How Do Doctors Care For Patients Who Don’t Care For Themselves?
Smiling through the pain
“Hello Brandy. I’m Michael Burg, an emergency doctor. How can I help you today?”
That’s my standard greeting at work.
I’m smiling.
The nauseating stench of ashtray mixed with neglect assaults me from across the room. It emanates from Brandy and from her mother, who is here with her.
I continue smiling, crossing the room toward my patient. She’s halfway through a double cheeseburger and a supersized bag of fries. The smell of onions, pickles and deep-fryer fat invades my nose as I near.
Twenty-two-year-old Brandy has aged far beyond her years and weighs about 12 to 15 times her age. Her hair hangs in greasy straggles. Dust covers her knees, elbows and feet.
I’m going to hate this.
“My stomach hurts,” blurts Brandy.
Her teeth!
About 20 are left standing, many black, rotting. Sourness arises from Brandy’s mouth, blending with the other odors trapped in the small space.
My smile is pasted on now, a fixture. I sit, smile maintained.
“Where does your stomach hurt?” I ask.
Brandy responds by gesturing vaguely, making a broad sweeping motion over her midsection’s wide expanse.
“And how long has this been going on?” I continue.
“Don’ really know. Maybe ‘bout a month. And I’ve been vomicking.”
I recognize the often-used mispronunciation of “vomiting,” noting it correctly in Brandy’s medical records.
Brandy’s mother weighs in with, “She’s been using my Vicodin and Percocet .” Both words are pronounced perfectly, like she’s a pharmacist in training. “Nothing works though. The pain just keeps getting worse. What do you think is wrong with her?”
My patient continues devouring her burger and fries.
Brandy’s mother looks to be an extremely well-worn woman in her late 30’s. She overflows the “big boy” wheelchair in which she sits, looking as though she’s fallen there from 20 feet up. Her fat laps at the edges of the armrests and supports that make up the chair, bulging from beneath her filthy, faded, graying mumu.
Brandy’s future, in the flesh.
Staggering on, I ask, “Is there anything more you’d like to tell me?”
I look at Brandy expectantly, smile now dimmed.
“What else has been bothering you? Have you had any other problems?” I prompt.
Brandy chews and swallows. “No nothing.” She states flatly.
“No fever or problems peeing?” Again prompting, using the word “peeing” deliberately, having learned long ago that “urinating” is unfamiliar to many, and just creates doctor-patient distance.
“Well yeaaaahhhhh!,” Brandy drags out the phrase, as though she’s saying “of course!” and I’m a moron for not knowing so.
“One o three to 104, and it stings when I pee.” She continues, in the “of course” tone.
Can a 20-something woman not know that fever and “stinging while peeing” are not “problems?” Why is prompting required to obtain this information?
I’m wearing a death mask, or so I imagine. My face, dry and tight, stripped of life. Loathing lurks beneath the surface of my being.
But pressing on, “When was your last period?”
“Can’t ‘member … few month’ ago.”
“Could you be pregnant, Brandy?”
“No way! Can’t be. My brother is sterile.”
Sex with her brother!? Is that what I just heard!? My face is impassive.
“No, no, no, no, nooooooooooo!” Brandy’s mother crashes back into the conversation, the inappropriate implications of Brandy’s nearly-random word salad crystal clear to her.
“Oh no, Brandy’s brother really can’t be a daddy. He’s a kinda simple mule. They do not have sex with each other.” She emphasizes the word “not.”
“Anyway, she can’t be.”
Brandy adds, “I can’t be, yeah, I can’t be. They tol’ me so.”
“Oh, who told you this?” I probe.
“Some clinic out there.” Brandy waves toward the walls of her cubicle, as if by gesturing she’ll clear up all uncertainty about clinic name and location.
“Have you ever been pregnant before?” I venture.
“Once” she says in return.
“Oh so you might be pregnant again? Is that possible?”
“No, I tol’ you already. I can’t be. They tol’ me.”
I’m nearly drowning.
The phrase “tragedy plus time equals comedy” drifts into my head.
A long time will have to elapse before this pitiful scene will translate into a comedic one.
Trudging on gamely I inquire if it’s OK to ask about social habits. I get a nod.
“How much do you smoke?”
“I’m gonna quit.”
Yes, but how much do you now smoke?”
“Two a day. But I’m quittin’”
“You mean 2 packs a day right?”
“Yeah.”
“How about alcohol? Do you drink anything with alcohol in it?”
“No.”
“How about beer or wine?”
“Oh yeah.”
My brain is quietly imploding.
Does she really not know that beer and wine contain alcohol? Isn’t that exactly why she drinks them?!
“How much beer do you drink?”
Brandy and her mom trade sly glances, then suddenly both burst out cackling.
“As much as ‘r checks let us.”
“Have you ever used drugs of any kind?” I emphasize the words “ever” and “any.” My attempt to get at truth with a single question.
“No.”
“How about things like marijuana or meth.” I deliberately choose two of the local favorites.
“Jus’ weed.”
Pressing on I ask, “How about any other drugs?”
“Well I used meth, long time ‘go.”
“What do you mean by a ‘long time?’”
“A while, you know, years.”
“OK, I understand.”
“Is it alright with you if I gently examine your belly? I’ll try not to hurt you. Then we’ll run some tests to sort out what’s wrong inside.”
It feels good to stand and move.
A shadow of a smile lights my face as I approach my patient.
Lifting Brandy’s straining Quiet Riot tee shirt I prepare to examine her.
“Is it alright if I pull these down a bit?” I say, gesturing at the waistband of her purple Capri shorts encircling her like the rings of Saturn.
It’s all worthless, including the pelvic examination, done later with a nurse in the room. Everything is so seemingly-tender that Brandy snatches my hands away as I gingerly palpate. Her rolls of adipose tissue mask every possibly revelatory physical finding as well. I could never have tried and I’d have the same information. Nothing.
Brandy gulps her remaining meal scraps as I exit her cubicle.
I order some lab tests and an abdominal ultrasound, then walk outside, into the ambulance bay, into the welcoming night air.
Even mixed with exhaust, the air soothes. It cools me. I suck it up. Its aroma, far better than what I’ve been recently subjected to. The air feels good. My boiling stills somewhat. I smile broadly, briefly calmed, and sigh.
I signed on for this, really? How is it possible to care for those who don’t care for themselves?
And in an instant, my mind ignites again.
I hate myself for hating a patient.
Gazing skyward, I again quiet my roiling, sucking in the sustenance of the cool night air, recognizing my temporary place in a timeless universe, an insignificant speck in the vastness.
The ambulance bay doors swish open. They close behind me as I go back inside.
Brandy is pregnant. “Thirty-two weeks” snipes the ultrasound tech. “Not an ectopic, I guess.” she snickers.
Brandy also has a urinary tract infection. Her toxicological testing, positive for methamphetamine.
Not using for years, huh.
My patient’s discharge form cautions her against all her chosen habits — drugs, cigarettes and alcohol in any form, especially while she’s carrying a member of the next generation. She’s urged to take her prescribed antibiotics and keep her hastily arranged follow-up appointment in the Obstetrics clinic.
Brandy is referred to Alcoholics Anonymous and to a drug rehab center.
The newly-discovered new-mom-to-be tears up when told she’s meth positive.
“Shit! I swore, no meth. My momma did it when she was pregnant with me. I swore I wouldn’t do it too. Shit!”
They go, and I watch.
Wheeling and shuffling, side-by-side, fat-imprisoned, shackled in so many other ways. Mother, daughter, mother-to-be.
They’re laughing.
My face arranges itself into a smile again.
Who is the next patient to see?
In 2006 when these real-world events occurred, a far more rageful version of this tale appeared in the Annals of Emergency Medicine under the title “Smiling in the ED.” Years and experience have tempered my feelings. Understanding has hopefully supplanted negativity.