Change of Shift
1998; Elsevier BV; Volume: 32; Issue: 4 Linguagem: Inglês
10.1016/s0196-0644(98)70186-6
ISSN1097-6760
Autores Resumo[Rasmussen R: Nuts. Ann Emerg Med October 1998;32:514-516.] The chart for cubicle #9 read: Chief complaint: “Shortness of breath” with the triage note specifying, “Patient wants to know if she is dying.” ”Oh, brother!” is my first thought, but on second glance I decide to take this more seriously. She is 86 years old with a past medical history that includes emphysema, hypothyroidism, and something called Cupid’s disease. Her respiratory rate is 26 and oxygen saturation is 86% on 2 L per nasal cannula. The slight woman I see lying in bed appears at ease despite her tachypnea. She is reading a fishing magazine and she looks up at me over her reading glasses as I walk into the room. “I want to see a doctor!” she shrills before I can introduce myself. “I am a doctor, Ms Nadine…nice to meet you.” I extend my hand, which she frowns at as if I am handing her a rotting fish. Her nostrils flare. “You look like a kid to me,” she snorts, “and you look like a cat that’s been drug through a knothole.” “I’m actually older than I look,” I reply, “and…” “You should let your wife dress you!” she interrupts with an audible wheeze. Things don’t appear to be going well. I already dislike her. I try a different approach. “So, what brings you to the emergency department today, ma’am?”, I query. “Lack of common sense mostly…and I want to know if I’m dying yet! Did they tell you that!?” She appears almost breathless. “Well, it looks like you’re having some trouble breathing…what has been happening to you over the last several days? Have you…” “I always have trouble breathing, doctor! I didn’t come here today just to be reminded of where I’ve been. I want to know where I’m goin’ and how fast I’m gettin’ there. I’m tired of frettin’ over it!” She is out of breath and her face is bright pink. I wait. “I have to let the folks know if it’s time to get ready to dance on my grave.” She hacks and spits something thick into a plastic bag. I am taken aback by her curt nature. She strikes me as somewhat melodramatic, and I find myself wondering why I had the good fortune of grabbing her chart. Why me? Still, I pity her and she does look ill. I regroup and try again. I tell her that she looks sick but I don’t think she’s dying “this minute!” (Was that a chuckle or a cough?) I remind her that I need to know more about her recent condition to give her a better answer. She searches through her covers. “Doctor,” she says as she conjures up what looks like a car antennae and points it at me, “may I ask you a question?…Are you a coward?” I know I shouldn’t answer this but I feel myself being drawn into the question. “I don’t think so. I’m not particularly courageous, I’ve never saved a child from a burning building, but I’m not a famous coward either.” I am trying to lighten our conversation. “Give it to me straight. Either you are or you aren’t.” She spits into the bag again. I notice her lips look slightly gray and her oxygen cannula is draped around her throat like a second necklace. Her oxygen saturation isn’t picking up on the monitor. “Ma’am, let’s put your oxygen back on while we talk.” Ms Nadine pinches a scowl into her forehead and stares at me. We are silent for about 10 seconds but it seems much longer. I feel like I have lost all control of this interview. “Are there any doctors here with ex-per-i-ence?” She says “experience” slowly and articulately as if it might be a word I would have trouble recognizing. I am beginning to feel that if there is going to be dancing on her grave, I want to be invited. I inform her that an attending physician will see her, too. “Any of ’em with gray hair?!” she huffs. I think she might be joking so I laugh. Feeling that the tone of our discussion is changing, I begin yet again. “OK, so what has been happening with you, lately?” Her scowl settles. She gives me a look of defeat. Now, perhaps we can get somewhere. I feel a sense of victory. I wonder about my other patients and wonder how long I’ve been in cube #9. The interview smoothes out. She answers questions quietly, tracing her recent illness on tiptoes, she doesn’t interrupt. She scratches her toes with her antennae (so that’s why she has it), avoiding eye contact. I discover she is educated, lives alone on a farm, has no family in the area, and has just finished an outpatient course of antibiotics without improvement of a “pneumonia.” Her chart arrives and it is grim. She has end-stage COPD. Her pulmonary functions tests are abysmal and getting worse. She refuses home oxygen and hospitalizations. She has a signed DNR/DNI order. She still smokes. It turns out “Cupid’s disease” is syphilis, a term I have not heard before. I go back to her room. She has a question waiting for me. “Doctor…how do you ride?” “How do I ride? Ride what?” “Horses.” I have no idea why she is asking me this. I tell her I don’t ride horses very often. She asks “Why?” “Because,” I hesitate, “the saddle hurts my rear end too much,” I say laughing. It is a lie. She stares at me, sighs, and picks up her fishing magazine. The attending does see her with me. He has no gray hair. She refuses blood draws, chest x-ray, and medication. She appears to be thinking clearly and understands the consequences of her decisions. All I can think is, “Why is she here?!” I am frustrated and it is starting to show. She seems uninterested when we explain that we can’t help her if she refuses any help. While the social worker calls a cab, she confronts me in the room. “I think you are a coward,” she says to me. “What!?” I snap back. “I think you don’t ride because it racks your nuts. My son is the same way.” I am silent. I am angry. But, as she leaves a coldness washes over me. I realize that what she is telling me is that I have failed her. All the time I was wanting to help this ill, frail, elderly woman (despite my dislike of her), but I didn’t hear what she was wanting. She didn’t come to the ED for help, she came to find someone who would “give it to me straight.” She fears the unknowing of death that she faces every day, alone. She understands that I can’t tell her when she is going to die, but she needs something she can grab onto, my honest opinion—that she is very near to death. She will fill in the particulars. Instead, I have not helped her in her time of need at all, and I was not completely honest with her. I feel bad. It is a mistake. As I think about her, I am reminded of something one of my teachers once told me. “It’s OK to make mistakes, but learn from them.” Ms Nadine was right about why I don’t like horseback riding and I promise myself that the next time someone asks why I don’t ride horses I will tell them that it’s because, “It racks my nuts.”
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