jekyll and hyde

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“OK, I’ll see you next week,” I say to Mr. V smiling genuinely and push my cart stacked with medical charts to the next dialysis recliner. I see Ms. H and my smile dissolves as I concentrate on not rolling my eyes. My entire being is transforming like some sort of Jekyll and Hyde for all to see. “Hi, Ms. H,” I say flatly as I pull her chart from the cart. She has been my patient for nearly a year now.

She is sitting up in the recliner with the leg rest extended. Her dingy peach-colored spandex tank top has retreated into a modified tube top. The left strap is slipping off her shoulder. The right strap is tucked into her armpit so that her right areola is one shiver from being exposed. Her belly protrudes below. She is scratching incessantly. Her legs. Her arms. Her chest.

“Hi Dr. Grubbs. How are you today?” Her tone is light, as if we are about to chat about the weather. Her Jekyll to my Hyde. As if she wasn’t just discharged from the hospital for chest pain after skipping dialysis to make time for huffing diesel fuel when the crack, heroin, and meth ran out. Again. Happens at least once a month, usually twice.

It is all I can do to not curse her out.

Ms. H is not an anomaly to me. At any given time in my small dialysis patient roster of about 20 patients at San Francisco General Hospital, there are 2 or 3 actively abusing drugs or alcohol.

Yet she is the only one that triggers the Hyde in me. I think this is because I see a lot of me in her. She is black, in her early forties, and is actually quite pretty. It’s as if I take her failures personally. And though I provide the standard of care she allows, I dislike her so much I often feel I shouldn’t be her nephrologist. But I didn’t always feel this way.

Earlier this year, I visited her in the hospital. She had been admitted for endocarditis. Bacteria she had inadvertently injected along with her drugs had deposited onto one her heart valves. So much so that the valve could no longer open and close normally.  A stethoscope on her chest amplified the whooshing of blood going the wrong way.needle and spoons

“You can do better than this,” I told her. “Get your shit together.”

I could see the doubt in her eyes. She didn’t believe she could do better. I understand the self-doubt, but not the self-destruction.

She went on to be kicked out from a couple of drug rehab programs for breaking the rules to the welcoming shelter of a port-a-potty on many a night.

“Doc, can’t you give me something for this itching?” she asked from her recliner, still scratching.

Many patients on dialysis have some itching, often from dry skin or very high blood phosphorus levels. Thick lotions for the dry skin and medications to prevent the phosphorus in food from getting absorbed into the blood stream help most. Ms. H leaves the hospital before she can be given her medications and she doesn’t go to the pharmacy. But I suspect a dose of something I can’t prescribe is really what would make Ms. H’s itching go away.

Before I can answer she says, “And I need my Losartan, doc. I need my Losartan. My blood pressure is too high.”

The Losartan was stopped because it can cause a person’s potassium level to increase to dangerous, heart-stopping levels. Particularly so in people who skip dialysis.

I explain this to her again and say, “You know, crack makes your blood pressure high. Stop using.”

“I ain’t even using anything anymore, since I been out the hospital,” she tells me while her gaze shifts from my face to somewhere on the floor.

How do you help someone who lies to you? How do you help someone who repeatedly takes chances with their life because they know teams of people—from the paramedics to the emergency room staff to the hospital doctors and nurses to me and the dialysis unit staff—will be right there to save them?

But what I really want to ask is, why do I have to? Why should any of us continually try to save someone who is actively working to destroy self?

Because she and all those just like her are afraid to die. So they choose dialysis. And here in America we believe in individual choice. Never mind societal good.

But, hey, maybe this is the time she will turn it around. Or die trying.