Friday, June 3, 2011

To Like Or Dislike

I was shocked by her appearance. Although she was in her early 50s, she looked closer to 80.  Matted peroxide hair.  Dull, lifeless eyes.  Sagging skin and deep wrinkles.  Protruding cheek bones.  Cracked, dry lips with a hint of yesterday's lipstick caked in their corners.  Gray and yellow-stained teeth, some chipped. In her prime and before alcohol and cigarettes became her every thought, I could imagine an attractive, lovely woman.  Now, sadly, what sat in front of me on the hospital cot in Room 12 was nothing short of a shell of a human being.  This was a woman who lived a hard life.

She had presented to our ER in respiratory distress.  Although she already had an established diagnosis of emphysema, she continued to smoke two packs of cigarettes a day.  On top of this, she had just finished a ten-day drinking binge, the last five of which she spent either passed out or drinking.  She claimed to have not eaten in that time.  I was called to her room because she was in such dire respiratory distress.

"Maam," I said after introducing myself, "how long have you been having trouble breathing?"  She was gasping for air, her nasal folds flaring with each struggle to breath deeply in.  Through her thin hospital gown, I could see her ribcage and diaphragm heaving, compensating for her non-compliant lungs, trying to pull that extra oomph of air into her body.

"I...don't...know," she managed to answer, each word a struggle for her.  Her hands, I noticed, were pale, their spidery veins popping through her thin transparent skin.  They gripped the top rail of the cot for dear life.

Immediately, I ordered breathing treatments.  Steroids.  BiPAP (a machine with an attached mask that would force supplemented oxygenated air into the patient's lungs every time she initiated a breath).  Blood work.  A stat chest x-ray.  The rapid intubation kit and ventilator for stand-by.  I asked more questions, questions she could answer simply by nodding her head.  "If you get worse, maam," I spoke, asking the most important question of all, "we may need to insert a breathing tube into your lungs, hook you up to a ventilator, and do your breathing for you.  Do you want that if it comes to that?"

A "yes" nod.  She tried to speak.  "I've...had...that...before," she gasped.  "You've been intubated before, maam?" I repeated.  She held up two fingers of her left hand in a peace-sign.  "Twice," she said.

Within the half-hour, surprisingly, she began to turn around for us.  I spent considerable time in her room during this period, making sure she would not decompensate before our eyes.  With the additional attention of two stellar nurses and a respiratory therapist at bedside, she thrived and slowly improved.  Finally, as her lungs began to fill with more air, her nasal flaring and ribcage retractions subsided.

After stabilizing her breathing, we began to treat her other problems.  For malnutrition and dehydration, we gave her several liters of normal saline and a "banana bag," a liter of fluid supplemented with thiamine, folic acid, and multi-vitamins, giving it a yellowish-color.  For her withdrawal tremors, we gave her Ativan, a longer acting valium-derivative.  We fed her ice-chips.  We gave her anti-nausea medicine and several low doses of pain medication for her evolving alcohol-induced pancreatitis.  Her chest x-ray revealed pneumonia in both lungs, and we began antibiotics to cover her for the common community-acquired organisms as well as for aspiration organisms (only God knew if she swallowed some puke into her lungs).

Finally, after a lot of attention and energy given to her, she was at the point where I could sit down a few extra minutes with her, making sure I understood all of her history and didn't miss anything.

"Maam," I started, "have you ever tried to quit smoking?"  "Yeah," she said, her voice now a little stronger, more gruff, "but I don't really want to.  I like it."  She looked at me with challenging eyes as she said it.

"And maam," I continued, "do you consider yourself to be an alcoholic?  Have you ever had treatment for it before?"  She answered immediately.  "No, I'm not an alcoholic.  I like my booze, but I don't drink nearly as much as my husband.  Now he's an alcoholic.  But I'm not."  She enunciated "he," spitting out the word like it was poison.  Her denial was remarkable.  And expected.  "Do you want help while your hospitalized for your drinking, then?"  "Why," she asked me, "if I don't have a problem?"

I asked her about abuse.  She denied physical abuse but claimed "that he yells at me a lot."  Again, she refused to accept any counseling.

Finally, as I was finishing, she said "Can I ask you a question, Doctor?"

"Of course you can, maam," I said.  "What can I do for you?"

"Well," she said, "I don't understand why doctors can't take care of my problems.  I don't like coming here all the time for belly pain and breathing problems.  Why can't they just get it right the first time I come in?"

I was shocked.  Completely and utterly thrown off my game.  Hackles up.  The nurse, standing at the room counter with her back to us, writing on her chart, turned her head around to face the patient, her mouth gaping and shoulders tightening.  I'm sure mine were, too.  Although we don't expect appreciation, we certainly don't expect to be blamed for a patient's medical problems, either.

"Maam," I said in my calmest , most respectful voice, "you have emphysema and, yet, continue to smoke two packs a day.  You have pancreatitis and, yet, continue to drink.  You completely ignore your body's needs, not drinking water or eating food for five days.  You are hacking up phlegm and don't use your inhaler or pursue treatment of these symptoms, resulting in pneumonia.  You've been intubated twice and have come to the ER multiple times.  And you can't understand why your doctors 'can't take care of your problems'?  Have you considered that your problems might be from your own poor decisions?"

I stopped and stared at her.  She stared back.  I waited for her to speak.  I was going to stand there all day if I had to.  Finally, with the nurse now standing along her other side, the patient spoke.  "I guess you are right.  Some of these problems are my own fault."

"Not some of them, maam," I said, "all of them.  By accepting personal responsibility for them, though, maybe you can move on and start treating yourself and your body a little better."  Although I'm sure my words fell on deaf ears, I still needed to have my say.  Especially when we all worked so hard to turn this unappreciative patient around from her multiple medical problems, some life-threatening.

I grabbed the patient's hand.  "Listen, maam," I said, "I wish you well.  I want nothing but the best for you.  But if you don't change your habits, I am sure I will see you in our ER again.  And again.  And, one of these times, I fear, we won't be able to undo your problems."

I let go of her hand and turned to walk out the door.  She was admitted to the ICU and was going to be transported up shortly.  Before leaving, though, she called out.  "Doctor!"  I paused and turned around.  "Yes, maam?"  She hesitated before speaking.  "Thank you for your help today.  I'll think about the counseling, okay?"

I nodded to her.  "Good luck," I said before continuing out the door.

One of the most frustrating parts of my jobs is dealing with patients' frustrations of their medical problems, simply because of their lack of personal responsibility.  It's rampant, too.  I cannot cure patient's who do not put their own effort into their health.  None of us in the medical field can.  We are here to help you along your journey, to walk sided-by-side with you in your, hopefully, healthy path.  Of course, some people do everything right, by the book, and still have medical issues.  That's different. But if you want to eat profuse and bad meals, please don't expect us to cure it with a simple "sugar" pill. If you want to eat fatty and greasy foods, please don't get pissed at us when your cholesterol pill isn't helping.

I love my ER patients.  Seriously.  I have met some very cool people over the years, from both different and similar walks of life, simply from what I chose to do for a living.  I appreciate and enjoy learning the diverse stories that rest behind their faces.  Sometimes, though, I get frustrated.  We all do in the medical field.  At the end of the day, we are all human, whether we perch ourselves on a pedestal or not.  And, regardless, we want the best for you, the patient.

To my patients that have made my job rewarding, a simple thank you...it has been my pleasure learning about you and helping you on your healthy path.

As always, big thanks for reading...I hope this finds you all well.  Enjoy the weekend...

19 comments:

Jake said...

Hello,

I can't seem to find another way to contact you, so I thought I'd try this way. I work for a television show called "Untold Stories of the ER". We are in production on a new season and are looking for Doctors with unusual, touching, humorous, critical or life changing stories from the ER." I read some posts on your blog and was hoping you might be able to help us! If you want you can contact me at jbarker@untolder.com .

Thanks!

Jacob

Katie said...

Your patience is (and your patients are) remarkable! Thank you for always looking after us even when we aren't willing to look after ourselves.

<>< Katie

Lynda Halliger-Otvos said...

Doc, your stories teach me so much about the way to deal with all types of people and personalities. I love the way you handled this woman, especially when you were able to be honest with her about her own participation in her medical issues, informing her in a compassionate yet firm way that the genesis of her problems lies within her own control.

My younger brother died yesterday at 48 after a massive MI a week ago from which he never recovered. I can see elements of his life, albeit for very different reasons, in this woman’s story you describe so eloquently. Thank you for taking the time to relate this tale; there are lessons to be learned here for me too.

jimbo26 said...

My brother is the same ( apart from not drinking ) ; he's on dialysis , but won't give up smoking . He's 66 but looks 80 and last Saturday he almost keeled over . Unless they ask for help , nothing can be done .

Mo said...

I enjoy your blog so much...thank you.
mo

Carrie said...

I loved and agreed with this post. When my husband had high blood pressure, but wondered why his medication wasn't making him feel better, I totally re-examined our family diet. I reached the conclusion that medication can only do so much-- WE had to make a change.

We did. No more high blood pressure, no need for meds cause he's cured. Unfortunately, many people aren't taught the skills (cooking, for instance) of good nutrition. The inner aisles of the grocery store are a death trap, literally.

A good support system is so important for good emotional, mental and physical health. Again, having this, identifying this even takes some work. There are too many people not willing to put in the effort. Good supports means you are held accountable because good supports don't let you get away with bad behavior.

Damn shame. People ask us all the time how we've managed with all the health issues my family has been through in the past three years. It's no secret: you take responsibility and act upon it. You become aware and develop insight into your own health. You work with the healthcare community and not against them. And you heal thyself...

Your patients are very lucky to have you, even if they don't know it.

Sarah P. said...

So many times I've had this same conversation with people...ot only with the pneumonia, pancreatitis and COPD, but also uncontrolled diabetes, morbid, STDs and repeated unwanted pregnancies.

Denial is a tough disease to fight!

Anonymous said...

Thank you for that. I should learn such diplomacy.

Teri said...

My first thought was dementia or short-term memory problems from the drinking, malnutrition and low oxygen. It seemed like a total switch from answering that she'd had lung tubes twice before, to then asking such a child-like, illogical question. Could the patient really be that unaware? Maybe you were TOO diplomatic and kind?

coulrophobic agnostic said...

Hey, Untold Stories of the ER is posting here, that's awesome! I've been absent from blogspot for a while (I tried this "real life" people have been telling me about...turns out I prefer the internet ;) ) but I'm so glad to read your entries again. How you keep from yelling at these people is beyond me. I've been mulling over going back to school for nursing, but I just seriously don't know if I can deal with it all.

Kate said...

You've been doing this long enough to know when your words fall on deaf ears, but you say them anyway. I admire that.

--Sunrise-- said...

This is a really neat blog post, thank you for sharing. I am a medical student who just blog-hopped on over from Doc Cartoon's blog! :-)

SeaSpray said...

Hey Jim! You had me with your first paragraph! As always, you take us right in the room with you.

I've heard that if women become alcoholic they will fall harder and faster than men. I recall there was a pretty young woman who used to come into our ER via ambulance ...totally wasted. So much so that she couldn't do anything but stare at you. She had the most beautiful light blue eyes lined with the naturally black eyelashes. And a pretty smile ...when she smiled and that is when she accompanied someone else to the ER. Anyway, after working there for 20 years, I saw the deterioration in appearance you described. She almost took on a witch like appearance it became so hard. Also, her family life deteriorated. When sober, she seemed so nice. It was very sad.

I know of someone continuing to smoke with emphysema. And my husband smoked for most of his life and once sadly told me, "I want to quit ...but, I LIKE it."

But then a year ago, a close friend (never smoked)was diagnosed with stage 3 lung cancer. he quit 2 days later using the Nicorette gum and never went back.

It is shocking how some patients blame the physicians and other medical staff for things when it is clearly their own lifestyle choices causing them to reap what they have sewn. I can relate because I wrestle with weight issues ..yo-yoing ..but is a struggle for me. I would n-e-v-e-r blame a doc though and any person with intelligence and clarity of mind would not.

You handled it perfectly!

I hope it impacted her enough to really want to do it. But, then she has to go back into the old environment. Miracles do happen though.

Anonymous said...

And will you get a "smack down" from your superiors for telling this lady the truth?

I haven't worked in an ER for 4 years...burnt out. Because the "powers that be" wouldn't let us use tough love on any of the patients. The suits thought that we had to "be nice" to everybody; just to get good Press-Gainy reports.


Steve (This is my 10th year as a nurse; and I'm ready to hang it up)

barefootmeds said...

Wow! I'm a third year medical student in South Africa and have recently been struggling with understanding patients who refuse to change their lifestyles. I want to be a good doctor, but I have to keep reminding myself why I want to help people who refuse to help themselves. Thank you for the posts; I shall definitely be returning.

ButDoctorIHatePink said...

I just found you from KevinMD. First, I was touched by your story of the son caring for his mother, and how it related to your experience. I am dealing with Stage IV breast cancer and worry very much how it will affect the lives of my children. Then, to read this story also touched me, as my mother recently died of alcoholic cirrhosis of the liver. My mother avoided doctors because she didn't want to be told to stop what she was doing, but I sure wish she could have heard your words.

I'm not sure why I'm writing except to say both of your stories resonated with me and I've linked to your blog from mine.

breast reduction surgery said...

It is good to be sharing through such difficult days in life.To write the pains and pleasures of life as it stands.The endurance you show is inspiring.

John Valenty said...

sounds like you gave her the wake up call she needed!

Anonymous said...

Sir, a doctor like you in the ER made me smarten up about my asthma, realize that my old PCP was an ass (he ignored my repeated ER trips, refused to tell me what if anything I was doing wrong, and refused to increase my control meds despite needing a Ventolin inhaler a week), and realize that if I wanted to regain my health, I couldn't sit around passively waiting for someone to come and save me, I had to be willing to be a firm PITA so I could get the care I need.

I changed doctors and over the past two years, have attained good control and more than doubled my lung function. I went from having a hard time walking across a room to considering a 15km hike a 'fun weekend stroll'. I think that ER doctor, coupled with my current PCP, have saved my life. I'm now applying for med school, and I hope that I can do for someone else what they did for me someday. :)

So, thanks for all you do, and rest assured that every now and again, you will get through to someone.