Wednesday, February 23, 2005


So often, my work is like looking at, dealing with, and addressing scars, both emotional and psychic. The physical scars are there too, of course, but it is the scars of trauma and life gone awry that make my work so challenging.

Today, once again, I had to actually tell someone that if they didn't start taking their health seriously and work with me closely, they would be dead within a few years. This scare tactic has worked before, and I see continued success in two people whom I have so directly challenged to "get on the bus" with me and do the serious work of recovery and healing.

In the course of this chilly but sunny day, I had to confront a certain individual who has never taken antiretrovirals---AIDS medications---and I had to tell her in no uncertain terms that the brain infection for which she was so recently hospitalized was a direct outcome of her ongoing refusal to concentrate and consider treating her underlying disease. She acknowledged that her inability to take her seizure medicines has landed her in the hospital several times with massive seizures, and I reminded her that if a major brain or lung infection takes hold at this point, she is most certainly going to die. She has so few T-cells (some of the cells that populate her immune system and give us a good indication of her immune health) that we sometimes joke in the privacy of our office that we could name each one since they're so few and far between. Poor gallows humor, I know, but so helpful when we're faced with such tragic realities.

Truly, it was not a "full-throttle" day, as it were, but I was more challenged than yesterday, and had many more plates in the air as I juggled my way through. Several times, I was struck with the awesome responsibility of assisting people through the healthcare system, of the underlying dysfunction of that system, and of many of my patients' natural or learned weakness in terms of self-care and self-direction. Many choices which seem like "no-brainers" (to borrow a very modern phrase) to me, are huge leaps for some of my patients to take.

For someone as priviledged as I, the obvious need to take medication to control a disease with which I am saddled is clearly obvious. Without a history of abuse, trauma, addiction, abandonment, deprivation, and disenfranchisement--not to mention second-class status in a world of white people who can't even see their own priviledge)---I can easily say "yes" to self-care, treatment, others' wish to assist me, the natural succor of love and compassion. But for so many people, the ability to say "yes", to rise above negative self concepts and self-loathing, is not so natural a skill. It is these individuals whom we try to reach as we send out the life-raft, offer a hand, extend ourselves a little more, offer a smile and a kind word on a consistent basis. Some take the bait, others try for a little while and eventually fall by the wayside. We will stop the bus and support them in their gradual or rapid demise, soothe their suffering and ease their pain, but there comes a point where there is no turning back and their death is only a matter of time.

I have watched these processes both as an objective witness and a committed player, attended the wakes and funerals, consoled the bereaved. It's not easy, I'll readily admit, and sometimes my frustration level is through the proverbial roof. That said, the show must go on, and whoever buys their ticket gets to play. For some, we force the ticket into their shirt pocket and drag them through the door. Others leave their ticket in the waiting room and return to the shooting gallery for their fix. There are always more tickets available but there are those who will never take the ride. My patient today is probably one of those who I will watch over as she fades into oblivion. I honor her scars, but can sometimes grieve her inability to take the proffered hand.

What do I do now? I offer consistent and caring advice for her to take. I meet her where she is and try to drag her further along if I can, either by logic or by coercion. If she doesn't take the bait, I do what I can and wait for her to crash and then pick up the pieces. If she dies, I tell myself I did my best and move on to the next person in need. It doesn't always feel like the best world in which to dwell, but I have my cozy abode, a woodstove, and a wife and dogs to curl up with when I get home. Priviledge has its benefits and its costs. I honor both, and begin anew each day.
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