Monster

There is a patient who came with the report that he was a "real charmer", with a glossy sarcastic tone. His story says it all: he has a drug history, including present use, and had a major heart attack while committing a crime. Ironically, it's lucky the police sought after him, otherwise he likely would have had the heart attack and accompanying cardiac arrest alone somewhere, doing drugs or passed out. The police involvement may have saved his life.

This was the report the unit received. He came to us intubated, all 4 limbs restrained, and on high doses of sedation. Per report, when he "woke up" from sedation, he became "a wild man", trying to pull out his breathing tube and fighting to hit or kick anyone near his bed. This is what necessitated the restraints and the heavy dose of sedative. This is all we knew about this man.

By the time I came to care for him, he had been extubated and his sedation was wearing off. He was beginning to show some personality, something most of us were dreading. "I'll bet he's a peach!", the nurses would add, giving me a "best of luck" look as they left. Truth be told, I was hoping he'd sleep for most of my shift so I wouldn't have to interact with The Monster.

It seems harsh to characterize a patient as a monster. After all, our patients are critically ill and usually desperate for good news or a sense of control. This context rarely brings out the good in people... desperation is an ugly color on anyone. Politeness and patience aren't commonly shown by even the most "civilized" patients in the early recovering stages from a major heart attack or arrhythmia. Gratitude and understanding may develop later, but we don't expect it at first. From this Monster, I didn't expect it at all.

To my surprise, he was pretty easy to speak with. His sedation (and illicit drugs) were slowly wearing off, so he was often disoriented and agitated/scared, but he re-oriented easily and was generally easy to care for. He didn't want to be in the hospital, and he was very clear about his intentions to leave if he didn't get exactly what he wanted. He used coarse language and yelled most of the time, but he wasn't really unlike many of the other patients that I've had... aggravated from not being able to eat, thirsty for anything with more flavor than "a few ice chips" as ordered by the physicians, and generally feeling caged into his bed without much say in matters. Add the shadow of confusion and residual discomfort from a breathing tube and a sore chest from CPR, and most of my patients express themselves in this way at some point in my care... just with less colorful language and a more mild volume. In fact, he was actually a little less offensive, in some ways, because his agitation was clearly directed at his situation and not the nurse "subjecting him to this", as some other patients imply.

The nurse passing him on to me that night began describing him to me in this way, and I commented, "He's not such a monster after all". We laughed, and she said 'good night' to our little Monster, and she headed for the exit. I slid into his room, finding him hot and sweaty from a fever, and confused (again). I went into his room to turn up the AC, and took off his covers, and offered to order him a fan. He grunted something obscene, and kept looking at his bed.

I went to his eye level and said, "Do you know where you are right now?"
"No." ... and some other expletive.
"You're in the hospital."
"I know that!" ... another expletive.
"Do you remember why?"
"No." ... you get the picture.
"You had a major heart attack. We had to restart your heart and give you a breathing tube. That's why your chest and throat are sore."
"Why am I so ** hot?!"
"You have a fever from an infection in your bladder and in your lungs."
"I had a heart attack?"
"Yessir."
"How did I get here?"
"The police found you and called an ambulance and revived you. The paramedics brought you to us. You've been in this room since then."
"The police found me?"
"Yessir."
"What do we do now?"

... I went on to tell him about all the different options. He scoffed at all of them, saying he hates doctors and doesn't want to stay here another minute. I did my usual song and dance about the necessity of staying in the hospital "a little bit longer", or else he'd leave and get sicker and have to return to a hospital for even longer, if he lived to return at all. Sounds harsh, huh? It's a reality. We see it again and again: patients who "hate doctors" and ignore chest pain until they can't breathe anymore and pass out... and usually end up with some degree of brain damage and/or need a major operation. This reality check usually helps with patients, but my Monster didn't care for any of it.

"There's no way I'm coming back after I leave."
"You have a lot of medicine still in your system, so it's not safe for you to leave yet. And you have two major infections that need to be treated or they'll get worse."
"I don't care. I won't come back. I'm just like that... I don't go to doctors."
"With all due respect, Mr. X, you didn't come to the doctors this time... you died and someone brought you back and here you are."
"Well that won't happen again."

I didn't pursue that response... what won't happen again? His heart stopping? Someone finding him? Him finding his way back to the hospital, conscious of it or not? None of these options sounded therapeutic, so I just let it go. At this point, because of the crime he committed and the medicine/drugs still in his system, he wouldn't be allowed to leave the hospital anyway. But I wouldn't tell him that. Again, that didn't sound like therapeutic information.

Reading through this conversation, I'm surprised at myself at how sympathetic I've become towards him. Again, he's not unlike many of my patients that come in with similar health issues. He just come in with a juicy story and sordid reputation in addition to his run-of-the-mill health crisis. But it was so easy to think of him as a monster when he was sedated and intubated, occasionally lashing out (not consciously), but otherwise totally unable to interact with the staff or show us his personality. When the opportunity to see his personality came, even his noxious language and demeanor couldn't obscure the Truth that he was a human being sitting in front of me, not a monster. He effortlessly transformed, in my mind, from a body to a person; a history to a story; a situation he survived to an experience he endured.

This may not be a universal perspective, but I know I'm not alone. People love movies and TV series about "the bad guys". American Gangster. Boondock Saints. The Sopranos. Goodfellas. Even the Ocean's 11/12/13 movies. All about bad guys with a heart of gold... or rather, a human heart. All about bad guys with underlying situations and pressures that explain their misgivings. All about bad guys who are conflicted and fighting with themselves... their "lesser demons". There's a new show on HBO about to premiere, Boardwalk Empire, set in Atlantic City at the beginning of prohibition, following the corrupt characters that profit from the radical law. I cannot wait to see it-- it looks so intriguing, and I know that I will be swayed to adore these characters which manipulate and enslave and abuse others for their selfish gain. I love knowing that I'll walk into this series disgusted with their behavior and lack of ethics, but will end each episode with a softer heart for them, until eventually I'll be cheering on their evil-doings because I want to see them succeed and be happier; and probably rooting against the "good guys" trying to shut down their operation.

I'm not cheering for my Monster's resolve to leave the hospital or to evade the police. But I do love that I feel a little more sympathetic for his situation. I love that, by the end of my shift, we were discussing his son and how he adores him and how his son thinks the world of his daddy. He showed me his tattoo for his son, and he softened when I asked him if he wanted to live long enough to watch his young son grow up. We talked about how he hates feeling confined. We talked about how after I leave at the end of my shift, another nurse will take over and propose a lot of the same things I've been talking about-- further care of his heart to prevent this from happening again. And he looked a little sad at the notion that I would leave him and someone else would take over.

I went into his room at the end of my shift to say 'good bye' and to wish him luck with whatever decision he made. He had already fallen back asleep. And like most sleeping people, he didn't look like a monster.