Wednesday, November 7, 2007

"Only-oxycodone-will-make-my-muscles-strong-again"

REFLECTING ON: Maintaining objectivity even in the face of a med-seeking patient...

It had already been a long day before Grace and I had entered a Community Care Home in the East Bay. My feet were dragging as we passed the neglected lawn and entered the assisted living facility for adults. Folks here at the “home” have both mental and physical disabilities. We were there to see Polly, whom Grace, my preceptor, told me was a hard case. We got much more than that.

The front waiting room was a mix of 1970s d├ęcor that I’ve mostly seen in shitty dive bars, funeral homes, and my grandma’s living room. The walls were olive-green velour and the furniture was of the finest cracked vinyl. Doilies adorned the coffee table and ceramic Halloween decorations sat on top of those. Halloween had passed a week ago, but the heavy layer of dust let me know the decorations had been there longer than that. The front desk sat unmanned, so we peered down the nexus of hallways that sprouted off this bizarre portal. The halls were wide and dark and smelled strongly of cigarette smoke with a hint of emesis, emptied colostomy bags, and chicken curry. As I searched for signs of life, I only noticed shadowy corners and a cold breeze that did nothing to alleviate the pungent smell of “group home” living.

Grace and I called out and were answered with muffled, unintelligible shouting. For some reason, we took that as our cue to walk further down the hall. A man in a wheel chair with one leg suddenly rounded the corner. He wore old hospital pants and booties, a stained white v-neck t-shirt, and a brimmed beanie. Around his neck he wore a money sign medallion emblazoned with plastic gems. Never looking up, he moved quickly passed us while sneering at everyone and no-one.

As we worked our way from the a slowly disappearing exit sign, we found a second desk with a short, stout, worn and once-pretty Filipina woman passing out meds from behind it. She wore no identification, had deep, dark circles under her eyes and was only identifiable as a staff member because she donned Dickies scrubs and was behind the counter instead of in front of it. Without identifying herself, Grace asked if we could see Polly. The worn woman looked down at our badges, sniffed, and then shouted something in Tagalog down an empty corridor. A short man, whom I later found out was named Ben, scurried around the corner, gestured for us to follow him, and then disappeared again. We walked briskly toward the spot that he had disappeared at, only to find him at the end of another hallway, pointing towards an open doorway. He disappeared again. I felt like I was following the white rabbit down the hole. It was only at this point that I realized the hallways were lined with doors, which were painted the same color as the walls. Ben had moved so quickly I never saw his face.

As we entered the tiny, double-occupancy room, a trembling mass of a human lay awkwardly in its bed. She lie with her neck pinched so that her head deviated at a near perpendicular angle from her body—as if she lacked the will to move from a clearly uncomfortable position. This was Polly. I smelled pee and stale smoke and hoped that my nose would habituate soon. A mop of unkempt hair that I vaguely recognized as a grown-out bowl-cut hid her glazed over half-mast eyes. I watched a flash of recognition cross her gaze and Polly launched her into her performance almost immediately. “I-am-in-so-much-pain. I-am-shaking-all-the-time. Oh, Grace, what-am-I-going-to-do?”

Her staccato words came out like a 4th grader reading aloud round-robin style from a history book. This was clearly a script. She never deviated from this style. I kept looking for an unpredictable inflection in her tone or something that would give actual meaning/life to her words, but found nothing but all-too-recognizable med-seeking behavior. As the act played out, with Grace responded by making monotone, half-hearted assurances that everything would be okay, I half predicted the back of her hand to fall to her forehead like a damsel in distress. Then, as if I willed it, she did exactly that, “Oh why-oh-why won’t-the-doctor-give-me-oxycodone?” Her hand fell against her brow. “Only-oxycodone-will-make-my-muscles-strong-again-and-I-will-be-able-to-walk-again. Oh, oh. What-will-I-do?”

I looked away to hide one of those smiles that just can’t be hid, inhaled deeply, and attempted regain my composure before I took her vitals. In order to get her blood pressure, I had to unwrap her from the four sweatshirts she was wearing, which was a near impossible task given her unwillingness to sit up. I finally settled on taking her radial BP on her forearm. 140/80. She cried out when I mentioned this number but stopped when I told her that 140/80 was my normal BP. Not horrible, but not great. Temperature was 36.5 C, HR 85, and RR 20. Unremarkable really, outside her slightly lower temp, which I attributed to her lack of movement and the many open windows. Her physical exam yielded still more unremarkable information except for her right lower leg being edematous (+2 pitting), which I attributed to her recent knee surgery. The site of the surgery was reddish, but seemed to be healing well. When I felt around the site of the wound, she launched into a new script, “Oh, please oh please do not touch me like that. AHHHHHHHHHHH! So much pain. So much pain. I was attacked last week by a man that lives here. He’s crazy. He ran into me on purpose with his wheel chair. He’s got one leg. I don’t know why he did that. He’s so mean. I think they are going to evict him. Oh. Please. Let me escape this place.”

Her last sentence actually sounded convincing. I was ready to leave too. My ears burned, which they do sometimes when I’ve about had enough of just about anything. By herself, Polly was manageable, but I had already seen too much that day. Luckily, Grace dismissed us, “We’re going to go see what is going on with your meds and we’ll be right back.”

The hallway smelled better than the room, but I quickly realized that I didn’t want to be there either. As we approached the med desk, I felt like a re-enactment of Michael Jackson’s Thriller video was taking place. People were moving everywhere in random directions with various parts of their bodies hanging while other parts twitched. All of them wore blank expressions and were moaning or drooling. One woman in a wheel chair with a lazy eye and a half paralyzed face was shouting, “I want my god damn mail. It’s a fucking federal crime to withhold my mail. Give me my meds and give me my mail. You fucking crooks.” The one legged man in the wheel chair egged her on, and then turned quickly to face me, flashing a sly smile.

I found it easy to dismiss both the wheel-chair-lady and Polly’s complaints because they were crazy, looked funny, and were incredibly manipulative. Any legitimate concern that they might have was so hidden beneath the layers of lies and psychosis, I felt less than obligated to advocate for them. I was concerned and surprised by how easily I switched into that mode. Judgment. Hmmmmm. “Better get a handle on that, Nat.”

Grace had worked her way through the zombie melee and was talking to the worn woman. As I sat down at the med desk, Grace handed me a list of the meds and asked me to cross-reference them with what they had behind the counter. My mind switched out of judgment mode and phased back to my very green clinical skills. I was trying to remember everything to check: medication name, dosage, time, expiration date, prescription date, mode of administration…what else? I was sure I would miss something with the groans in the background. Fucking hell. The woman in the wheel chair was now ramming her chair into the counter. I moved down a seat and went to work.

I wasn’t a minute into the list when I noticed something that wasn’t on my list: the vicodin were huge and there were only two of them at the bottom of the pill bottle. When I opened up the bottle and held it to my eye, I saw that there were two 800 mg Ibuprofen tabs at the bottom. Then I went to my green skills list: prescribed on10/23 with 90 pills, 1-2 pills PO q 6 hrs, PRN. What was that? 8 pills max/day? 8 x 14 days passed=112 pills. 112pills-90perscribed pills=22 pills that couldn’t have been given because they didn’t exist. 22missing pills/8pills a day=almost 3 days of missing pain meds, assuming that she had consistently getting the maximum dose at the regular six hour interval. There was not way this place was consistent. Couldn’t happen. Too god damn crazy to be regular.

I smelled bullshit because narcotics were involved. I switched back into judgment mode and was happy to observe that I didn’t just apply my bullshit detector to the patient. Was I being too hasty to judge? No I had done the math right. There’s now way this place was regular in its dispersal of the meds. No fucking way. I was, am still pretty sure someone was pocketing the hydrocodone and switching it with an over-the-counter pain med. Jesus. Okay, maybe Polly was med-seeking, but she also had a legitimate concern. Now I felt bad. My judgment almost allowed me to ignore the facts. God I love facts and diagnosis based on them.

I looked to Grace and nodded toward the bottle as I handed it to her. Grace is hip to the fact that I’m a skeptic and like unspoken communication. She looked in the pill bottle and frowned. Then she spoke, “Good catch, Nat.”

When we brought the information to the worn woman’s attention, her English suddenly got worse and she had a harder time understanding us. She also couldn’t produce the PRN record, saying that it was locked up in the boss’ office and that the boss wasn’t around. Now the bullshit smelled stronger than the piss and cigarettes. I looked around and caught more Thriller video. Then I looked at the worn woman’s tired eyes and felt a tinge of sympathy. Shit. I would want some narcotics too if I worked here everyday. I smiled at her and said, “You’ve got a hard job. I used to do this too and it’s tough.” She smiled back as she hung up the phone with her boss. Then she lead us out of the facility, closing and locking the door behind us.