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...

Hold A Hand

Our ER case manager and I recently walked out of the family room after having to tell an only-child that his 85 y.o. mother was critically ill. She was so ill, in fact, that she had required emergent intubation for her respiratory distress and was now being sedated and paralyzed. This allowed the ventilator to do all of her breathing, conserving this woman's body of some much needed energy. The patient's worsening circumstances had transpired over the past three hours at her nursing home prior to being transferred to us and, unfortunately, her son had been en route when his mother decompensated in our ER, circling the drain before our very eyes. Thus, he never got a chance to visit with her before her intubation.

As we left the family room to go back to the patient's room and continue medical management, the case manager and I walked in silence, affected by the situation at hand. I had tried to hold off this patient's intubation for a few minutes, hoping that her son might soon arrive to exchange a few words with his mother, but it didn't happen. Because the patient's living will had requested that she be a "full code" (my understanding was that she lived a fulfilling, independent life), all efforts would be employed in attempt to save her life and help her through this medical crisis. We had intubated her successfully and aggressively began her medical management.

Suddenly, the case manager stopped smack-dab in the middle of the hallway and spoke to me. "You are amazing in that room, do you know that?" I looked her in the eyes, trying to see if she had picked an inopportune moment to hassle me, to tease me the way that us ER co-workers sometimes do to lighten such heavy, burdensome moments.

She was being serious. "After introducing yourself and shaking this son's hand, you sat down on the couch beside him, touched his shoulder, introduced the rest of us, and asked him how he was doing before slowly, in words he could understand, explaining everything that had been done so far to save his mother's life."

"Yeah," I said, "so?"

She continued. "Did you not feel the tension in that room? And somehow, after you were done delivering the worst of the news, the room felt hopeful, at peace. You could see the son's face slowly accept the news you were giving him. You eased his worries by instilling that we were doing everything we can to help his mother, without falsely elevating his hopes."She paused here, taking in a deep breath. " You showed him that you cared."

"Doesn't everybody do this, though?" I said, knowing the answer before I finished asking.

The case manager laughed in a regretful, wistful kind of way. "Are you kidding? You would be appalled at some of the ways I've seen bad news delivered in that room. No introductions. No sitting down. Blurting out the bad news without any preparation to the family. Leaving without addressing any of the family's questions. Jim, you need to teach more doctors how to act and speak more appropriately in that room."

By now, we had started walking again and were standing outside of the patient's room. The son was going to be escorted back in just a few minutes.

Not one to gloat over getting a compliment, I walked back into the room and continued helping my senior resident with this patient's care. It was, once again, a thing of beauty to watch our team methodically go about each of their responsibilities and, as a result, we were soon rewarded with this patient's condition stabilizing. She was still very sick, but at least the son could now spend some time at her bedside. Which turned out to be a blessing as, in the end, this patient passed on that same evening.

Later on that night, at home, after tucking in my kids and a glass of wine in hand, I was giving much thought to our case manager's words. Just a few weeks prior, during a night shift, a nurse supervisor who had accompanied me in the family room spoke similar words to me when we were done. "The way you approach patients and their families is remarkable," she had said. I may have blushed, but her words were greatly appreciated and I viewed them as the ultimate compliment.

Why isn't everybody at their best, especially in that room? I thought to myself, though, becoming a little annoyed. When did medicine become so shifted to view patient's and their families as "its" and not as human beings, as "hes" and "shes"? When did we abandon learning patient's names and their life story? Of taking a little more time in their treatment room? When did compassion and kindness sneak out the window and rush, rush, rush sneak in. When did the the quantity of patients one treats replace the quality of care given to each individual patient, defining, in some peoples' eyes, a better physician?

Sadly, most of us in medicine know that answer. With the increasing struggles of our profession, from insurance cutbacks to legal threats, from hospital cuts of personnel to the shifting thought that patients' rights outstrip our own, medicine isn't the field it once was when I signed up for a career twenty years ago. Especially in the ER, it is now common for us to be 4-6 hours behind every day, patients now relying on us not only for emergent care but for treatment of their chronic illnesses as well as maintenance medications. Can you see the frustrations? This quantity has potential to impede on our quality, to cut into the time we spend with each patient and their family.

I recently gave an hour lecture to our residency physicians regarding kindness and compassion. I started it with a tragic video of 9/11, scenes playing out to Sarah McLachlan's "Arms Of An Angel." We then watched a synopsis of the Columbine tragedy before I started talking. There was nary a dry eye. "See this devastation, this grief, involved in such atrocious acts?" I asked the residents. "What makes this grief and loss any different from that which you will encounter in a patient's treatment room or our ER family room?" A dropping pin could be heard in the room. Grief is grief, I reiterated. Loss is loss. Death is death. Respect is necessary. Kindness and compassion are a must. Addressing such concerns, I assured the residents, is one of the most important jobs they will ever face. Put the time in and learn how to view this responsibility as a privilege and not a burden.

This lecture was never finished. Before my time was up, only half of the slides had been presented. Instead, we had spent a great deal of time talking about personal techniques on how to interact with patients and their families and how to deliver devastating news. My residents shared personal stories of their best and worst experiences. It was clearly evident that some of them were quite comfortable in their roles, while others struggled with this part of their jobs. This hour lecture on kindness and compassion had gone from the category of "light and fluffy" to receiving the respect it deserved. From the feedback of the residents, they were appreciative and definitely more cognizant of their roles in treating patients and their families.

As karma sometimes dictates, a few nights later, while reading Cutting For Stone, a brilliant fiction novel by a brilliant writer, Abraham Verghese (he who also happens to be a brilliant man of medicine), I happened upon a collection of words on page 519 that left me with goosebumps. In the novel, Dr. Thomas Stone, a leading liver transplant specialist, reads a letter from a mother of a trauma victim that he had treated. It follows:

Dr. Stone--

My son's terrible death is not something I will ever get over, but perhaps in time it will be less painful. But I cannot get over one image, a last image that could have been different. Before I was asked to leave the room in a very rough manner, I must tell you that I saw my son was terrified and there was no one who addressed his fear. The only person who tried was a nurse. She held my son's hand and said, "Don't worry, it will be all right." Everyone else ignored him. Sure, the doctors were busy with his body. It would have been merciful if he had been unconscious. They had important things to do. They cared only about his chest and belly. Not about the little boy who was in fear. Yes, he was a man, but at such a vulnerable moment, he was reduced to a little boy. I saw no sign of the slightest bit of human kindness. My son and I were irritants. Your team would have preferred for me to be gone and for him to be quiet. Eventually they got their wish. Dr. Stone, as head of surgery, perhaps as a parent yourself, do you not feel some obligation to have your staff comfort the patient? Would the patient not be better off with less anxiety, less fright? My son's last conscious memory will be of people ignoring him. My last memory of him will be of my little boy, watching in terror as his mother is escorted out of the room. It is the graven image I will carry to my own deathbed. The fact that people were attentive to his body does not compensate for their ignoring his being.

Brilliant. Simply and utterly brilliant. Thank you, Dr. Verghese.

We need to bring back kindness and compassion. We need to fix the medical field as it now exists so we can begin, again, to pay attention to that which is most import--the patient and their families. With kindness and compassion at the forefront.

Enough said.

As always, big thanks for reading. If you have had any experiences, either as a patient or as a family member sitting in that family room, that may enlighten us readers and make us better at what we do, please share...

For The Love Of Ruby

I have to admit, I wasn't one to really appreciate the offbeat behaviors and attachments that otherwise seemingly normal people develop with a family pet. I mean, really, have you ever seen a pet owner kissing their dog, tongue-to-tongue? Or letting their kitty-kitty-kitty lick them all over their face? Or letting their pet gerbil nibble the lettuce off of their nose? I'm surprised at the lack of short-term memory some of these owners must have to not have remembered watching their pet lick themselves...everywhere...just a few minutes before their face bath. I'll repeat myself...everywhere. I still cringe to think that before licking their owner's face, a dog may have been going to town on his anus. And that's just the boy dog.

It wasn't just the licking, though, but also that foreign language that I couldn't quite grasp. "Here, Muffy," the cat owner might say in a baby-talk voice, "come give your mommy a big kissy-kissy here on my lips." At least with the baby talk with a human baby, you eventually come to the conclusion that it will cease when the kid turns one, maybe two. An end is in sight, yes? But with cats? I don't think so. I think one is looking at 10-20 years of baby talk, minimum, with a pet cat. God forbid the day I scratch a dog behind the ears and whisper "goochie-goochie-goo." No way, no how--not for me.

I grew up around pets, yes, but they were at my grandparent's farm and they were outdoor pets. Besides several pigs, lots of chickens, and a little house full of rabbits, several cats and dogs were also part of the lot. They remained outside, though, and were well taken care of with their own private houses and feeding stations. We talked normal English to them. We pet them and fed them regular pet food from the 50 lbs. bag. They didn't wear designer outfits but, instead, relied on their genetics to thicken or shed their hair, depending on the season. The names rush me now--Sweet Pea, Prince, Trixie--and they were all awesome dogs, my buddies actually, when I was visiting for an afternoon or overnight. I don't think the dogs minded their lack of indoor living, judging by their playful run through the gorgeous, rich, adventurous farmlands.

So, with this upbringing, it seemed a little off to me that so much energy would be spent by an owner on making their pet so extremely comfortable within an indoor setting. Wouldn't the pet hair all over the floor and clothes be a deterrent enough? I've seen my share of ER patients with their clothing covered in pet hair. Cringe-worthy, I tell you.

Enter Ruby. Our family pet. Our yellow lab. I have to chuckle when I call her "yellow," though, because, if anything, she is actually pure snowy-white.

Most important? She spends the majority of her time indoors. Yes, I know, I'm eating crow. But she has single-handedly changed my way of thinking when it comes to indoor pets.

Five years ago, in March, our Ruby was born. Around the same time that Ruby was born, my mother passed away. Like any other family who has suffered a loss, try as we might, a certain "funk" seemed to linger around our house. Smiling was, at times, a chore. Sad realizations of Mom's death would interrupt happy moments. We needed to change things up.

My wife and her sister had a suggestion. Maybe it was time for us to get a family dog, something we had considered in the past but rejected. Sandy's family had two beautiful labs, both from the same breeder. This particular breeder focused her attention on two of the dogs' attributes--their gentle, mild disposition and their beautiful white coat. And she would not sell a person a dog unless she approved of them and the home her dogs would be joining.

Yeah, I'll think about it, I thought to myself. The breeder didn't have any available pups from the upcoming litters, giving me some available thinking time. Or so I thought. Because a few days later, Sandy called to say that the breeder had an about-to-be-born litter with one more pup than was supposed, confirmed by ultrasound.

"June said the pup is yours if you want it," Sandy said, exciting our family at the prospect.

Thus, the process began. First, we had to be interviewed by the breeder, June, a gruff woman with a heart of gold, whose profound love for her dogs was very evident. She, thankfully, felt that us receiving one of her puppies was meant to be. After a successful interview (brow-glistening included) and tour of her comfortable home, she led us to her enclosed back porch and the most beautiful litter of pups imaginable. And there, jumping on her hind paws and trying to get our attention, was our Ruby. Leaning into the enclosure, trying to climb out to us. The kids were sold. My wife was sold. And me? Standing there looking at the wrinkly, yelping little bundle of goochie-goochie-goo that so quickly took to our family, I knew I was hooked. Even if I hadn't been, I knew I was outnumbered.

Ruby, named for Mom's birthstone, came home with us in early May. Five years ago. Lifting that "funk" that had clouded our air for the whole spring.

Yeah, the carpets now get shampooed and vacuumed more frequently. Yeah, my socks have white fur stuck to them occasionally. Yeah, sometimes a leftover snack will disappear off the kitchen counter. Yeah, sometimes stepping in a pile of poop in the yard is annoying. Yeah, sometimes our house smells like wet dog after a walk in the rain. Worse, I've had to learn that dogs have gas just like humans.

And you know what? Who cares. Really, for all the love and smiles that she has brought to our lives, Ruby can certainly shed and traipse some dirt through the house occasionally. All it takes is one look at Ruby cuddling with the kids at bedtime to know that some things are worth the inconvenience. She is, quite simply, an important part of our family--our fourth kid, even.

So yeah, I've talked the (baby) talk. "Where's my Ruby, Ruby, Ruby?" you might hear me say when I get home from work. Without shame. That might be me on my knee, kneeling at her face level, tickling her ears while I whisper "We love you, Ruby." That would be my eyes, gleaming, as I throw the tennis ball and she chases it down, returning it at my feet.

My favorite thing about Ruby, though? Late at night, while we are all sleeping, she does her rounds, nudging open each of the kid's bedroom door and checking on them. Even my wife and I are included in her rounds. And if she suspects anything unusual, she can be found lying at the base of our stairs, ready to protect us as necessary. Otherwise, you'll find her randomly sleeping in one of the bedrooms, at the foot of the bed, every night. Snoring and farting. And fitting in beautifully.

Many of our family and friends now have indoor pets, most of them making adjustments similar to us, and we are happy to be included in this group. And, patients that come in with hair on their clothes no longer make me cringe. Well, except for the frail, elderly woman who has the hair of ten cats clinging to her wool sweater. Excuse me while I go sneeze...okay, I'm back. But I can easily picture these patients, in their home, cuddling up to their pets, their smiles bigger and better than any medicine I might possibly prescribe.

If you ever wondered about or considered an indoor pet, but opted out, reconsider. I am living proof of the convert that exists in all of us.

Happy 5th Birthday, Ruby! We hope you like your raw-hide presents and doggy-cake!

Now...get over here and give me a big kissy-kissy...

As always, big thanks for reading. This post is dedicated to my sister Rosie's little Havanese, Maggie, who will only drink bottled water and snack on mini-marshmallows! And my sister Susie's dog, Knuckles, who was the king of all self-lickers! LOL Have a good weekend...

Macys Or Mom

I walked towards Room 22 to see my next patient, an elderly woman who was found lying on the kitchen floor of her private home. She lived alone. Because of her advancing dementia, she was unable to provide any history as to how long she had been down or the circumstances that lead to her being on the floor. Unfortunately, due to the strong smell of stale urine and feces that permeated the hallway outside of her room, it was a safe assumption that she had been down for quite a while.

Not yet fully aware of how disheartening this patient's case would be, I opened the room's partially-closed glass door before sliding back the room's privacy curtain. I stepped into this patient's room as this patient stepped into my consciousness.

What I stepped into was sad. No, heartbreaking. The patient, rolled onto her left side by our staff and lying fully exposed on her treatment cot, was being tenderly wiped and cleaned by two of our ER nurses, one standing behind the patient while the other stood in front. Despite the slightly-dimmed room lights, I could appreciate the momentous task these nurses had of cleaning the hardened stool and human waste from this patient's neglected body.

I looked to unflappable Charlene, the nurse standing in front of the patient, who was shaking her head in frustration. "This is bad," she said, "really bad." She went on to explain that the patient was found by her two children, a son and daughter, on the floor of her kitchen, conscious but covered in human waste. Her own. The prehospital team believed she had been down at least several days. According to Charlene, the paramedics, our local experts on witnessing the best and worst of living conditions, said that this patient's home was among the worst conditions they had ever encountered. "There were multiple mounds of strewn garbage, numerous puddles of drying urine, and smeared feces everywhere you looked," Charlene said, repeating their words.

I shook my head. Although I hadn't yet learned the particulars to this patient's social situation, I had seen my share of elderly patients who were brought to our ER for treatment after they had been discovered incapacitated in their home, whether ill from a trip and fall or, worse, a catastrophic medical event like a stroke or heart attack. Unfortunately, they might sometimes lay there for several days, alone and possibly in pain, frightened of never being found.

The thought of a patient suffering in this manner always makes me shudder.

Descriptions of poor living conditions sometimes accompanied these patients, as well, but none to the degree that Charlene described. "Seriously, Dr. Jim, the prehospital team said that feces was even smeared on the kitchen counter." Maybe this patient simply struggled after going down, making a bigger mess of things.

I briefly observed this patient's body--her frailness, her thin, cachectic limbs, her slightly protruding belly, her transparent pale skin, her matted-down silvery hair, her deep facial wrinkles--before walking towards her head and squatting down to her face level, ready to introduce myself. "Maam," I said, caressing the right side of her face as I spoke, "I'm Dr. Jim and I will be taking care of you today." The patient stirred as I continued to stroke her face. And then, quite suddenly, she opened her eyes, searching eyes of hazel brown, that stared back into mine. After sizing me up, she gave me a big, confused, wondrous smile, the familiar smile of a good-natured dementia patient.

"Do you hurt anywhere, maam?" I asked, beginning my exam while the nurses continued to clean her. "No," she said feebly, shaking her head. I looked in her ears, her mouth, her nose. I listened to her heart, her lungs, her abdomen. I palpated every part of her body, rotating and flexing her joints to make sure she had no clinical evidence of fractures.

Outside of the obvious signs of dehydration and her frail body breaking down at her pressure points, I was happy not to find any obvious signs of injury or acute medical illness. Now, we could pursue a thorough heart and brain workup (including a head CT to rule-out a stroke) as well as several clearance x-rays and some additional urine and blood studies. More importantly, social services could be called to pursue further information on this patient's living conditions and social situation.

It was near the end of my physical exam on this patient, though, when I began to see the situation more clearly. As the nurses continued to clean the patient and I stood beside the patient auscultating her abdomen, the room's curtain flew back and a very meticulous, very well-dressed, very put-together woman hurried into the room. She was middle-aged.

"May I help you, maam?" I asked, pulling my stethoscope from my ears as both nurses looked toward the woman, taking her in as I'm sure I had done.

"Yes, I'm her daughter," the woman answered with severe enunciation, taking a corner chair while nodding towards the patient. I waited briefly for her next question, a question that never arrived--"How is my mother doing?"--while taking in her neatly highlighted hair, her pressed wool pants, her polished heels, her matching argyle blazer, the multiple bands of gold that hovered on her neck and wrists, her ring-covered fingers, her painted face. I looked back at the patient, now rolled to her other side, and back at this daughter again.

The dichotomy of the situation was startling.

I leaned against the wall, giving the situation a few minutes to play itself out. The nurses continued their diligent work, occasionally glancing at the daughter, while the daughter continued to sit comfortably in her corner chair. And watch. I didn't expect her to offer her help bathing her mother. And she didn't. I had hoped that she might offer to hold her mother's hand, though, or whisper some encouragement in her ear. But she didn't. No moments of tenderness or love ever came.

Finally, I went up to this daughter and introduced myself and the two nurses. "Can you please tell me what happened with your mother?" I asked, eager to hear what she could contribute to her mother's story.

"Well, we, my brother and I, hadn't heard from Mother for a couple nights, so we called her. When we got no answer, we went over to her house and found her on the kitchen floor."

"Any signs of trauma?" I asked. "No," she answered. "Any blood?" "No." "Was your mother awake when you arrived?" "Yes." "Did she complain initially of any pain or have any difficulty breathing?" "No."

After finishing my questions, none with answers that would change our treatment plan, I asked this daughter about the living conditions the paramedics had described.

"Oh, that," the daughter said, blase, "we think Mother may have tried to get back up several times and failed, creating such a big mess." I nodded my head, hoping this was the extent of it, hoping that there wouldn't be anything more to this story when social services investigated. But, by Charlene's account, the paramedics had said the whole house was in disarray, not just the kitchen. "My brother is over cleaning Mother's house now as we speak," the daughter added.

I continued. "And your mother has dementia but lives alone, I see?" She nodded 'yes.' "Why hadn't anyone seen her for at least a couple days? How often do you check on her? Who cooks and cleans for her?"

The daughter shifted in her chair. "Well, either my brother or I go over every day, but both of us were busy and thought the other had been over. We were wrong. We have a cleaning maid and meals delivered, too, but not on weekends."

Although most of the answers seemed adequate, something still made me uncomfortable about this case. Something I couldn't put my finger on. At this point, though, I saw this daughter's eyes glisten. "Maam," I said, acknowledging her first signs of compassion, "I'm sorry if these questions might upset you, but they must be asked. Your mother's health and care depend on your answers." She nodded her understanding.

After a few more minutes of talking with the daughter, I said goodbye to both her and her mother, but not before thanking the nurses for yet another awesome job of patient care. They are worth far more than what their paycheck reflects. I made a conscious decision to leave the rest of the social questions to our case management team and focus on the patient's medical care.

Unfortunately, the patient's kidneys had begun failing her, both from her moderate dehydration and from being clogged with muscle-wasting metabolites (rhabdomyolysis). She was admitted, obviously, for further medical care before ultimately being placed into a safe nursing home environment. She would never again be left alone at home.

I refuse to sit in judgment of this daughter. And the son I never met. But in my line of work, a healthy dose of suspicion is sometimes what the doctor must order. So I did. I have to trust that our system works.

I have several friends who recently lost their fathers. Just last week, my brother-in-law suddenly lost his mother. My world is filled with people who, regretfully, have lost one or both parents. Who have lost their spiritual guiders. Who would give anything to have just a few more minutes with their deceased parent. Who would do things a bit differently than this patient's family, I'm sure.

I know I would.

As always, big thanks for reading. This post is dedicated to those who give of themselves to benefit an elderly person in their lives. May your kindness and compassion be returned tenfold...see you again in a few days.