Playing Doctor

Initial Visit?

Friday, March 18

Three Steps to a Cynical Friday

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I worked overnight on Saturday night and a woman came in with a blood pressure of 230/135. For those of you who don’t know what a normal blood pressure is, the upper number—the systolic pressure—should be less than 120. Once it hits 140, every single digit higher puts you at higher risk for a heart attack and stroke.

She had a history of coming into the emergency room with blood pressures above 200. Usually she was complaining of a headache that would resolve when the pressure was brought down. She had been given multiple prescriptions for blood pressure medications, been given multiple appointments to a regular doctor. She said the medicines were too expensive. She could not say why she did not keep her doctor appointments.

She came in to the emergency department on Saturday night, not having taken any medication since the last time she was admitted to the hospital three months ago.

The only difference was now she was partially blind.

She reported her vision started going bad a month ago, along with a headache that had slowly progressed until she could not take the pain anymore. The CT scan confirmed she had infracted a good portion of the left side of her occipital lobe. A couple of old small strokes were also seen.

She was saying that it was too late now, that there was no use in pursuing treatment. She was right; she would not get her vision back. But it was difficult to get her to appreciate that she still had her kidneys, her feet, her heart, and most of her brain. That as bad as the situation seemed, she had many body parts left to loose.

Now I know, like any good liberal does, that it was Phillip Morris’s fault that she was still smoking. I know that it’s Reagan fault she doesn’t have a decent education. Nixon’s fault that Medicare pays for emergency room visits but does not pay for the pills to prevent the visit. And W. Bush’s fault that the economy is so bad that she works at Joe’s Sub Shack.

But like an even better liberal, I don’t want to give her any excuse in the world to continue smoking. She could use the ninety dollars a month she saves on cigarette money and spend the forty dollars on her medications and use the remaining fifty dollars for a gym membership and fix her morbid obesity so she could get off the medications.

I spend twenty minutes talking to her. Explaining that while she has lost some of her vision, there is still much to loose and therefore much to save. I explain that it is important to control her blood pressure every single day from here on out, not just when the headaches are bad. It’s my ‘Come to Jesus’ talk. We map out the different prices of drugs. I explain that I can create a cheaper regimen but that she will have to take pills more frequently. She chooses the cheaper option in the choices I present to her.

As I am walking away, a nurse tells me, “If I came here, I’d want you to be my doctor. You take the time to explain things to your patients in a way they can understand it.” Nurses are usually not so forthcoming with their compliments, especially with medicine residents, so I feel good about my exchange with the patient.

Then yesterday morning, I am told that she came back to the emergency department in the early morning hours having a heart attack. Her blood pressure was 215/128 on admit. Apparently, instead of filling the prescriptions, she mailed them to a company that had a two week turn around time.

I try to blame Benjamin Franklin’s Pony Express and the US Postal Service, but my efforts are lackluster.


Later in the afternoon, I’m working with a 22 year-old who, several years previously had been an architecture student when he jumped into a shallow pool and shattered his vertebra. Being an intelligent young man who had the world going for him, he was delighted to now be a quadriplegic whose weekly outing was playing checkers with his aunt.

He had debilitating nerve pain that required huge doses of not only narcotics but anti-epileptics as well. A side effect of the anti-epileptics was migraine headaches whenever he tried to read.

The attending and I discuss with him the particulars of what we were doing to fight the infections in his skin. When one cannot move, holes begin to burrow in the pressure points of the body. Infection can set in easily. We were treating the infection, and the holes were closing. We tell him we can give him medications, but his role in the treatment was to not give up. The young man and his father begin to weep when we said this. We talk serenely and give him and his dad some encouraging words and comfort, I hope.

The attending and I then walk back to her office. By the time her door is closed, she was trying to prevent herself from sobbing, while I go into her bathroom and begin vomiting.


Last night, I’m in my bedroom putting my clothes back on and I can hear [name deleted] from the bathroom telling me: “I love [name deleted], but we have not had sex in over three months. I just needed a release tonight without any emotional entanglements. You’re safe. I knew I didn’t have to worry about any emotions coming from you. I learned that the hard way.”

I am standing in my boxers, alone, but not, wondering if my life has really become such a soup opera cliché that these words are warranted. I am trying to think of something to say that is honest but not hostile. But I can’t. I can’t think of anything to say.

I can’t even think of anything to think at this point in my day. In this point in my week. In this point in my life.

I need a vacation. Tonight, I’m going home to Miami for a week.

I’ll try and send a postcard.


Anonymous Anonymous writes:

Even your most depressing stories cheer me up.


Anonymous Miss Kitty writes:

She had a "Come to Jesus" moment and she wasn't ready for religion!


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