Tuesday, October 31, 2006

Ghouls and Ghost Stories

Yes, I backdated my post to October. Suzan-Lori Parks may have been able to write a play a day for a year, but I know I’m not up to writing even a decent post a day for a month, so I don’t want to imply that I’m doing so by posting on November 1st.

Yesterday I supervised the residents for outpatient office hours. I mostly enjoy this part of my job; it’s a perfect opportunity to teach the art of medicine. There are all kinds of techniques for giving patients what they need and want AND being efficient. Sitting down when talking to them, asking “What else?” and “What else?” and “What else?” until they can’t think of anything more, asking “What questions do you have?” at the end of the visit instead of “Do you have any questions?” Explaining that something “isn’t dangerous” rather than saying “it’s not serious.” Oh, I’ve got tons of cute tricks up my sleeve.

Yesterday got a little out of control, however. We saw 17 patients between 2 and 5 pm, and most of these patients were not 10 minute visit types. A couple of them were very appropriate for Halloween, and haunted my thoughts all night. (Some details altered to shield identities.)

One was a patient I’ve been following for a couple of years; she got put on the resident schedule because I was out of town last week. This patient is truly horrifying. She’s an alcoholic, but not a flunked-a-couple-CAGE-questions alcoholic; no, she’s an old-school, drink-yourself-to-a-miserable-death alcoholic. She used to have a real job and a real life, but has lost it all. She has developed almost every sequela of alcoholism there is—heart damage, liver damage, brain damage, nerve damage—but most frightening is that she keeps falling down and damaging her flesh and bones. She drags herself into my office about every two months for follow-up from a visit to the ER with another horrifying injury. She fell flat on her face and smashed her nose in. She fell and bit through her lip, almost severing the whole bottom lip off. She’s broken both arms several times. She’s so malnourished at this point that she can’t heal properly. She’s a trembling, emaciated, misshapen wraith. And she’s always furious. Furious that she’s in pain all the time (and that I won’t give her narcotics, though she usually has plenty left over from the ER and the orthopedic surgeons). Furious that everyone is “shitty” to her. Furious that she has no life. And especially furious that everyone keeps “implying” that her problems are due to drinking, because she DOESN’T HAVE A PROBLEM, GODDAMMIT. She cries and shakes and fills the room with the fumes of whatever she had to steady her nerves that morning and licks her scarred lips with her cracked, swollen, vitamin-deficient tongue. And begs for sleeping pills.

My poor resident was terrified. I ended up doing most of the talking, because at least I’m used to her. There’s really not much to say; I just agree and express sympathy about the fact that her life is hell, and then decline to write prescriptions for mind-altering substances, explaining that I’m concerned they could make her fall even more often. I’m not sure why she keeps coming back. I don’t know how to help her. So that was the only lesson I could give the resident: sometimes there’s nothing you can do.

The second frightening patient seemed only perplexing at first. He was a new patient, a mild-mannered elderly man. He spoke only Albanian, so everything had to be said through the phone interpreter, and even the interpreter seemed to have difficulty figuring out what he was saying. He came with a “case worker” who knew absolutely nothing about him (and definitely didn’t speak Albanian). He presented with papers from prison stating that he had some medical problems and some psychiatric problems. He’d been released several months ago, and had been able to fill his regular meds, but not his psych ones.

The resident came out of the room and explained all this to me. “Someone has to know the story,” I said. “Talk to the case worker and find a number we can call.” She seemed skeptical, but returned to the room.

Turns out that this patient had been in prison for 25 years after becoming psychotic and strangling his mother. He’d been treated in prison with monthly injections of antipsychotic meds, which apparently worked well enough that he was released to a halfway house. Off his meds. The pharmacy hadn’t filled the prescription for the injection because they didn’t carry it.

We slowly and carefully went back in the room and got on the phone with the Albanian translator again, determined that the patient was not interested in harming anyone at present, and explained that we would be starting him on some new pills that he must take every day. (We also got him an appointment with psychiatry, but in our institution that takes a month or so.)

The last scary patient was frightening in what she had rather than who she was. She’s a sweet little white-haired 85-year-old woman who was recently admitted for a possible stroke. As they often do, the neurologists had sent a test for syphilis as part of her workup. The initial test came back positive, but they assumed it was a false positive, and discharged her with instructions to follow up with me and get the results of the confirmatory test.

Of course, the second test was positive too.

The resident was panicked. “How am I supposed to tell her?” he asked. “Her daughter is in the room!”

So I went in with him. First I asked if the patient understood why she was there.

“For the test results,” she said.

“And do you know what the tests were for?”


So I politely asked the daughter to step out for a minute, then dropped the bomb.

She sat for a moment, her eyes narrowing. Finally she said, “That brings back some bad memories. That no-good son of a bitch. My mother told me I shouldn’t marry him!”

Turns out her husband had cheated on her some forty years ago, and she found out because he’d given her syphilis. She’d been treated, but she didn’t remember how, since she was allergic to penicillin.

“That’s why I kicked him out,” she said. “He’s dead now, and it’s a good thing, because if he weren’t I’d throttle him myself. I thought this was over and done with.”

By the time I got home last night, HellBoy had already gone out trick-or-treating and come home—he’d had enough after just one house. He was having a good time sitting on the stoop with his dad greeting all the other kids.

I didn’t stay out there long. I’d had enough of ghouls and ghost stories for the day.


Mrs. Ca said...

That does sound like a scary night, although I hear that Halloween is always an interesting night in the ER too. Thanks for sharing the stories!

E. said...

Cute horsie. HB's shirt sleeves make me wonder where you live. Our town was cold as a witch's rigid nips last night.

The story of the hard-core alcoholic makes me so so sad. Sometimes there really is nothing you can do, and in this case seeing that fact brought before you over and over as she returns must be agonizing. I feel terrible for her. That's no kind of life.

Mignon said...

As I have before, I wonder again how a person in your position isn't overwhelmed by the lives of the sick people you see on a daily basis.

But then I see your beautiful boy, and I guess it makes a little sense. He's a boy now! Hardly a baby at all...

Lisa said...

I used to be a medical assistant for an internal medicine doc, and in the five years I worked there, we must have had 15 elderly patients test positive for syphillis. About half were women.

It was freaky.

Anonymous said...

..this reminds me of why I am choosing not to go into internal medicine...God bless you for having the patience and grace that clearly, I lack. I mean it.

Megan said...

Dr.Mama, patient #3 reminds me of some good ones (I'm a neuro nurse at a big univeristy hospital). Most recently, we admitted a 92-year-old (!!) man that had a stroke. We routinely test ALL patients with neurological changes for illicit substances....you wanna guess what he tested positive for??? Go on, guess...cocaine. It turns out his 19-year-old greatgrandson was supplying him with it!

On another note, I ran the Chicago 1/2 Marathon a month ago with my sister. We took 2h 54m to finish, but we ran the whole time! Thanks for the encouragment.

Ottoette said...

Funny, I thought the CAGE questions would have something to do with Nicholas Cage in Leaving Las Vegas. Guess he was pre-ordained for that part.
I was delighted to see a new post, but I can easily understand how blogging would be a bit down the list of priorities in your life.
Your son looks adorable. My 3 yr old lasted about 7 houses.

Orange said...

Our trick-or-treating involved two miles of walking. Although Ben got a piggyback ride for the last couple blocks, because two miles at the end of the day is a lot for a 6-year-old.

Before my grandpa died, when he'd become demented, there was some talk (don't know if it was confirmed or merely bandied about by the docs) that it might be old syphilis. Grandma's 94 now and in her right mind, so apparently he didn't transmit it to her if he had it. They were using condoms in the 1940s...my uncle was the result of a condom failure.

Anonymous said...

The alcoholic story was so sad. I hate alcoholics.

Did your neighborhood reschedule Halloween again this year?

meno said...

What a day you had. And probably a typical one. I hate denial, so the alcoholic story is so sad, and annoying.

Kal said...

I worked Hallowe'en, only picked up one costumed patient, was most dissapointed!

Did have an interesting conversation with a girl dressed as an Oxo (Boullion) cube, though.

Came to you from Barb, blogrolled!

Anonymous said...

Holy crapus. That's a scary Halloween, all right.

Will you please answer a silly running/asthma question? If you're not comfortable, I understand. Know first that I am visiting a doc this week, too, for the same reason.

I have a very mild form of asthma that I seem to have caught in my mid-20s (I'm 34) and it's exercise-induced and cold weather also brings it out. I might use an inhaler a dozen times a year.

Enter, however, running at 6 a.m. when it's chilly outside. Wheeze, wheeze! I need to run: I need the exercise badly.

Inhaler first, to prevent wheeze, or inhaler in pocket and use at start of wheeze?

DoctorMama said...

e.—yes, it does look as if we could be in a balmy clime, but then again, he’s the kind of kid who thinks it’s better to look good than to feel good.

mrs. ca—sometimes I feel as if every day is Halloween in my office.

Mignon—it’s mostly the haircut that makes him look older, but he’s got a couple of 2T shirts that he’s not completely swimming in, so I have reason to believe he is in fact growing.

Megan—way to go!

Kim—it is hard to fit the blogging in. There haven’t been enough boring meetings lately.

Orange—My uncle was a condom failure too! My grandma used to say “We thought he’d come out with a little rubber hat on his head!”

Denise—You remembered! It wasn’t quite as blatant this year, though there was a Halloween “parade” on Saturday. We didn’t have to think about it since we were out of town, and there were tons of people sitting on their stoops on the actual day. I think we got about 300 kids.

Emma Goldman—I hope it helps her at least a little bit.

Kal—a boullion cube is a pretty good one—I’m always relieved when women don’t dress as sluts for Halloween. Though why I should care, I don’t know.

Heels—inhaler first.

Anonymous said...

Thumbs up for a great run this morning. Thank you.