FOLLOW DR. KO: Counting Needles

needleThere she was in her bed, face buried in her pillow, her rear end pointing directly at me. I’m not sure what she was doing in that position. Rosa was a woman in her fifties, but with her pigtails appeared much younger. I don’t remember the reason she was admitted to our service… probably for “altered mental status” secondary to drug abuse. What I do remember, is that she came with a whole lot of junk and even more attitude.

By junk, I mean morsels of food, random pieces of paper, countless lancets (small needles used to prick a diabetic’s finger to check their blood sugar level), a myriad of prescriptions, new and old. All that was scattered all over her bed, and Rosa was sitting on the edge of said bed, dosing and almost falling off.

“Mrs. Rosa, I am Dr. Ko. Would you like to lie in your bed? Let me help you clean this up.” I offered kindly.

“Do not touch my stuff!” She snarled back at me and gave me a look of contempt, insisting she would clean up her bed when she was good and ready. Fine. I left and went on to see other patients. When I returned, Rosa was in the same position I had initially found her in, sitting on the edge of the bed, her head rocking back and forth, dozing off. My second attempt to assist this patient to lie down was rejected with even more disdain than the first. I tried cajoling, reasoning, humoring, and nothing worked. She sneered at me through her toothless mouth and eyed me up and down with what could truly be genuine hatred. Then she said: “Your mother must be so ashamed of you. I bet your own mother hates you. You are a disgrace to this world and you ought to rot and die.”

Ouch! What on earth? Working in the South Bronx, you need to have a thick skin. People can be rough, rude, and aggressive. Often times they are under the influence of various substances, other times, well, maybe no one ever taught them kindness. With experience, you learn to shrug the insults off, or even befriend the unfriendly. But it was the middle of the night, and I was tired and not in the mood.

My patience was wearing off. I called my intern and this time, I was the one to snarl: “Where are you? You need to be here to deal with your patient!”  Then I grumbled to the nurse: “The needles need to be taken away!” The nurse looked at me helplessly, knowing that the patient wouldn’t let her come close. I got even more annoyed. “Call security if you have to, the needles cannot stay!”

The intern came running while I was hissing away. “This patient was admitted half an hour ago, why weren’t you here? I’ve been here this whole time dealing with your patient.” I scowled at her. “I’m really sorry, I’m on it.” The intern whispered. I felt bad. I had become a bossy and mean senior who takes out her frustration on those of lower rank. I’m sure the intern was tired, too, and just taking a break. After all, this patient wasn’t in a critical situation and didn’t need to be seen right away. As a peace offering, I stayed with the intern, and the two of us spent almost two hours with the patient trying to obtain her medical history, perform a physical exam, and yes, put those needles away.

Eventually security came and Rosa agreed to put the lancets away, but only if she picked them up one by one and counted each and every single one. She fell asleep a couple of times while counting, and would have to start all over again.

The following morning, I rounded on her last and found her in that “modified downward facing dog” position. She was covered in sweat, groaning in pain and vomiting. I recognized heroin withdrawal right away.

Methadone is a synthetic opioid given to alleviate the symptoms of opioid withdrawal. While methadone acts on the same opioid receptor as heroin and morphine, it provides a more subdued “high.”. Rosa knew that, and as miserable as she was going through withdrawal, she did not want the methadone. (And we couldn’t force it down her throat). She knew better and demanded morphine, and she wanted it to be administered via IV push, meaning in a quick push through the intravenous line, which would produce a more immediate and potent “high”.

“Just give her the morphine and get her out of here.” My attending said. “She has no other medical issues.” So we gave her the morphine to calm her symptoms. And as per protocol, we offered her options for her drug dependence: Detox programs, rehab, support groups, etc. Rosa was not interested. “Well, there is nothing else we can do for you, Rosa, medically, you are cleared and you will be discharged from the hospital.” But Rosa refused to leave! Well, I guess when you get free food and board and free drugs, why would anyone want to!

New York is one of the most generous States in the US, offering free or almost-free healthcare to the underprivileged like Rosa who are on Medicaid. Not having a job does not have to mean not having food or money. Social security sends monthly checks and food stamps, and all healthcare costs are taken care of. Each day spent as inpatient in the hospital is about $4000-6000. For Rosa, that fee would be covered by tax payers.

Finally, she did agree to leave the following day because it was her birthday.  She would take her needles and count them somewhere else.


Melody Ko

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