Wednesday, January 15, 2014

Back to the point.



Grady Primary Care Clinic, 2014


"Here is what I want: something for my back. That's it. I want my back not to hurt and that's it."

"Okay. That makes sense. Tell me about your back."

"I've been driving a delivery truck for over twenty years. I also got in a car crash a couple years back. So now my back is messing me up. I can't take any of the boxes off the truck 'cause it hurt. So now they telling me if I keep asking for lighter duty, I can't work."

"Man. I'm sorry."

And so. I asked some questions about the nature of the back pain. How it started and how it has evolved. And then I looked in the chart to double check things like his lab work and vital signs.

Blood pressure:  188/103
Body Mass Index: 32
Kidney function: abnormal
Blood sugar: Just over the upper limit of normal (too high)
Cholesterol: High

And just as I parted my lips to speak, he spoke first.

"All I want is for you to help my back. I don't want you start talking to me about my blood pressure and a bunch of other shit. I let them draw some blood because they said it might help me if the orthopedics want to see me. But otherwise, I don't want nothing but for you to focus on my back."

I nodded and didn't say anything at first. Then I said, "Tell me what you've been doing for your back."

And so he told me about the physical therapy he'd tried and the anti-inflammatory drugs. He spoke of heating pads and special ergonomic chair pads, too. None of it was really working.

I went ahead and examined him next. Fortunately, there were no neurologic changes and his strength was intact. Most of the pain I could reproduce was localized to the lumbar muscles wrapping around his lower back. He winced as I pressed into the dense love handles spilling over the sides of his pants. Then I watched him walk. No abnormalities. Mostly just fine.

So this? This was more than likely some musculoskeletal pain and not much more. Wait. I take that back. He could have possibly had a very mild herniated disk or something but by "not much more" I meant that there was nothing that would call for an immediate referral or some kind of procedure.

He needed to lose weight. Like, a lot of it. And strengthen his core. And do some back exercises, too. And that? That would not be what he wanted to hear.

But on top of all that, he needed this other stuff handled. His chart showed me that this wasn't just a random blood pressure spike. It had been clocked this high over and over again. And each time he'd shut down any provider who tried to address it.

"Sir? Has anyone ever told you that your kidneys have gotten weaker?"

His response? He lifted one index finger and then pointed it to his back. That was his way of telling me that he wasn't going there with me.

I sighed and shifted nervously in my seat. "Ummm. . ."

"Please don't. My back is what I want to talk about. Like I said, that's it. After y'all deal with my back, maybe I'll want to talk about other stuff."

"For your back to feel better, you need to lose some weight. More than just a few pounds," I blurted out. And before he could say more I went on. "Your back will keep hurting as long as you carry this much weight on you. And losing weight will not only help your back, it will lower your blood pressure."

"This is from something more than me just being a big guy. I've always been a big dude. You ain't pinning this all on that. This is some bullshit." He started patting his pockets for his keys in a gesture to let me know that he wouldn't be staying much longer.

"It's actually true, sir. You've put on quite a bit of weight in the last few years. More than fifty pounds, sir."

"I want an MRI. You need to check me out with an MRI."

"I'm not against MRIs. But I'm wondering. . . .what would be the desired outcome of us getting one? Like if you had your way?"

"You could see if I have a slip in my disk or something."

"I'm not saying that's not a possibility. But if you do, it's more on the mild side."

"Still."

"Okay. But what if we did that and someone wanted to operate on your back? Even if they wanted to do that, they'd ask you to lose weight first."

"Here you go with that again."

"I'm saying that because it's the truth. An MRI right now won't change what we do. You don't have health insurance and getting an MRI will end up costing you some money. I don't want to have you get a test that you don't really, really need."

"I need something."

"You're correct. Sir, you need to get really serious about trying to lose some weight. Do you think this is something you can do? It would help your blood pressure a lot." I pressed my lips together. "How do you think we can support you in that?"

He rolled his eyes and didn't even try to hide it. "There's only so small I can be. I'm a big dude. Husky, you know? I feel like you got to have something else to offer me other than 'hey, lose weight.' That's not gonna get it."

I felt my patience waning. Clearing my throat, I coached myself to stay polite. "I'm not fully sure what you want me to do, sir. I mean, specifically."

He cocked his head sideways and looked at me like I was stupid. "Help my back so I can work."

"No, I get that part. But the thing is that we aren't really on the same page with ways to tackle your health."

"My back. You keep bringing up the rest."

"I can't pour a cup of water on the fire on the porch when the rest of the house is close to going up in flames, too. I can't just ignore your blood pressure and your labs, sir. I can't."

He stood up. "I can." He started mumbling under his breath some things about how what I was saying was "some bullshit." Which was the only part I could make out. He fished his car keys from his front pants pocket and jingled them in his right hand. "I'm good. I'll go somewhere else."

And you know what? He did. He left. Before a nurse could even discharge him or give him an after visit summary. He left.

I see patients all the time who come in specifically requesting certain things. Sometimes it's a test, other times it's a specific type of prescription medication. I talked to this man long enough to know that he wasn't there for narcotics or anything. He was just frustrated and scared at the same time.

And not ready.

This man was well on his way to kidney failure. And that blood sugar combined with the constant uptick of weight noted in our chart meant that he had a date with diabetic destiny coming sooner than later. But that stuff? The blood pressure and the weak kidneys? The metabolic derangements and the work it would take to get him on the right track? He wasn't ready to tackle that. He just wasn't.

And honestly? I'm never sure how to deal with patients like this. Like, how can I focus only on that agenda when the other is so urgent? See, he hadn't been to see a primary care provider in over a year. This meant I needed to seize the opportunity while I could. I couldn't blow off the sky high blood pressure or the chronic kidney disease. Or better yet, I couldn't not talk about it.

Sigh.

Let me tell you something: Human beings are a work in progress, man. That part I know for sure.

What will I do? I will call him a few times and check in on him. I'll chart stalk him in the electronic medical record to see if he's been into the system anywhere. And then I'll cross my fingers and hope that he'll come back to see us before something happens and the shit just gets real enough to force him back on all fours.

Yeah.

***
Happy Wednesday.

6 comments:

  1. a tough one....you did what you could.

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  2. Lord, aren't people complicated? He wanted a magic pill, and they don't make those. Flexeril, oxy, any pain meds would have prevented him from driving and cost him his job anyway. It's a long journey for a regular person to understand how connected our body systems are, and an even longer one to keep an open mind. You did your best, and maybe nobody can help him, which is a damn shame. You tried, though, and probably got more words in about his weight and bp and blood sugar than other doctors might have. Love the porch on fire analogy.

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  3. i am missing you!!! hang in, he'll be back, i feel it, and i'll want to read about it! xoxoxoxooxo big love from the other side of the world!

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  4. I am so thankful for you in this world for you reminding me there are physicians in this world for these conversations. For your goodness. I am so thankful.
    xor

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  5. That was a tough patient. I think that you did what you needed to do. You provided him with the information and a plan to make a change and he hopefully will change... before SJGR. You could have appealed to his need for an easy answer with an MRI and he would be right back to you (or someone else) to complain after conservative/surgical interventions failed). A person at some point needs to be in charge of his or her problems.

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  6. "I can't pour a cup of water on the fire on the porch when the rest of the house is close to going up in flames, too." This is exactly it. People don't want to make changes until they HAVE to...like until they wake up in the hospital.

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