Patience

Wild hair flying, sullen eyes narrowed, the overweight woman barreled through the hall on her motorized wheelchair.   She left the floor every day to smoke, fleeing her hospital bed for he relief of nicotine.   Her body had ravaged by polio, caught in the last gasps of the disease before the herd immunity of an immunized body politic saved almost all US citizens from the ravages of the disease.  She had diffuse neurological damage and was barely able to walk.  The polio combined with the stress of 50+ years of partial mobility to create diffuse and excrutiating pain.  She had been on immense quantities of painkillers for years, and had developed an opiate resistance to rival that of Keith Richards.  

She was here for no particular reason.  Her pain had acted up, fall storms driving her to seek solace at our hospital.  She had health issues enough that she could always get herself admitted, tearfully pleading for someone to fix her.   She got sullen every time, blaming us for not trying, for not helping.  Pleading evolved to a more strident beast, eventually culminating in demands for a neurosurgical procedure that she felt CERTAIN would fix her pain.  She ranted about her family, a victimization complex seeing every slight as a salvo in an orchestrated campaign to put her into a home.  She demonized the public health service, declaring her need for more than an hour a day of government sponsored home assistance.   She lectured us on our hard natures, blaming our inability to meet her demands on the fact that men never respect women.  Every day I saw her was a struggle, trapped in a room with a person whose struggles I felt for, and whose personality defied affection.  

She had disease, but her pain was magnified tremendously by her inherent depression, and her cultural biases shot our treatment plans in the foot.  She refused all the practical suggestions.  I spent hours talking to her, convincing her that chronic pain like hers is not curable, that there is no surgery,  no pill.  I reinforced that her opiates were maxed out.  I suggested trying medications like neurontin and amitriptyline, both of which could have helped her pain (and amitriptyline her depression), only to have these suggestions rejected because, of course, "I ain't crazy."   In a similar vein she rejected any suggestion of assistance from chronic pain psychologists.  

It came time, after a week, to discharge her.  We tried earlier, but were met with strenous resistance, accusations of not caring, threats of complaints and lawsuits.  The hospital, by nature a risk-averse institution, elected to let her stay until her coverage ran out, adding thousands onto an already astounding bill she was never going to pay.   When finally we called security to escort our most trying patient out, we were met with a barrage of profanity, and a week later, two malpractice complaints (the first of my career). 

I didn't like her.  I didn't like her because she wouldn't let us help her.  I didn't like her because she didn't like me.  I didn't like her because she was a waste of precious healthcare dollars.  I didn't like her because she was just intrinsically not likable.  I don't think she taught me any lessons (outside of showing me a post-polio syndrome, which is fairly interesting).   I have no great insight from this episode.  I didn't care for her, and I did my job.  I tried to help a demanding, uncaring, selfish disaster zone from hurting herself any more.  Because thats what I signed up for, and thats what this job is, and for every delightful person in the world, there is one like her, and they all deserve our effort.    

Those Eyes

My girlfriend's response when I informed her of the role of fungus in seborrheic dermatitis (aka, Dandruff) reeked of incredible disinterest.  "Really?" she asked me, with an incredulously malicious glint in her eye, "that's common knowledge to anyone with a beginner's understanding of hair care."  Despite my argument that this means approximately 1/2 the world's population is completely unaware of this phenomenon, I still had been thoroughly put in my place as late to the scalp health soiree.  She regaled me with a robust explanation of why dandruff shampoo included selenium, an active ingredient that disrupts fungal cell cycles.  She lambasted my poor understanding of how to keep a scalp healthy and flake free.   She gave me the treatment that I usually reserve for all my otherwise intelligent friends when it comes to healthcare. All this she did with a look in her eye, a patient but condescending look that I imagine I wear all the time.   Man, do I hate that look. 

The long and short of the facts of dandruff is that it results from a persistent fungal skin infection causing seborrheic dermatitis, a fatty flaky rash that generates the pseudosnow dappling some of our dark shirts and jackets.  The shampoo's and medications used to get rid of it are all antifungal in their function, and the one real take away message is that you need to rotate your antifungal shampoo in order to fully clear a fungal infection, as they will grow tolerant to monotherapy with head and shoulders (active ingredient: selenium). 

But I knew none of this.  It wasn't covered in my pathology class. I had heard of seborrheic dermatitis, but only in connection to HIV (which increases the incidence, as if HIV patients needed the insult of dandruff on top of the injury of HIV).  We don't educate well on the annoyances, the minor medical mysteries and problems that confound people on a day to day basis.  You pick that up in residency, in practice.  On that fateful day my girlfriend taught me two lessons.  First, a strong preliminary course in haircare.  Second, a lesson in humility.  Next time I give a patient or a friend a lecture, it will definitely come from a place of better understanding.