Friday, April 14, 2006

Truth and Consequences and Boerhaave's

Abuse of the self will only take you so far. I wrote about you here and here and here and rhetorically asked if there were any more I could do. I eventually decided that you could not be convinced that a painful and ugly fate awaited you around the corner. You seemed to be beyond hearing, beyond caring, beyond taking full responsibility for yourself and the consequences of your actions. Those actions came home to roost and it was not pretty.

Today, I visited you at the end of a trying week. There you were, clean-shaven, hair recently trimmed, your enormously swollen legs up on a chair. You shook my hand and almost smiled. Asked if you felt pain, you said "absolutely none". On this visit, you didn't tell me that you were hungry. Perhaps now you're used to the fact that your stomach is now an empty pouch, the esophagus above it non-existent.

The Infectious Disease (ID) specialist, a pretty young doc new to our facility, stops me in the hall and we discuss your case and your illustrious history of excess and poor choices. I tell of the many conversations you and I had had, or rather, the numerous times I had regaled you with tales of what would happen if you didn't clean up your act and take your health seriously. The doctor describes Boerhaave's Syndrome for me, and based on the fact that enormous amounts of gastrointestinal fluids and detritus poured into your chest cavity after your esophagus burst (and you did not seek medical attention for several days), we marveled that you're still among the living. We discussed the possibilities of you eventually having an artificial esophagus and what that might mean for your future.

I tell the curious doctor stories of how I would arrive at your apartment (prior to your eviction, that is) and knock, hearing sounds of hurried cleaning and movement behind the locked door. Of course, drugs and assorted paraphernalia were being summarily hidden upon my precipitous arrival, and you would deny all drug-related activity as we sat at your kitchen table, your friends in the other room, watching TV and smiling when I poked my head around the corner. You were a bomb waiting to go off. I just couldn't know what you would look like when the smoke cleared. Now we know what you look like, although the shape of the future is uncertain. Many months of hospitalization are ahead, with more surgeries, more complications, further discomforts and indignities.

I inform the ID doc that the floor nurse complained to me that huge herpetic sores covering your buttocks and scrotum are being treated only topically and seem to be spreading. Speaking of indignities, we ask you to stand and bend over your walker and we examine your buttocks with our hands gloved in those strange blue powderless latex-free exam gloves. She agrees to order intravenous acyclovir. Sometimes my intervention and input is all it takes to get something done. Other times, it's like screaming into the wind. I guess the wind's in my favor today.

As I take my leave of the floor, you're ambulating around the ward with the nurse and another helper. The urine collection bag dangles from your walker, I can see the outline of the feeding tubes which protrude from your abdomen under your hospital "johnny". Your ears look enormous in contrast with your gaunt face, skinny neck and close-cropped hair.

If only I could have shown you this potential future with a crystal ball, illustrating for you the fate which only you had the power to avoid. If only I could bring other troubled patients to see you, show them your feeding tubes, the CT-scan of your non-existent esophagus, have them sit with you a while, and perhaps decide to turn themselves around. If only the traumas of your earlier life of which I am ignorant had not occured, or you had recovered from them without turning to drugs and self-destruction. If only your siblings, who love their eldest brother despite his failings, could have helped you turn it around. If only.

You're in good hands now, off the streets, the life that you knew before a mere memory. While I regret your suffering, I also absolve myself of feelings of responsibility for this turn of events, knowing that I could not produce the deus ex machina that would magically transform your life and lift you from your despair. The deus ex machina can only be your own spirit now, a power within you that will carry you along this troubled road. May blessings of strength and courage anoint you at every step of the way.


Anonymous said...

Keith, did you read Gladwell's extraordinary extraordinary piece entitled Million Dollar Murray: Why problems like homelessness may be easier to solve than to manage?

Although Gladwell discusses some ideas for programmes concerned with "chronically homeless inebriates", I assume that many of the issues would be familiar to you from your client caseload.

I discuss the ideas in the context of non-formal carers
I wondered what your experience was of any programmes in the US that have been implemented using the power-law distribution ideas. And what do you think of the possibility of making any helpful interventions in the case of someone who presented the adverse life circumstances and lifestyle choices that you describe so movingly.

Take Care - Tony

Keith "Nurse Keith" Carlson, RN, BSN, NC-BC said...

I am not familiar with Gladwell and it seems I should be. In terms of "power-law distribution", that term is also unfamiliar to me. My ignorance is less than blissful at the moment, but I will try to get up to snuff and check the links which you provided. Thanks.

In terms of interventions with such individuals, our position is that we create meaningful therapeutic relationships over time and slowly begin to offer services and connections to lead the person out of their current state. Some people take the bait and others simply do not. Others may get on our wagon for a while and then fall back into old habits.

Unfortunately, the gentleman of whom I write here has generally eschewed our help and only surfaced when it was crisis time. His excesses took him to where he is now and although I would have liked to see a different deneoument, this was of his own making. It's the old adage of leading a horse to water.....