Sketches of a Monday

I hit the ground sprinting this morning. Everyone seemed to be racing today. Skid-marks on the carpet. Chaos is a frequent visitor to our over-crowded office and today was no exception. Let me illustrate:

Patient #1: Advanced AIDS, now on meds and doing OK. Almost died from liver failure last time she tried antiretrovirals (AIDS meds) due to her poor liver status from Hepatitis C infection. She has new-onset mental status changes and may be failing the prophylactic regimen we have been treating her with to prevent toxoplasmosis (a brain infection), a full bout of which she had last year before she started her new AIDS regimen. The visiting nurse calls to tell me that she seems worse today and I plan to pay her a home visit in the afternoon. I worried about her all weekend.

Patient #2: severe depression with psychotic features, anxiety disorder, hypothyroidism, osteoporosis, asthma. Originally from South America. I've worked intensely with her over the last 12 months to help her apply for citizenship. I successfully found someone to take her to Boston two weeks ago for her interview with the Feds and we had the citizenship exam waived due to her psychiatric disability---not a small feat. She passed her interview with flying colors and will be ceremoniously made a US citizen at the Hynes Convention Center in Boston on Wednesday. I take time today to search the web for bus schedules and call a few taxi companies in Boston to get an idea what it will cost her to take a taxi to the convention center from South Station. She calls me: she isn't sleeping at all and wants sleeping pills. I have to speak with her primary doc who called out sick today. Hasta manana, OK?

Patient #3: Brittle diabetic with poor control of his disease, Hepatitis C. Lives in a motel with his 22-year-old son. They are both IV drug users but my patient has been clean for a few weeks and is trying to get it together. His son shoots up in front of him which is a big "trigger" for him. Patient never showed for our follow-up office visit last week, and while I'm at another patient's house, I receive a page that he's at the office waiting for me. I call the office and tell them to send him packing. He needs to make an appointment. No kid gloves for him.

Patient #4: forty-year-old male with AIDS (fully controlled with meds for four years), Hepatitis C (treatment for which he failed), narcolepsy, uncontrolled hypertension, depression, and a history of IV drug use (for which he's on methadone maintenance). He's been showing signs of mental deterioration over the last year. Neuropsychiatric testing shows major deficits. We treated him inpatient in 2004 for presumed neurosyphilis but now the symptoms are back. I visit him at home--he breaks down crying as we sit on his bed, his wife standing to my right, Planet of the Apes on the TV. He's having suicidal thoughts and thoughts of harming others. He doesn't feel at risk of doing anything but I give them the number for Psych Crisis, just in case. I make a note to discuss his case during our HIV Provider Meeting this afternoon at 4, if I can make it back in time to the clinic.

Patient #5: I spend 90 minutes in the depressing home of a new patient, meeting for the first time. Arthritis, severe osteoporosis with multiple fractures of various bones, bilateral cataracts, emphysema (and still smoking 1 pack per day!), coronary artery disease, angina,pernicious anemia, a metal plate screwed into his broken hip last fall. Not a happy camper. Where do I begin?

Patient #6: African-American female who has come and gone from our program several times. History of IV drug abuse, violence, incarceration for assault and battery, young son with sickle cell disease, lost one of two twins while pregnant last year, the surviving baby doing OK and sickle-cell free. Patient has severe COPD (emphysema), still smokes, suffers from crushing migraines, and has severe depression and a relatively chaotic life complicated by parole. Her head feels like it's going to explode. I manage to find her an appointment for tomorrow. Just hold on and go to the ER if you can't make it through the night......

Patient #7: dry alcoholic with anxiety disorder and recent deep vein thrombosis (DVT--a huge clot in his leg from his ankle to his thigh). Couldn't walk for three weeks and never called me. If a piece of the clot had broken off (common occurrence), it would've traveled to his lungs and killed him instantly. He's now on blood thinners but can't keep up with the instructions, blood draws, and dose changes. Hasn't taken any Coumadin for five days. Can I scream now?

There's so much more, but you get the picture. The constant headaches, no-shows to appointments (a HUGE problem!), complicated lives, dysfunctional families (they've taken the "fun" out of dysfunctional), drug abuse, poverty, Medicaid fraud, inability to understand and process instructions correctly, you name it.

Do I love my work? Yes. Do I feel that I change people's lives for the better? Yes, often. Do I sometimes feel like I can't take it anymore? Absolutely. This is a Monday where I question my resolve to continue but know that I will. My spirit still keeps me in the moment and I shoulder the responsibility and continue on. I sometimes pine to be a nurse in a small town doctor's office, swabbing throats and taking the blood pressure of arthritic Jewish matrons. Is that in my future? I doubt it. Thriving on Chaos is not just the name of a book.