Tuesday, January 03, 2006

What More Can I Do?

You are a middle-aged man with poorly-controlled diabetes. You inject heroin and cocaine periodically. Since your veins are shot, you often inject using a technique called "skin popping" wherein you inject under the skin rather than intravenously, sometimes developing infected abscesses in your arms that have to be surgically debrided. You have massive lymphedema (picture elephantiasis) of one leg, and ulcers frequently open on your legs and arms. You go to methadone every morning, but they're going to discharge you because your toxicology screens keep coming up positive for opiates and cocaine.

I'm worried that you may lose your leg or die from an infection. I have the visiting nurses see you every day to dress your wounds and administer your medications and insulin. As far as the open wounds, I now have you connected at the Wound Clinic. Since transportation is an issue, I actually pick you up and take you personally to your appointments so that your treatment is expedited. I also serve as translator. When you're sick I come to the house to visit you, and I keep your primary physician updated regarding your status. When you miss an appointment, I reschedule it since you don't have a phone. The visiting nurse and I consult about you almost every day. Only a handful of patients in the United States have this type of intensive and personalized healthcare delivered to them at no cost. I wish you could grasp the reality of that.

Despite all that I do, you still miss appointments, avoid the visiting nurse, skip medications, make excuses, and increase your chances of harm to yourself. I don't know your complete history, but I imagine there is a long story rife with psychic trauma, perhaps violence, abandonment, addiction, family stress, poverty, mental illness, and learned helplessless. I have no idea what experiences brought you to this point. From my standpoint of relative normalcy and stability, I cannot really understand your life, but only empathize with what it must have been like.

I want nothing more than to spare you frightening and painful outcomes which are lurking around every corner, but I can only do so much. Compassion fatigue is real, no matter how traumatic the patient's past. There's a point where I have to decide that I'm working too hard for you, doing too much, enabling you to not help yourself. Where do I draw that line?
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