Morning Rounds: Sometimes the Most Important Lessons Come from the Most Difficult Patients
Thursday, September 15, 2016 2:31 PM
Every emergency department has patients who doctors and nurses see on a regular basis and, often, we get to know them fairly well.
Dr. Mark Fourre, currently chief medical officer at LincolnHealth in Damariscotta and Boothbay Harbor, has been chosen by the Board of Trustees of Coastal Healthcare Alliance — which oversees Pen Bay Medical Center, Waldo County General Hospital and their community-based health care services — to take over as CEO at the end of the year, when Mark Biscone, the current CEO, is set to retire.
When I first began working at the Maine Medical Center Emergency Department, Bobby was one of ours.
He seemed older (at least he did then), in his late 50s. And, he was homeless. Bobby frequently came to the emergency department complaining of chest pain, especially when the weather was cold or rainy.
There were a few things that stood out to me about Bobby. One of them was that while he was homeless and clearly an alcoholic, he always managed to somehow have a neat haircut. The other thing about Bobby was that he was incredibly difficult to deal with.
When he arrived, he was always drunk. He would announce himself in triage by complaining that he had chest pain and that nobody was paying attention to him. He usually smelled of urine or vomit, or both, and he would shower you with profanity if you suggested that he seek help for his drinking or if you tried to connect him with social services.
We had our share of difficult patients, but there was almost always a doctor or a nurse who was able to develop a rapport with each of them. No one connected well with Bobby.
Because the Emergency Department was smaller in those days, it was also impossible to shield patients from his presence.
Complicating things further, Bobby actually did have heart disease and had suffered several heart attacks, so despite repeatedly “crying wolf,” we had to take him seriously.
Since he used so many hospital resources that were badly needed for acutely ill patients and because most often he was clearly looking for a warm place to spend the night, we developed an unspoken consensus about how to treat Bobby.
We would examine him, check an EKG (a standard heart disease test) and blood work, and if those came back negative, we would discharge him back to his day-to-day world. He always refused attempts to get him into treatment for his alcoholism and there was nothing we could do to force him to stop drinking.
It wasn’t that we didn’t care about him as a patient. We worried that he would drink himself to death or step in front of a car, but after seeing him dozens of times and talking about his heart condition with cardiologists, we felt like we understood him pretty well. We were experts on Bobby.
And then one day, he walked in and he was a completely different person.
He was no longer angry and red in the face. He was clean and well groomed. He waited his turn in triage and when I treated him, he thanked me for his care both that day and in the past. He was articulate and thoughtful and his vocabulary had expanded dramatically.
It was possible to talk to him about his condition and his treatment. I told him it was great to see him and I meant it. I congratulated him on his sobriety, of which he was clearly proud.
I asked him what he had done for a living before he started drinking and he told me about his education and his career. Before his addiction took over, he had a life with relationships and responsibilities.
That lasted for several months but then, unfortunately, the old Bobby was back. And, he was just as difficult as ever. But something had changed in me. I was more conscious of the sober Bobby beneath the belligerent, angry man in front of us.
Over the next few years, that cycle of sobriety followed by longer stretches of abusive Bobby repeated itself two or three times, with one period of sobriety lasting about a year.
And then, one day, he stopped coming. After I hadn’t seen him for a long while, I asked one of my colleagues what had happened to Bobby.
“He died,” they told me. “Someone found him lying dead in the grass in Deering Oaks.”
Today, every time I drive through Deering Oaks and see somebody lying on the grass I think of Bobby. Working with him and dealing with the Jekyll and Hyde nature of his personality has made me think more deeply about addiction.
I don’t have any great clarity of vision when it comes to addiction and I am not even sure that I would handle the technical aspects of his care much differently if Bobby arrived at the emergency department intoxicated and belligerent today.
But we as a society are doing a terrible job dealing with those suffering with addiction, and one thing I learned from Bobby was just how easy it is to dehumanize people. Doing that makes it easier to treat them like a problem, but it doesn’t make the problem go away and it diminishes us in the process.
So when I get patients like Bobby, sometimes I try to think of what they would have been like when they were kids. We all had a time when we played and laughed and when people cared about us and looked after us. When I think of them in that light, it often makes me more open to them as human beings. That’s important, because behind the addiction they are still real people. Bobby taught me that much at least.