It was Saturday afternoon. It was one of those rare days when the weather was perfect for laying in the cool, newly sprouted Spring grass while chubby white clouds drifted over. Glancing out the window with unadulterated yearning on my face, I ached for the rare potential to relive a careless day from my youth. Instead, I was making rounds in the hospital. Since it was the weekend, I had double the patient load. My hope to escape to the outdoors was piteous. There would be no escape from the sick today.
Standing inside a dark room while my pneumonia patient coughed violently into the bedside commode, I felt as if I was going through clinical withdraw from…from life. My dark reverie was cut short as the pager went off for the hundredth time that morning, its aggressive soul-puncturing beep calling me from the room on yet another unpleasant errand.
The nurse who paged me informed me her 53 year old patient, Ms. D, had a blood pressure of 220/120 and was refusing any medications. I sighed and reviewed the medical information on my patient list. “Morbidly obese, urinary tract infection, high cholesterol, chronic kidney disease; admitted for hypertensive emergency.” In other words, our average patient. I made a quick check of her morning lab work before visiting her and was unsurprised to discover her diabetes test had come back positive. Very positive.
When I entered the room, it was with a smile. Maybe the patient was scared and no one had explained the urgency of treating her high blood pressure. Maybe she just needed someone to spend time with her. I went in with a goal—to bring her blood pressure down to a safe level and to have a much needed discussion about her new diagnosis.
The nurse met my eyes when I entered. I could tell from her exasperated look the patient was being difficult. There’s a certain visual malevolence nurses get when they are fed up with a patient. It’s as unmistakable as a stray dog watching you from a bowed head…reach for that food bowel and you’re going to get bitten.
Ms. D met the profile I expected with her list of diagnoses. She was fantastically obese, her stomach overhanging down her thighs. Her small knees sat above large calves which were marred by the leathery skin changes caused by lack of circulation. Her gigantic upper arms strained the cuffs of her gown’s arm holes. She had an IV in place which was secured with half the hospital’s available tape…if that thing came out, it wouldn’t be replaced easily. Her legs jutted out in a splayed and aggravated fashion, her bed sheets kicked carelessly off the side of the bed. She was hot. The room was freezing. She looked old, much older than early fifties. She breathed heavily, a consequence of the pressure from her immense abdomen, as well as the pull from two massive breasts which rolled off to the side since she was also braless.
She was Caucasian. Her hair was flaxen and thin, pasted to her forehead and uncombed. It had the yellow tinge of nicotine, indicating she was a heavy smoker. She had a dour look on her face, accompanied by silver-framed glasses squished against the bridge of her nose. The lenses were covered with greasy finger prints. She had pig-like eyes hidden behind the flesh of her face. She had few teeth.
As soon as she saw my white coat, she ‘harumphed,” and turned her face to the wall.
I paused. The patient was easy to dislike from first glance, but I thought maybe I would be the doctor who could get through to her. “Ms. D, I am Dr. Ren. I’m one of the resident physicians here. I am helping to cover for the weekend.”
“You’re too damn young ta be a doctor. Get out and send a real one.”
I laughed, gently. “What does a real doctor look like?”
She turned then, looking as if I surprised her. “A real doctor is old…like me.”
“Unfortunately, I’m the only one here. My attending will be by later. He has grey hair, if that will suit you.”
She sat up with some effort. “Never mind. If you’re it, you’re it. I suppose you want me to take some of that crap for my blood pressure?”
“I do. Your blood pressure is high enough it could hurt your brain or your kidneys.”
She crossed her arms like a petulant child. “I don’t want it. I came here because I was pissing fire and now you all have me here like a prisoner! Day after day after day of medicine and bullshit! And the food here sucks! Just sucks! No salt, no taste!”
I smiled to myself as she ranted. Glancing at my patient list, I saw she was only admitted yesterday morning and had been placed on a low sodium diet because of her blood pressure.
“You’re always free to leave, Ms. D. Though it would be nice to take care of some of your other medical problems while you’re here.”
“I ain’t got no problems! Just this UTI or whatever you call it.”
“Actually, your high blood pressure is a big problem. If you would let me treat it, we could talk about it more.”
“No. No medicine.”
I thought maybe she didn’t understand what hypertension was. “Do you know what high blood pressure is?”
“Yeah, I know. Means my heart is working too hard.”
I was surprised. “Do you know what can happen with pressures as high as yours?”
“Yeah. I can have a stroke.”
I paused, not knowing where to go from there. “Can I ask why you won’t let us treat it?”
“CAUSE I DON’T NEED IT!” She burst into a shriek which was heard down the entirety of hallway. I sighed and sat in the chair in the room, hoping it might make her less confrontational. I kept a cool temper, though she was starting to irritate me. The outside looked lovely from her room and I couldn’t believe I was sacrificing a beautiful day to deal with her nonsense.
I thought a change in subject might help. “Can we talk about another issue? Besides your blood pressure, I saw some concerning things in your blood work. Would you like to discuss it?”
“Go right ahead, little miss doctor.”
I took a moment to cool down. The nurse was watching me with a conspirator’s grimace as I began to recognize the enormity of the problem this patient must have caused for the nursing staff.
“Do you know what diabetes is?”
The patient looked at me warily from the corner of her eye. “Yeah…a sugar problem.”
“In a sense, yes. It looks like your other doctor tested you for diabetes and it came back positive. I would like to tell you what tha—”
“YOU GAVE ME THE DIABETES?!” Her voice rose to an impressive level. I wouldn’t have thought her smoker’s lungs would have allowed such projected volumes.
“Diabetes happens over time—” I started to explain.
“I DIDN’T COME IN HERE WITH DIABETES, AN’ I’M LEAVIN’ WITH DIABETES, SO I GUESS THAT MEANS YOU GAVE ME DIABETES!” She said this with complete condescension in her voice, as if I were wearing a dunce hat instead of a white coat. I suppose that’s when I got…irritated. I stood.
“Ms. D,” I said tersely. “You have diabetes because you’re fat and you eat junk food. You did this to yourself. There is only one person to blame here.”
“AND THAT PERSON IS YOU! GET THE HELL OUT OF MY ROOM!”
A glance at the BP monitor continued to read her blood pressures at dangerous levels. Mine was probably not too impressive at the time either. I left the room and grabbed her chart so I could document. I had to ensure my story was written down, to protect myself legally whenever Ms. D inevitably stroked out.
I paused in the middle of the hallway, feeling defeated and angry. I’m embarrassed to admit it, but a part of me wanted something awful to happen so I could say, ‘I told you so.’ I wanted to scream back. Write a passive-aggressive note in her chart. I was full of rage that this fat, mouthy woman accused me of something ridiculous, tested me, and tossed my kindness back into my face. I wanted to cry, because the world outside was beautiful and I was tied to these awful people. These sick people who couldn’t take care of themselves or understand why they were sick. I felt enraged at a social system that encouraged chronic illness and failed to treat it. And I felt hopeless, because she would leave the hospital and be right back in, waiting for the next white-coated victim to try and help her.
Sometimes, there’s no way to help, no way to explain. And yet, I’m the one who felt like the failure, for losing my temper, for failing to reach her. All the training I had about trying to understand the core of a patient. Was she afraid? What was her emotional reaction reallycaused by? Did she want to die? Did she need attention so bad? What could I have done different? Did I do the wrong thing by giving up and walking out? And…is it really my job to proffer psychological analysis on each difficult patient? I just don’t have the time.
The nurse followed me out, asking what she should do.
“Just put her on a sugar free diet.”
I went to write my note.