Tuesday, March 29, 2011

Underneath

A heartfelt appreciation to the readers who shared their personal stories, both devastating and hopeful, on my last post.  Your courage to share was felt and your words of wisdom were heard...thank you.

Walking into Room 33, my next patient, who had come to the ER complaining of cough and cold symptoms, seemed just as I had expected.  He appeared relaxed on his medical cot, lying back at 45 degrees, facing the room's door, his legs comfortably extended in front of him and his gown tied correctly behind him.  He was a few years shy of middle-age and appeared to be in good physical shape. His sandy blond hair, sprinkled with gray, framed his slightly weathered, apprehensive face.  Between coughs, he managed to give me a faint smile.

"Hello, Mr. Brown," I said, extending my gloved hand and introducing myself, "I'm Dr. Jim.  What can I do to help you in our ER today?"

He coughed before answering in raspy voice.  "I had a bad cold about two weeks ago.  It lasted about a week before going away."  Another cough.  "But now," he continued, after taking a deep breath, "it's back.  Back with a vengeance, actually." Yet another cough.  "I've had three miserable days of this stuff," he said, swirling his hand in front of his runny nose, reddened eyes, and dry lips, "and have tried every over-the counter medicine out there."  Cough.  "I just don't know what else to do."

As he spoke, my senses were acutely attuned to him.  I listened to see if he was speaking full sentences of five or six words or fragmented sentences of just a couple.  I listened for audible wheezing.  I watched to see if his diaphragm and intercostal rib muscles were struggling, under his gown, in their respiratory effort.  I noticed the skin coloring of his arms, the pink of his nails, his reddened, irritated nares, and the slight sheen to his forehead.  I listened closely to his cough, to observe if it was of a dry, hacking quality or a wet, congested effort; whether it came in short, interrupted bursts or was continuous and drawn-out.  I watched to see how quickly he recovered from these coughing spells.      

The patient probably thought that I, standing beside his cot with my stethoscope in hand and a smile on my face, was simply waiting for him to finish his coughing and complete his story.  And I was.  Of course, I was eager to learn of any other input he might share so that we could get him on the right road to recovery. What Mr. Brown didn't probably realize, though, is that as important as his providing a detailed history may be,  these obscure observational moments, wordless and symptom-producing, can provide just as much, if not more, information to a treating physician like myself.  I, for one, would much rather hear the cough than have a patient struggle in his description of it.  Penile discharges, though?  That's another story.

Back to Mr. Brown.  Even without doing my physical exam, I suspected he might be suffering from a community-acquired pneumonia.  "Sir," I said, touching his shoulder, "I'm going to perform a physical exam now."  He nodded his consent.  Starting with his head and taking my time, I closely looked in both of his ears (clear), his eyes (slightly bloodshot from his coughing spells), his nasal passages (angry red with significant turbinate swelling), and his throat (red, no exudates or swelling, mild anterior lymphadenopathy).  His tongue was dry and his breath smelled of neglect, like skipping a brushing.

Moving the exam along nice and smoothly, I next focused on his torso.  "Mr. Brown," I said, "we need to remove your gown so I can listen to your heart sounds and auscultate your lungs."  Trying to help, I untied his gown's back tie while he untied his neck.  Slowly, he pulled off his gown, somewhat hesitantly.  And after he did, I understood his reluctance.

His entire anterior torso, extending from his left shoulder to his chest to his abdomen, was a patchwork of skin-grafting.  Thin, transparent, papery patches of transposed skin were bordered by longitudinal, thickened keloid scars.  Some of the patches were less transparent and more natural-appearing, some of the scars less protruding and more flesh-colored, but it was obvious that multiple skin-grafts from multiple body sites had been a necessary, life-saving event at some point in Mr. Brown's life.

"I know, I know," he said, watching my eyes closely absorb the view of his torso.  "I never remember to mention these skin grafts.  Out of sight, out of mind, I guess."  He was almost too blase, leading me to believe that these physical scars walked hand-in-hand with his mental scars.

"May I ask what happened, Mr. Brown?"

"It happened when I was young, in elementary school.  Believe it or not, I had been playing with matches.  No, not on the playground," he chuckled here, "but in my backyard.  All I really remember is my shirt catching on fire, a lot of pain, the smell of my skin burning, and then my mother's screaming." He coughed a few times, his face mildly grimacing with the effort.

"I'm so sorry, sir," I said sincerely.  Imagine spending a large chunk of your childhood undergoing multiple reconstruction surgeries, missing school and losing friends, at a time when those things matter, in the process.  Being treated differently than the healthy kid standing next to you.  Not to mention the constant pain.  And feelings of lessened-worth.  Too many doctors appointments, no sports, lots of dressings.  I was letting my mind race in that brief minute.

I looked more closely at this patient.  Everything had seemed to change after seeing what was underneath his gown.  And now I understood his symptoms even better.

"Sir," I said, "do these scars restrict you when you need to take a really deep breath?"  He nodded "yes."  I continued.  "And do you get a lot of pain from these scars with your coughing spells?"  "Doc," the man smiled, "I think you get it.  It's been pretty hard with the colds this year, but these scars sure don't make recovering any easier." 

I did get it.  Because of his torso scars, his thorax, when stressed with illness, couldn't expand as easily as yours or mine. His fibrous scars and skin-grafting, lacking pliancy, prevented him from taking as full a breath as necessary.  Kind of similar to being wrapped and squeezed by an anaconda, I would imagine.  His work effort, thus, was increased.  And not exchanging air in the depths of his lungs, because of this momentous effort needed, would set him up to acquire pneumonia.

Not only this, but now I understood why he probably put a lot of effort and time into staying in decent physical shape.  "If I put on even ten pounds," he told me, rubbing the scar tissue around his umbilicus, "I start to hurt right here, from the outward pressure.  It seems any weight I gain goes right to my stomach, of course, and not my ass or legs.  Hell, I'd even take a double chin.  So I really have to be careful with my diet and exercise unless I want to have constant pain."  Talk about the pressure of eating right and hitting the gym.

Me?  I work out just so I will always look better than my brothers.  There is a lot of pressure being the best-looking boy in the family.  Clearly, he had better reasons than me to visit the gym.

After finishing Mr. Brown's exam, we got an x-ray, some baseline blood work, and an EKG.  His WBC count was slightly elevated, going hand-in-hand with a very early consolidated pneumonia viewed on x-ray.  We took no chances--he was placed on a strong antibiotic, given albuterol and atrovent nebulizer treatments and a machine to do the same at home, and, probably most important, he was given a strong cough syrup with hydrocodone to ease the stress that his cough was bringing.  He was quite appreciative upon his discharge, his cough lessened and his breathing a little easier.

"Thanks, Doc," he said, after he was dressed, "this was a good visit."

Meeting Mr. Brown initially, everything was just as I had expected.  Until we removed his gown.  And then, I saw what was underneath--the physical limitations of his body during a time of illness.  And underneath this, I was fortunate to learn of his hidden strengths and stoic fortitude that his life experiences taught him.  He seemed the better man for it.

I gave this some thought, about how much we all have in common with Mr. Brown.  How we show the world what we think they want to see.  But underneath, don't we all have something we are hiding, just like Mr. Brown?   Something that may even be limiting our full potential?  May it be physical.  May it be mental.  May it be both. More importantly, underneath, buried in doubts, don't we all have more good that we can give this world of ours?  If we just get over our fear of showing... What.  Lies.  Underneath.

Mr. Brown, thank you for trusting me to show me your underneath.  It made a difference.

As always, big thanks for reading.  I hope this finds you having a good week...

19 comments:

Heather said...

You know...this reminds me of Maslow's Hierarchy of Needs... Safety comes before love. Because if you cannot trust someone, you can't move any deeper. I tell that to my students and half the time they don't believe me...eventually, they get it. Trust...the word of the day!

rlbates said...

Great story! Best to you and him.

Priya Raju said...

Great story. Very well written.

Hope said...

Can this man not be helped further? Could the scars be loosened, somehow?

Peggy Arteberry said...

As always, this blog touched me deep inside. Thank YOU for being *that* kind of doctor that sees inside. I think you are a rare gem~ and I'm not just ruffling your feathers. I am always lost in your writings as if I'm there... My heart left with that gentleman that left the ER that day.. thanks to you, he will breathe easier and feel better soon. God bless you~

Jabulani said...

What a lovely story. Reminds me how we blithely ask someone "how are you?" and get told "I'm fine." Ever wonder what 'fine' means? A girlfriend told me it stood for Frustrated, Irritated, Neurotic, Exhausted. Or my preference (as I once blogged), Feelings Inside Not Expressed!! Perhaps the person we think is "fine", might carry scars we don't see!

Katie said...

Can I just say "Amen!"?

And I love the anaconda analogy. ;-)

<>< Katie

Life on Pause said...

This was a great story, and message. When I was 4 years old my dad suffered 3rd degree burns over 30% of his body, most of it being on his chest. He's had multiple skin grafts to on that area, and I suppose it never occurred to me why he has such a hard time with "a little cough." Thank you for making me think.

I also have Narcolepsy w/ Cataplexy, which can be made ten times worse than normal. I've had trips to the ER for something like a stomach bug, because with the Cataplexy episodes, it puts me at risk for aspiration... people don't always realize how some seemingly unrelated condition can hinder getting over even a "minor" illness.

Anonymous said...

Touched moved and indeed a wonderful story that bought our the human in one

jen mccafferty warren said...

Underneath...once again a compassionate point of view. You are certainly not educated beyond your obedience of opening your heart and mind to these patients. Nice work, and you do look the best of all your brothers ..Just as much as I try not to be the flubby sister on the beach...LOL Keep being a blessing....

Anonymous said...

Beautifully written! And it's great to see doctors like you who really care for their patients :)

Have Myelin? said...

Love the anaconda analogy. I understand how that feels (I think?) since those of us with Multiple Sclerosis get the "MS Hug" and right now I am grappling with the flu/cough/MS hug all at once.

Oxygen please? LOL.

coulrophobic agnostic said...

I wish more doctors were like you. I've never met one that really seemed to observe or care. Hell, most of them don't seem to want to hear your list of symptoms before they're off and running.

Carol said...

Love your writing. When I was a customer service rep at a bank, I had a young man who had been burned over his entire body and face. He came in with his mother, and they always waited patiently for me. I always wondered how much pain he suffered, but more than that the pain from other people's expressions when they looked at him. You are a wonderful doctor.

donna said...

I have been reading your blog for awhile now. Love it! It stands alone because of the faith aspect and compassion. I felt the need to post because this is the FIRST time
I have read a doctor listening to the patients lungs on bare skin!
I have asthma, though VERY mild, with a history of pneumonia and bronchitis. It usually happens after a moderate attack. In ALL my
years of going into doctors for UTI symptoms, I have never had a doctor or NP listen under my clothes. It is usually over a shirt, sweater (shirt) and then another sweater (I am Always chilled when I am in with this). I have offered to remove or pull up the clothing, 'nah..okay'. So kudos to you and your dying breed of doctor (at least in my area this is true). You are one of a kind! I always cry or am touched by your stories. Please don't change!
Donna

Have Myelin? said...

I had to come back and share my experience. I ended up going to Urgent Care Saturday for my chest strangulation issue (only to be told my Medicaid was inactive- there's a glitch but I was TOLD it was fixed!) so I either had to pay at the desk or go to the city ER which is 20 miles away (yikes!) but I luckily I had a credit card. What if I didn't?

Getting past the front desk without paying was not going to happen. I really do have Medicaid (my paperwork problem isn't their problem) but they don't know that.

I couldn't breathe. I had been on O2 all morning but it didn't get my O2 levels up. Anyway the kindly Dr (she was nice but she wanted to be paid first of course!) immediately put me on a steroid nebulizer treatment right then and my lungs opened up. Yes I shall live another day! That wasn't all she put me on but that's another story.

It is scary to be in the hands of incompentent Medicaid techs who lose a piece of paper. (my Medicaid caseworker tells me everything is okay...but everything is being denied in the meantime)

I do understand money talks but I was really gasping for air. I have O2 at home. I will be yelling at my Medicaid caseworker if I can catch my breath tomorrow, lol.

Can we clone you?

SeaSpray said...

Wow Jim! I was meant to read your post at exactly this time! Your final paragraph has personal significance for me ...based on something I just wrote that I have been wrestling with about myself and facing the future with some things. When I actually DO it ...then I will write about it. :)

Your entire post was excellent. Blessed patient to have gotten you at that time. :)

I know of someone (through a friend)who was burned so badly, that when they were finally released from the hospital after multiple skin grafts ..if they fell in the snow ..they could not get back up without assistance because no elasticity in his skin.

Most of us have so much to be grateful for ...even on our worst days.

Thanks for sharing. :)

Hold my hand: a social worker's blog said...

A very touching story. I'm glad you took the time to find out the true cause of his medical issue.

You are right, we all have scars that we are continuously hiding. Until some day, someone or something makes us look at the scar-- and life-- from a different perspective.

Doris
www.doris-socialworker.blogspot.com

Anonymous said...

Thanks for this post, it was very significant. I haven't had burns but have had 8 abdominal operations over the past 2 years from necrotizing pancreatitis and have lots of internal and external scars and keloids. I knew it had something to do with why my breathing is more labored, but didn't realize it put me at a greater risk for pneumonia.
Thanks for what you do...I have spent a lot of time in ERs and am thankful for doctors like you.