The Yale Journal for Humanities in Medicine
In the Trenches:
One morning, during team rounds, we followed our resident into Mr. P.’s room. “Can you tell me if you’re having any problems this morning?” the resident asked. “Yeah, I haven’t gotten my breakfast,” Mr. P. responded. “That should be coming soon,” the resident replied, “but aside from that, can you tell me if anything is wrong?” “Yeah, I’m hungry and my breakfast hasn’t come.”
Breakfast has been a recurrent problem for our patients, in that it’s either late or consists of the wrong items. One of the amenities of the hospital is that patients can order meals from an extensive menu, then wait for them to be served at designated times. It’s a convenience that spoils a patient. Even for Ms. B., who never voiced a complaint about her treatment course, breakfast was always an issue. Being a picky eater, she would only have juice and cereal for breakfast, so when the breakfast tray came with the usual pancakes or eggs and bacon, she saw it as a mistake that warranted complaint. With any other patient, we would have said that they’d have to compromise their standards when it came to hospital meals, but since Ms. B. had recently lost weight, so we had to indulge her fastidious demands. She eventually built a collection of juice cans and cereal boxes to the side of her bed, reinforcing to us that those were the only foods she could stomach.
Breakfast can be am arguable issue for our patients because it’s one of the few decisions over which they have full control. In being handed a menu each morning, patients know that the kitchen staff is at their mercy. For certain diagnostic procedures, patients have to be restricted from eating foods beginning the night before the procedure. Patients seem to complain less about that than if they were to have gotten the wrong kind of pancake syrup. The restricted oral intake was at the discretion of their doctor, but the freedom to choose their pancake syrup is a right to which they are fully entitled, and thus, sufficient grounds for raising hell to the hospital staff.
Ms. G. was 32-year old African-American female who came in with cellulitis of her left leg. Her arms and legs were covered in track marks, documenting her 12-year history of injection drug use, but after a through search, we managed to find an intact vein in her right forearm for insertion of an intravenous line. Ms. G. pleaded with us to treat her with oral antibiotics, but we told her that the severity of her condition required us to treat her intravenously. Ms. G. began whimpering as we unpacked the IV kit, and while one nurse struggled to hold down her flailing arm, another rushed in to pin down the rest of her body. Her vein, difficult as it was to appreciate with our fingers, was a moving bull’s eye target, and after a few near misses, we drove the needle in, only to elicit a prolonged howl that was heard echoing down the hallway.
While many patients harbor a fear of needlesticks, injection drug users can be particular averse to them. It all has to do pleasure, or lack thereof. Injection drug users are accustomed to sticking themselves with needles and deriving an immediate sense of pleasure. If they were to stick themselves without receiving the accompanying sense of pleasure, the painful sensation may be multiplied exponentially. The anticipated absence of pleasure is what creates the anxiety and self-prophecy that the medical needlestick will bring enormous pain, and some patients will whine and writhe in whatever way possible to avoid being stuck with a needle that they hadn’t intended for themselves.
Ms. K. was a 28-year old Caucasian woman who came in because of a persistent fever, which she attributed to a recurrence of endocarditis. Ms. K., an injection drug user, had shot herself up with heroin to alleviate the pain of the fever, so she also presented in acute heroin withdraw. We entered her room to find her kicking and screaming, shouting, “bring me my medicine, I NEED MY MEDICINE!” We put her on Buprenex to treat her withdraw, but it took several days for the symptoms to subside. Each morning, I would stand outside of her room and not hear a peep, and on making my entrance, she would start moaning about the muscle pains she was suffering. The intern and I never got a consistent story on where the pain was, and we could never reproduce the pain by palpating her muscles. One day, when she reported pain in her chest, I asked what it might be due to. “Oh, I forgot to tell you,” she replied, “the other week, I got in a fight with this large woman, and she threw me on top of a radiator.”
It wasn’t clear what Ms. K.’s motive was for exaggerating her symptoms. She was going through withdraw, so the aches and pains could have registered more intensely because she had a much lower threshold for withstanding them. Ms. K. had also reverted back to being a child, which happens to many patients who are hospitalized. Lying in her bed, she could have the doctors and nurses at her beckon call, either by pressing a button or feigning an outrageous symptom that warranted further attention.
Tough an initial echocardiogram showed no evidence of vegetation on Ms. K.’s valves, she was diagnosed with endocarditis based on her clinical symptoms. A blood culture returned positive for Methicillin-resistant Staphylococcus aureus (MRSA), a situation that was further complicated by the fact that she had already failed the first two lines of therapy for MRSA. We started her on the third-line therapy, leaving her with little or nothing else if that were to fail.
Ms. K. became more amenable as the week carried on. While she initially refused to be examined during rounds, she eventually grew tolerant of our daily routine. She survived the torturous experience of withdraw, so she no longer needed us to be as attentive as a baby would need of its mother. Her hospital stay also neutralized the disposition she initially came in with. On coming to the hospital, Ms. K. – who later told us that she prostituted herself to support her heron addiction – had brought in the ruthlessness of the outside world. As with many other patients, though, the anonymity of the hospital gown and the sedentary routine of lying in bed all day dissociated her from her alternate identity, the one that existed outside of the hospital. As much as Ms. K. used her role as a patient to baby herself to us, we used our roles as caregivers to play mother to her.
Over the next few days, Ms. K. kept spiking fevers, indicating that her blood was still swarming with the infectious agent despite antibiotic treatment. One morning, on listening to Ms. K.’s heart, I heard a new murmur, prompting us to order another echocardiogram, which showed a 3 cm vegetation on her tricuspid valve. Because there was now clear evidence of endocarditis, and because Ms. K. kept spiking breakthrough fevers, we had to try an alternate course of therapy. The third-line therapy had consisted of Nafcillin and Gentamycin, with Gentamycin used at a sub-therapeutic dose to potentiate Nafcillin. As a fourth-line therapy, or therapy of last resort, we tried the two drugs again, both at therapeutic dose.
It was at this point in Ms. K.’s hospital stay that my rotation came to an end. When I went in to tell Ms. K. that I was leaving, she asked me what her likelihood of recovery was. “The doctor told me there was nothing he could do for me,” she said. I thought about that statement for a moment, then realized that she may have quoted a variant of what the doctor actually said. “There’s nothing else we could do for you,” was probably what the doctor said, making full reference to the fact that her medical team was doing all it could to treat her infection. Ms. K. may have read the statement in a pessimistic light, but I couldn’t think of any way to introduce a grain of optimism to a situation as bleak as hers. I told her to stick with her therapy, and hope for the best, as generic as it may have sounded. Ms. K. looked as if she had hoped for a more encouraging response, but wasn’t surprised by the paucity of what she got instead.
While Ms. K. was making an unspoken plea for things to work out, I couldn’t help but think of how childish she was in dealing with her disease. Based on her prior hospitalization, she knew it would take a similar four weeks of intravenous antibiotics to treat her endocarditis, and yet, she tried to make it go away by shooting herself up with heroin, a habit that had all along contributed to her disease. She was also childish in demanding a quick remedy for her withdraw symptoms, and it wasn’t until she had broken out of that spell that she began to take her other disease, endocarditis, seriously. Even for that, she wanted a quick and easy fix, not realizing her own complicity in making the disease refractory to treatment. In my own mind, Ms. K. had morphed from the patient we had grown to like – the hospitalized Ms. K. – back to the Ms. K. of the outside world, the one we had never known, but could surmise based on a reported history of prostitution and heroin use. Not wanting to let that impression override the one I had built in the preceding weeks, I tried to think of Ms. K. along different standards, realizing that any achievement on her part would be nominal compared to patients who were more mature in dealing with their disease. I tried to think of the changes that Ms. K. had made in recent days. In her voice, right now, I heard it well enough, that she cared enough about her health to want it to get better. For someone like Ms. K., that was quite a stride, one I’d like to remember her by.