Sunday, December 24, 2023 – 14:00 hours
A 71-year-old woman turns up to the place where you practice just 3 weeks ago and soon makes the place her own. She moves about with a wheeler and pants behind a face mask, her eyes showing that she is still keen to live. She came to the practice seeking help for a wound on her back, a burn from a pharmaceutical heat-therapy dressing for back pain that burnt her skin. In the kafuffle, she injured her leg. So, she came bearing wounds a-two.
On the tenth day, having had six visits previously, you see her and she says, as she walks through your door, I have dizziness and was hoping you might know the cure. “Everywhere I go, I ask the doctor hoping that they might know.” So, this lady’s smart. She’s obviously heard of you (and your exploits), and comes in real coy, but also straight to the point. You’re not sure quite how to take her. But, her two issues–she agrees–are her dizziness and her breathlessness. The dizziness has kept her company for years.
This is her history. It’s all you need to know: COPD and Neuropathic pain. I mean, you examined her ears, and they were fine, and you scanned (we talking MRI, not just your acutely exclude a bleed CTB) her head and it was ok.
Meds: Lyrica 150 BD, Cartia 100, Crestor 5, Diabex XR 500, Diltiazem 60, Indapamide 2.5, prn ondansetron 4 mg, pantoprazole 40, prazosin 1 BD, salbutamol and Trelegy Ellipta (LABA, LAMA, ICS combination), previously taking Trimbow (LABA, LAMA, ICS, in combination). How did she get COPD? No one knows (she never smoked). But they are her meds.
So, what do you do?
You look through her meds and, when you tell her to reduce her morning Lyrica to 75 mg, she tells you she needs it for her pain. You tell her to reduce it anyway. And you get the nurse to make a dressing change to her wounds of two.
You see her three days later. This time you ask her to reduce her sleeping tablet, oxazepam, to every second day. And, having looked at her wounds, you get the nurse to change her dressing. This lady likes you. So, she comes back a third time.
Two days later and you meet again. As the nurse takes her dressings down you ask for an ECG and compare it to a previous one. It shows a RBBB with NSR at 95 bpm. She tells you she has T2 diabetes, as you continually and on-the-go reconceive and build on your mental picture of her with each visit. You start her on aspirin and ask her to come back to have her dressings changed in 3 days’ time after ordering for her an AXR because she’s bloated and that can’t be good for her breathing (is she bloated because of a gastroparesis (Diabetes does that), because she’s constipated, or because of something else, you wonder … but not for long but long enough to allow it to percolate through your mind).
She’s back. Three days later, as promised. She weighs 52 kg and some of that weight, you think, is poo, as you review her abdominal X-Ray. So, you add some Movicol to her diet, thinking you’re real smart. And she starts to laugh. So, in response (I mean, you’re not stupid–you’re a doctor–and you respond in real-time too), you tell her to take one only every second day. You remind her, here, that the oxazepam too is now only every second day. And now she likes you. So you hit her with it: “take the Prazosin in the evening only,” you tell her. And she thinks you’re cool; her BP is up but you tell her to halve her alpha-blocker: what, are you nuts? You do it anyway. And she obliges–because she likes you. This woman trusts you. (And you think Movicol will save the day!). Two days later, when you see her again, and once again review her wounds two, you learn that she is sob at rest and the dizzy moments are almost continuous–and you BELIEVE her. She pants before your very eyes, and she walks in with her walker so tentative that it belies her real strength. She’s not THAT frail, you tell yourself. (She’s unsteady.). You add in some Atacand.
Two days later still, now the sixth time you’ve seen her. Before you can say anything, she places a printout from an automated machine at the patient’s disposal just outside: it says “BP 189/81. Pulse 96.” And she looks at you as if wondering what she saw in you in the first place, saying: “I think I should go back on the morning Prazosin.” Now it’s’ your turn to act coy: “You’re only taking at night, like I told you to? “Yes, I did exactly as you said,” she says. You sit her down and talk and then, you place a BP cuff on her right arm, and you take her BP, don’t you? Her BP is high, you wait and chat to her a bit and you repeat it again in a few minutes. Her BP is 156/72 and her pulse 77. And you’ve won. Her wounds look better and something deep in your unconscious tells you that she’s getting better. (And you trust it.)
Two days later, on her seventh visit with you, she walks into your room a different person. Less panting, less timid. You say nothing but your mind’s eye tells you that you’re winning, even if your conscious self has yet to register it. And then it dawns on you too. She is better. “You’re better,” you say, finally, aiming to trigger her. And she doesn’t smile or thank you or even reply with “yes.” Instead, she looks at you and says–without acknowledging the part you had to play in this–she simply says: “I had this pressure, that was in my upper abdomen, pushing up into my chest, and it lifted after I reduced the Lyrica. I can breathe better.” And she seems more mobile and agile on her feet. And her wounds two are getting better. And she walks around as if—as if—you had nothing to do with her breathing better. But she knows you did. And that’s how coy wins. Coy can make the dizziest lizzy fall in love with you.
