Work Hurts

There are certain patients I know I will never forget. Several people from my years in EMS have made such an indelible mark. I'll never forget one of the first calls I ever was a part of: a man in his mid-30s who had stabbed himself five times with a kitchen knife. I can still see the blood stains all over the carpet as we rushed through the front door. The mixed smell of blood and sweat. I was sitting in the airway seat in the back of the ambulance, leaning over him, trying to keep him awake and talking... "Why won't you just let me die??"

I remember the first time I did CPR. I remember the first time I got duped by a drug-seeker (and the second time). Each of these experiences will stay with me, some perhaps longer than others. I always had a moment of detachment, just a brief second, when I was acutely aware that this encounter was different from others. For the patient with multiple stab wounds, it was right after he asked us why we were trying to save him. It was a real "wow" moment: "Wow. This man really wants to die."

As always, I have to change most/all of the patient identifiers for obvious reasons, but I recently saw a patient who will stay with me for a long time. A couple weeks ago, a young Hispanic lady, maybe upper-30s to mid-40s, presented to the clinic with a chief complaint of elbow pain. She sat quietly in gray sweatpants and a navy hoodie sweatshirt, hands folded in her lap. She was unassuming, and maybe a little embarrassed that she had to see a doctor. She told me her the pain started a couple weeks prior, but now it was interfering with work. When I say "she told me," I mean she wrote all this down on a piece of notebook paper. She was deaf. The history and physical were all communicated via a sheet of yellow, wide-ruled notebook paper. Each question was asked individually.

When did your pain start?
Three weeks ago.

What brings you into the clinic today?
Work hurts.

Work hurts. I asked her where she worked. I put toys in boxes. How many hours do you work? There and at my second job. She was working every single day, Monday through Sunday. Packing and sewing, sewing and packing. She was averaging about 12 hours on a good day, and her symptoms were getting worse. She had tried taking pain-killers, but when I asked how many, the lady had only tried to take one pill here or there. There was a clear lack of education. After going back and forth trying to gather the history, I wrote that I was going to take a look at her elbow. I put the pen down and mimed the motions I wanted her to make. I inspected, palpated areas of point tenderness, looked for good pulse and sensation, and tested her full range of motion. She squeezed my hands. They were coarse and calloused. They were working hands. The exam was almost universally benign, but she did have pain when I pressed on certain areas of bone, as well as during pronation of the wrist.

I'm going to go and get doctor in charge. I will be right back.
Ok.

My preceptor joined us after talking quickly about the case. There was no need for X-rays. He did a full examination on the joint, and then wrote out the diagnosis. There was clearly an inflammatory process present, but nothing immediately concerning. As we had discussed outside the room, a trial of 800 mg of ibuprofen 3-4x a day with light duty at work would be a good trial, with follow-up in a month. If it got worse, she might need to see a specialist. This was all communicated via computer paper now, each instruction carefully written down.

Four 200mg tablets at a time. You can take these 3-4 times a day for 1 week, and then use them as needed.
Ok.

She had just one more question. I need a note for work. Just for this morning. She wasn't even asking for the whole day off. With just a signature she could have had the entire week off. I thought, "Fly to a beach somewhere! Do you need a stronger pain medication? Rest! Come back and everything will be fine and dandy! Please." But she needed to work. The note was written for the morning.

I got lost daydreaming in the room. I'm a wonderfully good complainer, an expert really, and I had been agonizing over a couple assignments that I had been putting off. That afternoon I had to have my nose in Harrison's Internal Medicine, scrolling through UpToDate, writing and learning about a couple of diseases I would report on later that week. I would have to sit in some fancy coffee shop with an overpriced decaf Americano and my laptop as I bunkered down and studied. I would have to eat a home-cooked meal, and then spend an entire hour ironing my dress-shirts. Ironing. That was what my terrible evening would be filled with. Ironing. Whoa me, what a terrible and tough life I live! I felt sick. This woman may not know when her next meal would be, and I spent the night before talking with friends about which new restaurant we would try next weekend. I realized I was tearing up as I was daydreaming.

I snapped out of it. I don't know why this visit affected me like it did. For some reason she just hit a nerve. There are many patients who are just as desperate and deserving; so many who make me realize I'm a piece of shit for ever taking my situation for granted. I don't know why this was different. I get to be a doctor. I get to do something that is so well-respected, so well paid, such an honor... the fact that I ever forget this is just disturbing. I'm too busy being caught up in myself to realize the world doesn't revolve around my Google calendar.

As she got up to leave, all I could think to do was write, "It was so nice to meet you!" in my little black notebook, scrawled quickly over the last page. It was so inadequate; a pathetic attempt to show that I cared. I mustered up the best smile I could. All I wanted to do was hug her.

She smiled and walked out the door, off to work. I realized I probably wouldn't see her again.