something is different. But I digress greatly now. :)

Media .. what young people are exposed to before they are fully developed in their thinking processes.

Sometimes I have wondered if it was fair for me to think parents haven't done a good job ..because our sons were so easy. It must be quite difficult if there is add, etc.

Yet I wonder if children aren't over medicated too, but how do parents discern the need for their child?

We have so many things to make life easier and yet seem to have more stress than ever. I wonder why?

tracy said...

Thank you for understanding, Dr. Jim. Not many people do, let alone doctors.

girlvet said...

OMG She is crazier than a fricking loon. She should have been booted out the door.

burned-out medic said...

what an excellent idea - breed. exactly what she needs. and exactly what we need. in about 15 years there'll be one more violent criminal lining to mug me on my way to work. yay.