Charles is a stubborn man in his upper 80s. He lives alone in a ranch style house and gets
around in a wheelchair that is leashed to his bedroom by a very long oxygen
tube that often gets tangled as he rolls from room to room.
He's grumpy and never tells people anything about his health. He's not interested nor ready to get help for
a noticeable difficulty with breathing that started a few days ago. Determined to keep going in his independence,
his breathing shallows to the point that he gets dizzy upon any exertion. Still determined to not call for help, he struggles
to stand up to put on his sweater that is on a hook at the top of his basements
steps. It's more effort than his ailing body
can absorb. He passes out, falls down
the steps and lays there until his son stops in for a random visit the next
morning.
Finding his dad at the bottom of the steps urine-soaked and soiled, the
son calls 911. The ambulance, medics, and
police arrive and take him to the hospital for care of his obviously broken
wrist and lower leg. At the hospital, it's
also discovered that he has very advanced pneumonia which the doctors immediately
recognize as the primary cause of Charles having passed out and fallen.
Casts are placed around the broken bones and antibiotic therapy is immediately
provided to clear up the pneumonia.
About a week later, Charles is transferred to a nursing home for therapy
and rehab of his broken bones and to monitor is clearing pneumonia.
**********
Hannah is a delightful and stubborn woman in her 20s. She lives on the streets, gets around by foot
and finds food for the day at local outreach ministries. She's been on the street for years as she
does what she needs to do in her life as a homeless woman with Substance Use
Disorder in its addicted phase.
She's settled into a routine of what drug combinations she prefers and
has avoided overdose until recently. For
reasons that she can't identify, she's overdosed four times in two weeks and[1]
been revived by Narcan each time. At her
third overdose, she was taken to a very local hospital where the nurse told her
to get out. Hannah returned to the
street and overdosed for her fourth time four days later. This time, she fell and caused enough of a
bodily injury that she had to be taken to a more advanced local hospital that
could handle her injuries. And that the
hospital did.
They tended to her injuries which were the direct result of falling as
she overdosed from her use of street drugs.
While fully aware of her use of drugs, the hospital, according to their
policy, did not treat her symptoms of dope sickness that were increasing by the
hour and day. "We don't detox
patients on this floor. Detox is done in
a different unit." They explained to me.
With four days of medical care for her injuries and no real care for
her dope sickness, to relieve that sickness, Hannah signed out AMA[2],
made her way to Kensington, consumed her first bag of medicine and began to…
As you read this, Hannah's story is unfolding on the street in a way
that could oh so easily march her right into her fifth and final overdose.
**********
Charles' fall and resulting broken bones were the result of passing out
due to insufficient breathing caused by pneumonia. The hospital treated his injuries and his illness
simultaneously.
Hannah's fall and resulting injuries were the result of passing out due
to overdose caused by street drug use.
The hospital treated her injuries and would have treated her withdrawal
issues only upon transfer to the detox unit.
Charles was transferred to a nursing home where his healing continued
under the watchful eye of professionals who have pledged their careers to the Hippocratic
Oath.
Hannah transferred herself to the street since it's far faster to do a quick date for the money to buy a bag of drug and relieve her dope sickness than it
is to wait a few more days to be transferred to the "proper unit."
In a few weeks, Charles will be heading home, this time with arrangements
for a daily visit by a community nurse.
Hannah, well, Hannah might be dead by now. I don't know.
She may be deceased by an overdose that could have been avoided if the
hospital had treated her in her entirety and not symptom by symptom.
Now that Charles is home, his son visits him on a daily basis and asks
him why he's so stubborn. They laugh
about it a bit as Charles agrees to be more honest about his health issues.
My concern for Hannah is that the day will come when her cousin will
hold Hannah's youngest child in her arms as that child looks down at Hannah and
ask "Why is my Mommy asleep in that pretty box?"
When a patient of Substance Use Disorder is admitted to a hospital for
treatment of any injury or illness, that hospital MUST do everything within
modern scientific understanding to provide comfort and relief of withdrawal
symptoms while they attend to the illness and injury.
Make Hippocrates proud of you!
I swear to fulfill, to the best of my ability and judgment, this covenant:
I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow.
I will apply, for the benefit of the sick, all measures [that] are required, avoiding those twin traps of overtreatment and therapeutic nihilism.
I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon's knife or the chemist's drug.
I will not be ashamed to say "I know not," nor will I fail to call in my colleagues when the skills of another are needed for a patient's recovery.
I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. Most especially must I tread with care in matters of life and death. If it is given me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God.
I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person's family and economic stability. My responsibility includes these related problems if I am to care adequately for the sick.
I will prevent disease whenever I can, for prevention is preferable to cure.
I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.
If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.
—Written in 1964 by Louis Lasagna, Academic Dean of the School of Medicine at Tufts University, and used in many medical schools today.
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