1. Adams, Margaret MPH, MSN, RN, ARNP


An irredeemable pain lies beneath some patients' nonspecific symptoms.


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You were the patient who came in for your routine follow-up, 75 years old, anxious, hypertensive, and nauseous. Your health history noted that your parents had died in refugee camps and that you'd had your first child at the age of 14, fathered by your uncle in the house where you'd been sent to hide. I wasn't ready for you. I tried to prepare to go over your lab work with you before I walked into the exam room and introduced myself. Your cholesterol was elevated and your occasional high-pitched laughter seemed entirely inappropriate.

Figure. Illustration... - Click to enlarge in new window Illustration by Hana Cisarova.

That first day you told me that you dry heave after every meal, and that you try to manage the chronic pain from your cauliflower ear-malformed memento from your abusive first marriage-without any medication. "I don't like to take Tylenol much," you said, touching the relic of devastation lightly with your fingers, "because one time I put 76 Tylenol pills between two pieces of white bread and ate it like a sandwich." You smiled. You told me that you called up a friend and told him not to call anymore because you would be dead. And the friend called the police and the fire department came and kicked your door in, could I imagine it?


For some reason, I picture you kneeling by your bed, arranging your Tylenol-and-white-bread sandwich on a coverlet, rather than in the kitchen. You segued dizzyingly from girlish conspiracy, showing me the flower tattoo on one shoulder, to recounting attempts to kill yourself, with a cheerful, pathologic remove, your affect heavy with disarmingly casual disassociation.


So practiced was your detachment from your own trauma, in fact, that midway through our conversation I began questioning the unconscious quickening of my breath, the mounting feeling of anxiety in my own gut. What's wrong with me? I thought, as I saw myself reacting emotionally to a series of facts delivered with little-to-no visible emotional engagement.


But despite the practiced nonchalance of your recitation, it wasn't the weather you were telling me about, and my response was entirely reasonable. I left your exam room with my stethoscope jammed awkwardly in my pocket and my breath caught uncomfortably in my throat. Struggling to gather my thoughts to present your case to my preceptor. Searching for some form of grace in the encounter.


I've come to recognize patients like you-sometimes by your disturbingly long and detailed allergy lists, but more often by the frequency with which you come in for the same constellation of symptoms: fatigue, headaches, dizziness, general malaise. Something happened to you- maybe years ago, maybe recently-and it left its mark on you in irredeemable ways, leaving raw gashes through your character and exposing the broken bones underneath to everyone from the woman who bags your groceries to the son who calls you twice a year. Every ED employee who ever wondered, Good God, what will happen to them now? This is what happens to you now. You're in the clinic every month, maybe a few times a month, trying to figure out what's wrong, bewildered by your own recurrent pain.


I am no longer a student, and I have met you countless times now. You are the patient who only ever leaves the house to come to my office. You are the patient who dry heaves from anxiety after every meal, but who keeps eating meals anyway. You are the patient for whom panic attacks are an unnamed, unexamined part of your daily routine. You get up, and though you consistently fail at normalcy, you continue to try.


This is the beauty and the tragedy of these primary care confessions: that despite the failure and the chronic pain, the self-acknowledgment of defeat and the persistent shortness of breath, you keep going. Long after you've left the ED or the marriage, the car accident or the country, you continue to iron shirts, boil water for tea, and keep appointments.


You sit in waiting rooms, on poorly upholstered, peeling plastic chairs, holding out your arm for the needle to bite gently into your flesh, draw out your essence. And as the vials of blood are collected, carted off to be held up and looked at by a latex-gloved hand, you think to yourself, maybe this time they will finally find the cause of my fatigue.