The Breakthrough

I smelled the patient, unfortunately, even before walking into his room to introduce myself. From the hallway, his odor of lingering stale smoke flared my nostrils, instigating childhood recollections of the wood-burning furnace at my grandmother's home. From a distance, the scent of smoke was just that--charred-burnt air, its weight clinging to my nostrils. As I approached the patient, however, the scent of smoke smoldered my wishful memories of Gramma's furnace. This was not the smell of crisp, dry maple and oak wood pieces flaming to heat a house, but rather the lingering smell of those little brittle white sticks of tobacco that come twenty to a pack.

I walked into Room 21, its closed curtain contributing to the suffocating staleness of the cigarette smoke, to find a 53 y.o. man sitting upright in hit cot, facing me. His face was wrinkled and leathery, his eyes weary. His thick gray hair was combed back away from his forehead. His lips were dry and cracked, his nose bulbous and veiny. He looked years older than what his chart conveyed. Sitting in the corner was a younger woman, maybe thirty-ish, wearing a warm smile. Her eyes danced with the kind of energy that we all wish we had.

I returned a smile to this pleasant woman while I continued to advance to this patient's cot, extending my hand in welcome to him.

"Hello, sir. My name is Dr. Jim and I will be your doctor today while you are in the ER." I turned and introduced myself to the woman in the corner as well, learning her name was Denise and identifying her as this patient's niece. I turned back to the patient. "What can I do to help you today, sir?"

He inhaled a deep, raspy breath before beginning to answer my question. "Well, Doctor," he said, "I just moved to town to live with my niece here (he paused, nodding his acknowledgment to his niece) when I got me some really bad chest pain." He assured me that his chest pain had since resolved. I quickly listened via my stethoscope to his acceptable heart and lung sounds while a flurry of activity occurred around us--an EKG, a portable chest x-ray, blood draws, and IV starts. I then continued with our conversation.

I asked him the usual questions. What was he doing when the chest pain came on? Sitting watching TV. Has he ever had problems before with his heart? Yes, three cardiac stents in his past. "And they told me I needed surgery, too, but I didn't want to go through with it." I asked him about his risk factors, for which his every answer was "Yes." Hypertension? "Yes." High cholesterol? "Yes." Diabetes? "Yes--just pills, though." Besides his own personal history, did he have a family history of heart disease? "Yes--both my parents had heart attacks."

Finally, I asked about the risk factor that I already knew the answer to. "Sir," I asked, "do you smoke?" The patient looked me in the eyes with his own intent, sincere gaze. "Not anymore I don't, Doctor." His answer intrigued me, of course, so I asked him to clarify his answer. "Well, I had my last cigarette right before the ambulance came to pick me up." Upon pressing further, the patient admitted to smoking at least two packs of cigarettes a day.

If each of us in the ER setting were given a nickel every time a smoking patient told us they had their last cigarette before seeing us, we would all be living in mansions and driving German sport cars. I would be cheering for this patient's efforts to quit, but two packs a day? This patient faced one heck of a mountain to climb over after his thirty-year habit.

We talked a little more about his health. He had required three stents total in his past, most recently in 2011. Despite his poor health, he continued to smoke and rarely took a baby aspirin a day, let alone his other required medicines for his hypertension, high cholesterol, and diabetes. "Well, sometimes I take them all, but I try to take my diabetes medicine every day."

It was here, at this pivotal moment, that the energy in the room became palpable, changing for the better. Denise stood up from her corner chair, speaking as she began to approach my side by the cot. "Uncle Bob," she said, reaching for her uncle's hand after her arrival, "that's all about to change. Now that you moved to town to live with me, we are going to make sure that you do everything right."

I liked Denise immediately. Who wouldn't? I looked from her back to her Uncle Bob, noticing the tears beginning to collect in the inner angles of his eyes. Slowly, the tears spilled over, trickling down his cheek. Denise and I remained quiet, a wistful calm settling in the room as I looked down to watch Denise's thumb stroke over the back of her uncle's trembling hand. After watching this rhythmic comforting, I looked back to Uncle Bob's face. It was contorted with a look of relief, of the knowledge that one wasn't alone in an uphill fight.

Slowly, Denise leaned in and kissed her uncle's cheek. It was sweet. It was simple. And it was an astounding privilege for me to witness such tenderness.

I stepped back from the cot and became invisible while Denise spoke to her uncle.

"Uncle Bob," Denise spoke, quietly and calmly, "Mom died two years ago, leaving us only with each other. I am glad you finally moved here to be with me and my family. Mom would have wanted you to live with me, so it's about time you got here. Now we just need to get you better so you can enjoy my children and they can get to know their Uncle Bob."

The patient, at his niece's words, completely fell apart, sobbing openly. Before exiting the room, to give Denise and her uncle the privacy they deserved, I asked him quickly again if he had any further chest pain. "No," he answered, "only a broken heart." I had hopes that his broken heart would be healed in the capable hands of his niece. And like clockwork, accompanying that thought as I walked out of the room, I overheard Denise continuing to speak. "It's all going to start by you throwing out those cigarettes of yours." Yep, I definitely liked this Denise character.

Thankfully, Uncle Bob's initial cardiac tests came back unremarkable, barring a high glucose level. He needed to be admitted for further cardiac work-up and, more importantly, to be plugged into our health-care system. With proper medical care and Denise's support, I had hopes that Uncle Bob might just be able to pull himself out from the current of neglect he created for himself.

Sometimes, when I meet a patient and their family, I get a gut-feeling that our efforts might be for naught; the familiar rut of a patient's self-negligence and non-compliance will eventually overtake any forward efforts made by the medical community. However, in most patient encounters, I do leave the room hoping and feeling that the patient's emergency room experience will make them more cognizant and energized to face their illnesses. Sometimes, this cognizance comes not from the patient themselves, but rather from a friend or family member. Thus was the case with Uncle Bob. We should all be so lucky to have a "Denise" in our corner to help us battle our way back for all of the right reasons.

I hope I don't ever have to hear from or see Uncle Bob again, for the simple wish that he conquers and controls all of his concurrent illnesses with proper outpatient management. With Denise in his corner, I think his chances of this are significantly improved. I hope I witnessed his breakthrough. And I hope if I do have to meet Uncle Bob again, instead of smelling a smokestack, I smell the refreshing scents of Irish Spring and Old Spice.

As always, big thanks for reading. More essays to come…I hope this finds you and yours well. Jim