Thursday, July 28, 2011

The short fuse.

*names, details, all that stuff changed to protect anonymity. . . .
image credit

em·pa·thy/ˈempəTHē/ (n): the ability to understand and share the feelings of another.


This one time at the Gradys. . . . .

I was talking to this seventy-something year old man with a 80 pack/year smoking history. For those who aren't in medicine, here's how you do the pack/year math--for every year you smoke, you multiply that by how many packs you knock out in a day. This gent had been puffing a staggering forty cigarettes per day for forty years so his equation went a little something like this:

40 years x 2 packs per day = 80 pack years.


By this point, all that tobacco use had led to some health concerns. For real. Such as:

1. Oxygen-dependent COPD (also known as emphysema.)
2. Peripheral Arterial Disease (also known as "poor circulation.")
3. Hypertension (also known as "high blood pressure.")
4. Congestive Heart Failure (same thing as "heart failure.")

(Just to name a few.)

Now check it. The real problem is that despite all that this patient was still smoking. In his defense, he had cut back to one pack but still. I mean, damn. I felt myself getting irritated with the thought of it all. I looked at the rubber tubing nestled inside his nostrils feeding him supplemental oxygen while taking in the tell-tale scent of cigarettes emanating from his skin. It was like the entire room had been fumigated with it. I released a sigh . . . . feeling all of my empathy seeping out of me into a pool on the floor.

Like seriously? Even after annihilating his lungs, withering away his blood vessels, and pooping out his heart, he was still smoking? Oh come on.

Now. . .before you hate me. . . let me first confess something. . . .

On this day, I wasn't in the best of moods. Any time my day starts out with a crash and a bang, it ain't good, and that's exactly what had happened. See. . .first of all, I'd overslept (and so had my human-alarm-clock kids) that morning. This made my house complete mayhem and it made me rush so much that my already short fuse had become undetectable.


To make matters worse, everyone with a Y chromosome in my house was ridiculously freakin' whiny--including my 40 year-old husband who virtually stalked me from the moment I woke up about ME making coffee. Yes. Despite the obvious fact that I had just woke up two minutes before I was physically supposed to be at Grady. (Insert deep breath with fist balled here.)

Woosaaahhhh . . . .

Which reminds me: Ladies. Gentleman. When and if you get married or otherwise boo-ed up--please. . . heed my advice--start the game the way you want to finish it. In other words, if you start the game being the one who makes the coffee every morning while whistling like Andy Griffith. . . and just if, by doing that, you somehow get your spouse/partner/boo/fill-in-the-blank to believe that when you make it (or any sandwich for that matter) that you somehow put "love" in it which is why it always tastes better when YOU make it. . . . then guess what? Even if you are late as hell you can guarantee that you will still be stalked for your love-coffee. (Or your love sammiches, depending on the situation.)

Fact: There is no such thing as love in a cup of coffee. Or a sandwich. Or a sammich.

But I digress.

So where was I? Oh. Mr. Gill, his oxygen and my short fuse. Yeah, so all I'm saying is that I wasn't in the mood to be trying to convince a grown-a man with a flammable gas strapped to his face that lighting up anything nearby was . . .uuhhh. . yeah . . . . not such a great idea.

Um, yeah.

Isn't that terrible that I was thinking all that? I know. . . .it was. The good news is that I wasn't so off that I didn't realize that acting on these feelings was inappropriate. So right then and there I started coaching myself to get over my craptacular morning full of whining and java-stalking. I swallowed hard and began shadow boxing in the corner of my head to deal with Mr. Gill and his love affair with cigarettes.

I thumbed through the chart once again and stopped on his pulmonary function test results.

"Severe Obstructive Lung Defect consistent with advanced COPD."


After examining him and reviewing the changes in his medications, I knew it was time to go there. "Okay. . . .so let's talk about the cigarettes, Mr. Gill."

He shut that down real quick.

"Nawww. It ain't nethin' to talk about there." His voice was crunchy like velcro and his will as strong as steel. This wasn't going to be easy.

I tried to think carefully before speaking; still coaching myself to be professional. "I wish you didn't feel that way."

Mr. Gill launched right back again with another zinger. "Oh yeah? Well, I wish y'all would stop trying to talk about me and smoking! But y'all keep on askin' so I guess everybody got a wish that don't come true don't they?" He let out a raspy and sarcastic laugh punctuated by a prolonged wheezy-sounding hack.

Man. He was too quick for me and this was requiring me to think faster than expected. I bit my cheek and tried to think of something insightful but came up with nothing. Instead I just told him what I was thinking.

"Mr. Gill, sir? The thing is the oxygen. That's the issue I mostly have because--"

"Do you thank I'm stupid a' somethin'? I ain't stupid, hear? Baby, I know damn well the oxygen don't mix with matches and cigarettes! I don't never smoke near the oxygen. I take it off every time."

Wait, huh?

"But sir. . . .you're supposed to be on oxygen all day. Smoking that much time every day with your oxygen off of you is dangerous, you know?" He cocked his head and looked at me like I'd just said the dumbest thing he'd ever heard. It was intimidating. This man was older than my father and firm in his resolve. "Look, Mr. Gill. . . . . I mean. . .I realize that you've been smoking a long time. . . . "

"Yeah. Longer than you been alive."

This time I did have a comeback, albeit a lame one. "Long as I have been alive actually."

His eyelids fell to half mast. Smart ass.

Finally he shook his head and said, "Miss Manning? Look here . . .regardless of all that. . . . I ain't ready to not smoke at all. I'm just not."

I swiped my hand over my face. Mostly because I didn't know what to say just then. He was too fast and I was too irritable.

"Mr. Gill, sir. . . have you ever quit at any point in these forty years?"

"Nawww, not really. I went up and down and done cut back here and there. But nawww. . . .I ain't never really quit altogether. See, I drove trucks for years and even after that I just always was a smoker. It's just parta who I am."

I stared at his leathery fingers with their yellowing tips and clubbed fingernails. His face had deep grooves throughout with the exception of the fine wrinkles framing his mouth filled with tobacco-stained teeth. The portable oxygen tank provided to him that day hummed beside him; he would periodically ball his fist and let out a gelatinous cough. The khaki pants he wore had been cut at the knees into shorts, revealing shiny, hairless legs that were textbook for circulatory impairment. And in his shirt pocket was a pack of Newports. Mr. Gill was as unapologetic about that rectangular box as he was about his refusal to quit smoking.

clubbed fingernails

Yes. This was part of who he was. I could feel my icicles melting. I wanted to "get" what he was feeling and suddenly felt much more intrigued than annoyed.


He raised his eyebrows but didn't speak.

"What do you think it would take to get you to quit altogether? Like. . . have you ever just been tired of it? Like. . .sick of all the nagging. . .the cost. . .all of it?"

Mr. Gill narrowed his eyes and thought about my question. I appreciated the fact that he at least was giving it some thought.

"You know. . . .I do get sick of the nagging. But the rest? Honestly, not really. No, matter of fact. Not at all."

I'm not sure what I expected him to say, but for some reason I felt disappointed when he said that. It must have shown all over my face.

Mr. Gill gave me an endearing smile. He seemed a little amused by my earnest efforts to understand him and move him toward smoking cessation. Even if neither was working.

This patient was in what we call a "pre-contemplative" phase--the point where you aren't anywhere close to even thinking about changing a behavior. When people are in this place, the main order of business is patient education and not much more.

But with Mr. Gill we had been there and done that. He'd been given information out the wazoo and had been told all the risks of continuing/benefits of quitting ad nauseum. At this point he just needed to quit already.

"Miss Manning, you ever smoked in your life?" he finally asked.

"Smoked what?" I answered. We shared a quick chuckle at my comic timing, but after that I quickly got serious. "No, sir. I haven't smoked."

He pressed his lips together and nodded. "Then you don't know. I mean. . . no offense, Miss Manning." He paused and coughed into a clenched fist again. "See, smoking is part'a who I am. And I like who I am."

I tried to understand his perspective. I really did. But this was killing him. He had to acknowledge that this part of his life was killing him. And so I told him that.

"But see. . . that's not how I see it. See, I see it like enjoying a piece of sweet potato pie when you know you got sugar. Sometimes when you get older you just got to enjoy your life. You can't be worried about every single thing you do that ain't perfect. See, I'm almost eighty years old. At this point I jest might die with a cigarette lit in my hand." He let out that sandpaper laugh again and shrugged. "And I'll be happy 'cawse I enjoy it. I sure do."


How do you compete with that?

"I want to say 'it's okay,' Mr. Gill but I just can't, you know?"

"I know, baby. This your job to do this. You 'sposed to give it all you got to get me on the straight and narrow so I could put them thangs down." Again that laugh. "But you got to understand-- smoking is part of my life. I get up, have me some coffee and a cigarette. Then I make me some breakfast and eat it. Have me one after that."

"I know what's next," I chimed in remembering the countless patients at Grady who've shared with me the common practice of blazing up on the commode. "The toilet, right?"

Mr. Gill threw his head back and laughed hearty and loud at that. "You sure you ain't smoked?"

"Naaah. Just been working here for a minute, that's all."

He softened his eyes and continued. "Yeah. I guess it's just such a part of my day, my people that I hang out with and play cards with . . . my whole daily routine--all of it. You know. . . me and my wife used to smoke together 'fore she passed on and I jest. . .I don't know. I jest don't have no desire to quit. I don't. I know i's bad but there's a parta me that love smoking."

I listened to his side and felt the sincerity in every word. Finally, I got it.

Ah hah.

He was right. I had never been a smoker and no, I had never tried to quit. Hearing his perspective made me think about someone plucking part of my daily routine away from me and how it would make me feel. Like if I was told I couldn't have coffee in the morning or that I couldn't put my hand on Harry's back at night when I sleep? What if. . .one day. . . a doctor marched into an office, wagged a finger in my face and insisted that I altogether quit . . . .writing? How would I feel? What would I do?

As he implored me with his compelling arguments, I quietly wondered how willing I'd be to give those things that are "a part of me" up. . . .even if I knew they were detrimental to my health. The truth is I wasn't sure.

"I hear you."

That's what I finally said. And I said that because it was true. I did hear him. . .and every other long time smoker. . .for the very first time.

I can't say that this encounter swayed me to think smoking is a good idea. Nor am I ready to adopt a "do you" attitude. But one thing for sure that can say is that on that day, I saw a little of myself in my patient. . .which is technically what empathy is all about, right?

"Mr. Gill, sir?"


"Will you think about the stuff I told you about quitting and your health problems? Like the reasons it could be good for you?"

He flashed his large beige teeth. "I will, baby."

"That's all I ask." I smiled back and signed one of the encounter forms to wrap up our visit. When I put down the pen, I noticed his eyes resting on me. The right side of his mouth turned upward in a coy smile. It was a little embarrassing.

"Miss Manning?"


"I want you to think about what I told you, too, hear?"

I stuck out my hand toward him and smiled as my fingers were lost in the grasp of his coarse palm and bulbous fingertips. . . .and in that moment, I was okay. . . okay with my day. . .okay with his choice. . .okay with that moment. . . .okay with it all.

Happy Thursday.

Now playing on my mental iPod. . . . not fully sure why. . . but for some reason it is. . . .


  1. Boy, you have some interesting days, that's for sure. You also have much wisdom.

  2. Sometimes empathy is all you got to give. And you gave it in spades. This man will probably not stop smoking but he will remember how you cared. And that is something big. I forget the exact words but the saying is something to the effect that, "People may not remember what you say, but they will ALWAYS remember how you made them feel." You listened and you respected him.

  3. You clearly have way more patience than I do! My standard line for my smoking patients is "The single best thing you can do for your health is quit smoking. If you want suggestions or medications for helping you do so, I'm more than happy to give them to you." I use it every time I see a smoking patient, but I never spend much more time than that if a patient is resistant to the idea of quitting.

    As an aside, why does the patient have clubbing? Has he been scanned for a possible lung cancer?

  4. SD-- You're all over it! ;)

    Yep, he has been assessed for lung cancer--lucky guy. . . .nothing to report. Although his clubbing isn't as severe as the example I've shown, it is significant and was enough to make someone think of hypertrophic osteoarthropathy for sure. (My mom said that picture was too "graphic" by the way -- LOL) Anyway. . . . His baseline O2 lives around 80 something so looks like the clubbing is all just chronic hypoxemia from such terrible COPD.

    My approach to folks like Mr. G is pretty standard, too--mostly patient education and motivational interviewing. I'm trying to "get" it more. . . . .

  5. You know.... I used to try and explain to people what it was like. I used to say it's as if you had to tell someone they weren't allowed to eat anymore. It truly becomes an extension of who you are.... and if I am honest I have had my fair share of slip ups since quitting smoking... and even now it is a struggle pretty much daily.
    It is just something I have to live with... choosing everyday to not give in to the addiction of it. I want to smoke because I miss it and I loved it and in many ways life on the other side has only been "better" because I don't want to have to quit all over again.
    I know its hard as healthcare workers to have compassion on people who smoke despite the ruin they cause their bodies... but if at the very least you can remember just one thing...

    They are the ones who will have to put the hard work in to quit.
    They are the ones who will struggle daily and grieve over the loss of something so integral to who they are. They are the ones who will have to do what feels impossible and maybe to them it is not worth it. I get that. It's sad but I get it.


"Tell me something good. . . tell me that you like it, yeah." ~ Chaka Khan

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