The Holy Trinity

He was the last patient of the night. My student and I walked into Mr. Stephen’s room. I noticed the smell right away. An off smell, musty. Funky, was what one of the attending physicians used to say, back in the days that I worked on the general surgery floor. To me, he smelled like a giant mushroom, going bad. He was polite and soft-spoken, sad looking, and about a hundred pounds overweight. “I came because of these sores, they’re getting worse again”. He took his shirt off.

The chart had said “abscess on skin” and that had sounded like a fairly simple way to finish off the evening. Our triage nurse is hilarious, a master of the understatement. The clinical name for his condition is hydradenitis suppurativa. Simply put, he had pus oozing from dozens of boils in his underarm and groin areas. “I can tell you’ve been suffering from this for quite a while, haven’t you?” He nodded. He didn’t say much. I could tell he was trying to hold it together. His skin condition was humiliating and isolating him.

I had my student, Jessica, start the physical exam. She handled it like a trooper. His appearance was shocking, even to me, but she never showed it. She did her job properly. The back of his neck was scarred from old boils that he’d had years ago. The condition was marching across his body, spreading to all of the susceptible areas. I talked to him about his condition. It’s really a severe form of acne, and notoriously difficult to treat. The latest blow for Mr. Stephens had come just a couple of weeks ago. He’d gone to the emergency room for a severe flare-up of his infection, and someone had mercifully chosen to admit him. The physician at the hospital had even ordered a surgery consult, hoping to get some of the lesions excised. Sometimes that’s the only thing that will work for this condition. For about twenty-four hours, Mr. Stephens really got his hopes up. Then the pre-op lab work came back. They gave him an additional diagnosis of diabetes, uncontrolled. Surgery cancelled, patient discharged, and now here he is before me at the free clinic.

After we cleaned and dressed what we could, we ordered antibiotics in the hope that we could keep him from returning to the emergency room. That is, after all, one of the main reasons our clinic exists. We also spent a long time teaching him about his condition. I had to tell him that being so overweight was making it worse. He didn’t want to walk, didn’t want to be outside. Around people. He didn’t have many clothes, and the drainage ruined the ones that he did have. Our job was to find, and show him, the kernel of empowerment that would help him keep on going. Help him try one more time to dig his way out of this spot. That was our job, and we gave it everything we had.

His blood pressure had been high for several years, and he was already on medication for that. I ordered some blood work to check for further signs of infection or other underlying conditions. I included a cholesterol panel to check his lipids. It would be another case of the holy trinity, I thought. Hypertension, diabetes, dyslipidemia. We see it over and over again, night after night. It is a plague in this country.

At my university I teach a graduate course called Clinical Management of Adults. It’s a challenging course because I’m trying to teach people the basics of being a primary care provider in a fourteen week semester. In my first class, I start by telling the group that there are, for the most part, only two diagnoses in primary care in the U.S., with every other illness being a symptom of these two conditions. I challenge the students to identify the two diagnoses. Hardly anybody recognizes that the two conditions I’m talking about are inadequate nutrition (overeating and undernourished) and inadequate exercise. Nobody wants a lecture on that, though. Not my students, as the topic lacks the excitement of discovering the latest news in drug therapy and figuring out mystery diagnoses. The patients? They’ve been conditioned to believe that there is either a tablet or laparoscopic surgery that can reverse any self-abuse they’ve been engaging in for the last few decades.

The free clinic where I work has been around for over 30 years, serving the working poor. Our county is fortunate to have several similar clinics. I’ve worked in rural counties up in the panhandle that had nothing like this for people to fall back on, and that can really be a mess when you’re trying to figure out how to keep someone alive and taking their medication.

I get a lot of satisfaction out of my volunteer time, and the patients are really grateful, at least the majority of them. Not like a lot of jobs now. That’s become a popular expression about nursing. It’s a great career, but a lousy job. I don’t hold it against people who quit and start over at something else, but I do think some of them may be a bit shortsighted.

There’s always a mix of returning patients and new patients who want to be seen. There’s also always a student to work with me, usually a graduate nurse practitioner student from our master’s program. When I got to the clinic that night after work, Jessica was waiting for me. She’s been attending the clinic faithfully for several months, trying to make the difficult transition from a critical care clinician to a primary care provider. She’s a true cardiac expert, but she needs to learn how to recognize that other body systems can cause problems, too.

Jessica reminds me a little of a pulmonologist I used to work with who liked to point out that the only purpose of the heart was to pump blood to the lungs, which are clearly the most essential organs. Well, we all have our biases. The problem arises when you are unable to develop a differential diagnosis, which involves thinking of all possible causes of a problem. My student was essentially suffering from a lack of imagination. In Jessica’s mind, all roads led to the heart as the causal organ. I think it was Maslow who said that when the only tool you have is a hammer, every problem starts to resemble a nail. I was trying to add a few items to Jessica’s toolbox. So, we came to the clinic faithfully, each for our own reasons.

Jessica was starting to get attached to the clinic, like I had. To some of us, it’s more than just supporting the mission of the place, it’s proving to yourself that yes, dammit, we can make some form of healthcare available to people without all of the politics and the constant calls for “insurance for all”. Show me that what I’m doing is of lower quality or is worth less than what someone with Blue Cross gets. I dare you. I am an old nurse and my feet hurt. Get out of my way.

The clinic waiting room was packed when we walked in. There were whole families waiting, and a bunch of people standing in line at the pharmacy window. The pharmacists are volunteers, too. They’re really helpful, but mostly retirees who like to go home at five o’clock and have dinner. As luck would have it, we also have no pharmacy volunteers on Fridays. That means things can get a bit messy on Thursday nights, which is my night in the clinic. We see eight patients a night, so the clinic often runs until seven o’clock or so. You can imagine what might happen if I walked into an exam room after five o’clock and found someone with no blood pressure pills and a BP of 198/120. That is the kind of thing that can motivate a nurse to hoard drugs for her patients. So I do.

Sometimes whole families come to the clinic with a sick family member. Sometimes it’s a two-for-one deal, with two people in the same family hoping to get seen together. Patients have to come when the clinic opens in the morning, to see if they can get a spot on the list that evening. They are taking a day off work to be here, and they walked, bummed a ride, or waited for the bus in the heat. The volunteers know this, and they rarely cancel. Most of the patients at this clinic are Hispanic. They dress in their nicest clothes, to show respect and to look respectable. Dresses or pressed slacks, the women in heels and earrings. They dress up their children, too. There’s a noticeable difference between them and the Anglo patients, who often wear shorts and ripped, grubby t-shirts, just like any other day.

Sometimes the clinic is a breath of fresh air after my faculty job. It’s not difficult to appreciate the contrast between handling students’ complaints about their inconvenient schedules, and handling patients’ complaints about how they are too sick to work, or walk. It’s also an instant antidote for moments of self-pity.

My time at the clinic and my other job at a student health center are what give me the confidence to keep teaching clinical courses. You can’t teach anything about clinical practice if you are even a year behind. You’ve got to keep seeing patients because if you don’t, you will quickly become obsolete. No offense, but the nursing curriculum is not 18th century French literature. All of the new stuff, the medications, the genetics research, the overall amount of medical knowledge, is moving under our feet. Flowing and flowing, oozing daily from the journals and the internet updates and the brochures for continuing education programs, and it’s not going to stop.

Earlier in the evening, we had seen two other patients who shared some problems with Mr. McGraw: overweight with multiple chronic medical problems. There are lots of expensive medications in the United States, but food, at least bad food, is super-cheap.

If people really studied the amount of time that is consumed with basic patient education, I’m sure there would be a fundamental change in medical and nursing education. I mean really basic things, like hygiene, healthy meals, and understanding one’s own bodily functions. Sometimes the lack of knowledge seems almost unbelievable. I congratulated Jessica on her work-ups on these patients, and she seemed really pleased.

One classic catty remark about nurses is that they eat their young. It really infuriates me when nurses say this about themselves. First of all, it’s crap. Not because it isn’t true in some cases, but because everybody does it. If you think senior nurses treat new nurses badly, try watching attorneys or, God forbid, doctors. They can be brutal. We’ve all slogged our way up the pecking order, getting more experience and more credentials to climb out of the early jobs. We all hope to eventually land in something that’s truly intellectually stimulating and not just challenging in the sense that it’s way the hell more work than you can possibly get done.

There’s something that is pretty unique about nursing, though. Rarely do you meet a nurse who went straight through from a bachelor’s degree to a doctorate, and into an academic career. It can take twenty or thirty years for a nurse to believe she’s expert enough to convey knowledge to a novice. Maybe a lot of nurses just can’t picture themselves as anything but clinicians, but at times it seems like some sort of self-esteem problem that afflicts our profession.

Maybe our collective self-concept also explains the workload problem. A lot of new nurses don’t want to admit to themselves that no one exists who can manage the number of duties that are heaped on their shoulders in some of the hospital jobs. Some people who do nursing workforce studies have pointed out that there really isn’t a nursing shortage, just a shortage of nurses who are willing to do so much work for so little reward. The staffing problems have always been a dirty secret, and floor nurses are told never to tell patients that they are not getting good service because of understaffing. This would make the hospital look bad. Of course, they are also told never to lie.

That’s one reason why we’re getting so many students in our master’s program now. They’ve had it with the impossible jobs with minimal authority. They want to be a provider. To be the one making the big decisions. To give primary care when it can still make a difference. They’ve been in a hospital, and they’ve realized that hospitals are dangerous places, with their own threats, and accidents, and diseases that prey on patients. They are ready to tell people how to stay healthy at home, and not just passively accept them as they come rolling in on stretchers with yet another terminal problem that was completely preventable.

Jessica and I saw a young Hispanic woman who works in a restaurant. She told us that she’d been feeling fatigued for several months. I turned to Jessica and asked her what some of the more common causes of fatigue were. She thought for a minute. “Um, heart failure?” Her differentials were definitely going to take some work. We got a history and a brief physical, then ordered some blood work to help us rule out several possible causes of her symptoms. This can actually be a pretty tricky problem to figure out, but we need to rule all of the basic causes in or out. Often, these patients are suffering from depression. Another possible cause in this group of the working poor? Actual physical exhaustion. Sometimes fatigue is, well, fatigue.

I thought back to several months ago, when I saw a similar young woman. She was under forty years old, and had fatigue but also said she had been having rectal bleeding. I had a bad feeling about her. I did an exam, then sent her for a colonoscopy. Later, the clinic director came to me. “Wow, good call on that colonoscopy. Huge tumor, unfortunately not resectable.” My patient was going to die of colon cancer. That’s one of the discouraging things about working in our system of care. There’s way too much deferred maintenance. That’s really what it is. Putting off screening and treatment because you don’t know enough about your body to recognize an ominous symptom, you don’t want to take off work, or you don’t even know where you can go for an exam. That’s what it comes down to for a lot of the patients we see here.

Long after dark, we walked out to our cars. Jessica turned to me. “Good night, Dr. Curry, thanks again. I really learned a lot. When’s your next clinic day?” I encouraged her to keep coming back. Perhaps when she graduates she’ll want to be a provider here, too. Some of my graduates can’t manage the schedule at the free clinic. They take jobs in specialty practices that keep them busy until late in the evening, seeing lots of patients with a limited range of diagnoses, and making a great living at it. Maybe Jessica will land a job that ends at five o’clock. Maybe the clinic will get another volunteer.