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FORUMWhat's Wrong with Mrs. Jones?"
Mrs. Jones, ... ahem, Mrs. Jones," I called out from the corner of the room. Boy, what a tough time I was having trying to get the older woman's attention. Smiling and waving my hands to even get her to look at me were evidently not productive gestures. She just sat there listless, motionless, gazing at the opposite corner of the room, deaf to my calls, oblivious to my presence, unaware that my patience was being stretched thin by this futile encounter. In less than 20 minutes I would have to present her case to the senior resident. At this rate, I thought, I'd be lucky just to get her vitals. What excuse could I use: "The patient was non-compliant ... and a poor historian"? Yet none of this standardized "medicinese" could really convey this elder patient's situation. As I stood there in my corner of the room, neatly dressed in my white coat, wearing the stethoscope around my neck, I tried to make sense of all this. Now aged 64, Rosemary Jones had obviously been through difficult times. She had been divorced a few decades before, but that was not unusual in America. Besides, she must have gotten over that a long time ago. However, she had lost her eldest son to a car accident only a few months earlier and was now faced with a diagnosis of terminal breast cancer, compounded by an acute pneumonia. Help?Where was her family when she needed them anyway? Her other son was a successful but busy business executive in the midst of a company crisis, who currently had his hands full trying to keep the company afloat. And her only daughter seemed somewhat estranged from her. Maybe living in a nursing home really was the best solution in her case, after all. But something had to be done about the pneumonia, I resolved, jerking myself back to the world of medical reality.Just then a nurse popped into the room. "Is she being difficult again?" she exclaimed within earshot of our patient. I felt somewhat embarrassed by the nurse's question, even though I was probably thinking the same thing subconsciously. Nevertheless, what if she had heard the nurse's comment? She certainly was not deaf, even though she appeared disengaged. Struggling to appear in control of the situation and to project an aura of medical sophistication, I replied, "Well, I don't think she is doing too well. Perhaps we should consider a psychiatric consultation—she may be depressed." As the nurse stepped back out of the room, I looked again at my watch—my heart jumped! Only 15 more minutes before rounds, and I still had one more patient to "pre-round" on. "All right Mrs. Jones, you get better now, OK? Do call us if you need anything. See you in a bit," I said, stepping out of the room. I could not help noticing that she glanced momentarily in my direction, her eyelids drooping, her expression sullen and melancholic. I read despair and abandonment. Boy, I blew it this time, I thought. But what was I to do? I could not force her to cooperate against her will. Resigned that I had done the best I could under the circumstances, I quickly reviewed the nurse's notes on her that morning, looked up her latest lab values, and started formulating my treatment and action plan. Seven more minutes to go—next patient! Hopefully, this one will be easier to deal with. At rounds a little later that morning, the residents had an equally hard time connecting with Mrs. Jones. The senior on the team, who had initially begun speaking to her in soft tones, began to raise his voice, but to no avail. Determined to do the job more resolutely than I had, he placed his arm on her shoulder, and looking into her eyes declared as empathetically as he could, "Everything is going to be all right, Mrs. Jones. We're going to take good care of you. I just need to do a few things—listen to your heart and lungs, feel your pulse, you know, the medical routine. It won't take long, I promise. Then we'll leave you alone." And with those words he proceeded to take her vitals and perform a quick but reasonably thorough medical examination. Hmm, now why didn't I think of that approach? I said to myself. A little later outside the room, I was quizzed on her case by the medical team. Feeling more confident than I had earlier that morning, I was able to explain the pathophysiology of the pneumonia and the etiology and implications of the breast cancer; I even earned extra points for suggesting a psychiatric referral and offering to call the patient's family members and other relatives. PersistenceIronically, though, I knew that I had missed the mark. Indeed, we had all missed the mark. There was clearly something else going on with our patient beyond her physical condition, even after factoring in her presumptive depression and loss of affect. I determined to go back later after my day's work and attempt to make some more headway.Five-thirty p.m. Finally. Done with my official duties for the day, I decided I now had leeway to go back. I chose to take a break first, though. The day's activities had left me quite drained and exhausted. Running between clinics and conferences, trying to cram in between, I hadn't even had time to reply to my e-mails. Ten minutes spent walking around the hospital gardens refreshed my spirits considerably. Meanwhile, I contemplated what I would do and say when I went back up to room 941A. At a quarter to six I was back on the 9th floor. Running into Mrs. Jones's nurse, I smiled and said, "Hi" only to be greeted by, "What are you doing here? I thought you guys were done by now." "We are, but I just wanted to stop by and see how things were with our patient," I replied. "Good luck! Don't stay too long. Remember to save some energy for tomorrow," she chuckled as we went in opposite directions. As I pulled a chair close to the elder woman's bed, she continued to ignore my presence. Determined not to be offended this time, I proceeded. "Hello, Mrs. Jones." Pause. No reply. "I wanted to check up on you and see how you were doing. Can I get you anything? Is there anything you would like to make you more comfortable?" Pause. Still no reply. Then slowly, her head began to turn in my direction as her first word came out: "Water," she muttered. "Sure, no problem," I replied. "Would you like it warm or cold?" "Cold," came the icy reply. Yet I felt the ice between us had been broken. Returning with her water, I paused to let her take a sip before continuing. "I know it must be difficult for you, but we are here to help you any way we can. You know, it's quite beautiful outside now—spring is in full blossom. If you want me sometime to take you outdoors for a while, I'm sure that can be arranged." By now I was beginning to get the sense that I really did have her attention. My optimism was mounting, but then she responded, "No thanks. I'm fine in here.... Besides, I have a nice view from my window." Silence. What to do now? Pause. Not a sound. I decided to break the silence. "If there is anything on your mind that you would like to talk about, please feel free." A last moment of silence, and then she began. The rest is history. —Nii Tetteh is a fourth-year HMS student in the Health Sciences and Technology program. He wrote this chronicle last year for the Spirituality in Medicine course. The patient name is a pseudonym.
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