Wednesday, March 22, 2006

Of Angels and Icing

She has an angel made from white felt on her refrigerator. My name is scrawled in black magic marker across the angel's torso.

"You see," she says in Spanish, "I told you that you were my angel."

She weighs 98 pounds, cannot quit smoking no matter how hard she tries, and has severe emphysema and asthma (Chronic Obstructive Pulmonary Disease). She also drinks a fair amount of alcohol but will never elucidate for me exactly how much that is. Chronic pain plagues her, morphine keeping it somewhat at bay. Hepatitis C lies in wait in the background, and the alcohol that she consumes is like pouring gasoline on a fire.

This physically frail but inwardly tough woman has been hospitalized four times this year alone, and she's been intubated more times than I can count. During all of those intubations, she actually experienced delerium tremens and had to be carefully sedated so that she wouldn't pull out her tubes and IVs as she thrashed violently in bed. Since I've known her, I've had to visit her in the ICU several times, certain that she might never recover, but each time she makes her way back and returns to her two-room apartment in a large senior apartment building overlooking the highway that bisects the eastern part of the city.

Today's visit was prompted by a phone call. "I fell on Saturday, and my knee is swollen and painful." Today is Wednesday. This is a woman who had a complex fracture of the ankle (actually the right lateral malleolus for you orthopedic fans out there) and waited almost a week to call me with reports of "pain and swelling" (a vast understatement). Years on chronic steroids have rendered her bones very prone to fracture, a fact I always bear in mind. Memories of that gigantic ankle with a massive joint effusion sent me driving across town to her apartment faster than you could say "E.R."

The knee was impressively swollen with decreased range of motion, large ecchymotic areas, pain on dorsiflexion of the foot, and a very boggy patella. Unable to reach any of my Nurse Practitioner colleagues or the primary doc, I scribbled some orders on a requisition form, co-signed the doc's name, and told the patient to get her friend to take her for some x-rays by the end of the day. (This particular doc has given me carte blanche to order just about anything in his name---an unspeakable luxury and honor.)

So, have I earned my white felt angel? I'm not certain, but if that characterization of me keeps her engaged and facilitates improved self-care, I'll be almost anything. Am I a devil when I reproach her for drinking and smoking and avoiding care for weeks at a time? Perhaps, but a devil with a purpose---avoiding untimely death and avoidable suffering.

Angel, devil, pain in the ass, it doesn't really matter. What the patient thinks of me can be a nice fringe benefit, but the outcomes of improved health, increased adherence to treatment, and better quality of life are what we're really striving for. Has she quit smoking? No. Does she still drink? Yes. How many hospitalizations this calendar year? Four. Is that perfect? No, but at least she called today. Those white felt angels? They're icing on the nurse's cake.
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