The King of Denial

“I don’t need to be here. I wouldn’t be here at all if she hadn’t made me.”

He’s short, stocky and just a little belligerent. The kind of belligerence that hides fear. He wouldn’t have let his wife browbeat him into coming to the hospital if he wasn’t scared.

“So tell me what’s going on with you today,” I suggest gently.

“Chest pain,” his wife says flatly. “He’s been having it for three weeks.”

“I have not,” he denies hotly. “It hardly hurts at all. Now.” He turns toward the door as if he’s trying to leave. I shift just a little to block him.

“Now? Has the pain gone away?”

“Yeah, hardly feel it at all now,” he nods, sneers at his wife. “I told you it was a false alarm.”

“He’s lying,” his wife rolls her eyes. “He’s been bitching about his chest hurting since he was in here last. When he gets to working in the yard, it takes his breath away.”

“That true?” I ask him, and he nods grudgingly. “So why don’t you tell me about this pain,” I suggest. I guide him toward the bed and pull up a rolling stool for myself.

“It’s hardly nothing,” he sighs. “Kind of like an ache. I’m just sore.”

“Where, exactly?” He grimaces, makes a vague movement over the left side of his chest.

“Over here. And in my left shoulder. Left side of my neck, too. But it ain’t bad. Doesn’t even hurt worse when I move. Like I said, just an ache. No big deal.”

I sigh. “Define ‘no big deal’, Mr. Robichaux. On a scale of 1-10, how does it rate now?”

“A three,” he tells me, with a triumphant glare at his wife. She doesn’t respond, just looks at me with a plea in her eyes.

“Uh huh. And how about earlier, when the pain was worse?” His bravado fades.

“Maybe a seven.”

“Riiiight. Well Mr. Robichaux, we’ve got some things to do,” I tell him as I begin attaching monitor leads and applying oxygen. He immediately rebels, pushing the nasal cannula away from his face.

“Whoa, whoa, whoa. I ain’t staying in no hospital.”

“Who said anything about staying in the hospital?” I ask reasonably. “Just let me get these things done while we do a few tests to see if we can figure out what’s going on with you.” I’d rather not have the confrontation just yet, but he doesn’t give me much choice.

“Why do I need oxygen for a bunch of tests? And this monitor thing? And you ain’t sticking me with a bunch of needles.”

I sigh, and look him directly in the eyes. “You need oxygen because you may be having a heart attack. The monitor is so we’ll know immediately if you should go into cardiac arrest. And yes, I will be sticking you with needles. How do you think we get the test results? Magic?”

“Shut up Lenny, and let the man do his job,” his wife warns. She and I have had to tag team Mr. Robichaux like this before. He doesn’t like hospitals, which is understandable. Neither do I. But I’m not having angina right now, either. He is.

Mr. Robichaux acquiesces. He plops down on the bed, folds his arms across his chest like a petulant child, and submits to the indignity of admitting he’s sick. Within a couple of minutes, I’ve gotten a 12-lead EKG, given him some aspirin, and smeared a little Nitro paste on his chest – all with only the most grudging cooperation from the patient.

“So what does that say?” he asks, nodding at the 12-lead.

“It says you have anterolateral ischemia right now. And a previous heart attack at some point in the past.”

“I’ve never had a heart attack in my life!”

“Oh really? And who told you this, your cardiologist?”

“He don’t got one,” his wife chimes in accusingly. “He ain’t even seen his regular doctor in ten years. Told him he had high blood pressure, told him to go on a diet and quit smoking, and put him on blood pressure pills. He quit taking the pills after three weeks and ain’t been back to the doctor since.”

“I ain’t ever had no heart attack,” he insists doggedly.

Well, I’m no Elizabeth Kubler Ross, but I recognize denial when I see it. So, being the tactful, caring professional I am, I knew the right approach to take with Mr. Robichaux.

I hit him over the head with the cold, hard facts. Repeatedly.

“Yes, you have had a heart attack,” I tell him bluntly. I point to the large Q waves on his EKG. “See these things, right here? Consider those the Grim Reaper’s calling card. ‘Sorry we missed you, but Death called on you today. We’ll return on insert date here.’ Only, you were too busy being fucking hardheaded and telling yourself it was indigestion. Just like you’re doing now.“

“I’m healthy as a horse. I know my own body.”

“You’re a horse that’s one step away from the glue factory. Unless you wise up and start listening to these warning signs. Anybody in your family have heart disease?”

“All of ’em. My father and uncles, my mother, both my sisters. None of the men in my family have lived past fifty, except me. I’m healthy.”

“Yeah, you’re real healthy. You have high blood pressure that you ignore, you smoke like a chimney, and you can’t walk from the wheelchair to the bed you’re sitting in without getting winded. You have a family history of heart disease, and instead of trying to dodge that genetic bullet, your lifestyle might as well be putting the muzzle against your head.”

“I don’t smoke that much.”

I lift his fingers and inspect them. “Unless those are iodine stains on your fingers, I’d say you smoke what, maybe two packs a day, at least?”

“Sometimes three,” his wife furnishes helpfully. He shoots her a dirty look.

“Like you said, it’s genetics. If I’m gonna die, I’m gonna die. Ain’t nothing I can do about it.”

“Bullshit. That’s a weak argument. You can do something about it. You can start by admitting that you’re having a problem right now that needs treatment. Were the rest of the men in your family so stubborn?”

“Daddy denied he had heart problems till the day he collapsed from a massive heart attack, right in front of me in my k
itchen.” Tears are welling in his eyes.

I’m getting through here, I know it.

“Congratulations Lenny, you are your father’s son. And pretty soon, your kids will be able to experience the same nightmare – their Daddy dead on the floor from a disease he could have controlled. I hope you taught them enough of life’s lessons now, because you won’t be here for them in five years. Maybe less than that.”

I feel like a real bastard when I talk to patients like this, and you guys need to know that I don’t treat most of my patients this way. But for Lenny Robichaux and men like him, this is the language they use and understand. They’re strong and simple people, and they appreciate honesty and straightforwardness. They don’t pussyfoot around. Neither do I when I deal with them.

Lenny sighs heavily, deflating before my eyes. Tears well in his eyes, and his wife pulls her chair closer to the bed and grabs his hand. Someone steps around me, and I turn to see his kids enter the room. How long they’ve been standing behind me, I don’t know. From the tears in their eyes, it’s been long enough to hear most of the conversation. Doc is back there too, standing in the doorway taking it all in. He winks at me and walks back into the nurse’s station.

I drop the chart on the desk in front of him, sigh and prop my elbows on the desk, massaging my eyeballs. “The guy in Bed One is having chest pain – “

“I heard all of that. Let’s go ahead and order the usual, see what we’ve got.”

“He needs a little prodding. Maybe you could go in there and -“

“Why?” Doc asks reasonably as he signs the order sheet. “I heard what you said. Sounds like you pretty much laid it out for him. Oh, I’ll go in there and talk to him in a bit, but let’s get the labs cooking in the meantime. Maybe his family can soften him up a bit, too.”

“Okay,” I sigh, “CBC, lytes, chest x-ray, cardiac enzymes and a coagulation panel. You got it.” I drop the order form off with the ward clerk and walk back into Mr. Robichaux’s bed.

“Time to start that IV now, Mr. Robichaux. When I start it, I’ll draw blood from the catheter hub and save you an extra needle stick.”

He bitches impotently, pisses and moans and keeps making noises like he’s leaving. When I make the stick, he jerks his arm and says “Goddamn! You trying to kill me?” Only my grip on his elbow keeps me from losing the line. I bite off my reply until I get the line secured. It’s not the needle stick that bothers him. He just needs something to bitch about.

“Yep, that’s the goal. We make it a point to kill as many people as possible when they come in here. That’s what hospitals do – we take perfectly healthy people, kidnap them, and make them sick.” I wink at his wife and kids, who smile in return. The sarcasm sails ten feet over his head.

“Hospitals!” he snarls. “Half of my family has died in hospitals. Once they get you in the bed, you never make it out alive.”

“Gee, ya’ think that might be because, besides heart disease, being mule headed runs in your family too, and they deny they have a problem until they’re too damned far along to be helped? You know, kinda like you’re doing.”

“You’re a real hardass, you know that? You talk to all of your patients like this?”

I sigh, and soften my tone a bit. “No, just the ones that need to hear it. Lenny, how many times have you been in here lately?”

“I dunno,” he shrugs. “Four or five. This is the first time with chest pain, though,” he adds, almost defiantly.

“You’re a mechanic, right?” He narrows his eyes, nods at me suspiciously. He’s not sure where I’m going with this.

“What if someone brought you a car…someone with no mechanical experience…and told you the thing wasn’t running right? Let’s say you notice the engine is missing, smoking a little. Not much power. Let’s say maybe you figure it’s a burnt valve.”

“Uh huh.”

“So what do you tell this person?

“I’d tell him that he’s got a problem, and unless he fixes it now, he’ll have a new engine to buy pretty soon.” He’s refusing to meet my gaze now, looking away with his hands folded across his chest. He knows where the simile is going.

“Excellent. And if this guy told you ‘I know my own car, I drive it all the time, and you don’t know what you’re talking about’, you’d think he was a hardheaded fucking idiot, wouldn’t you?”

“Probably.”

“You’re being a hardheaded fucking idiot, Lenny.”

His head snaps around and he looks at me in surprise.

“Right now, your engine is knocking, smoking and losing compression. If you start to baby it and do some preventive maintenance, maybe a light overhaul, right the hell now, you might be able to keep it from seizing on you and drive it for another hundred thousand miles. If you wise up and listen to the mechanics.”

“I ought to whip your ass,” he retorts. But he says it with a grin.

“You’re a heart patient,” I shoot back. “If I can make you miss the first couple of swings, you’ll be easy to take. You don’t scare me.” He shakes his head and chuckles. So does his teenage son. I turn to leave, saying, “We’re still waiting on your labs, but it shouldn’t be more than a few minutes. When we have the results, Doc will be in here to explain ’em to you. Listen to what the man says, okay?”

“Yeah, well tell him this damn IV still hurts!” he yells after me. I shake my head and ignore his bitching. His IV site is still patent. Five minutes later, his lab results are back. Doc peruses the report, clucks his tongue and clips it to the chart.

“So, what are they?” I want to know.

“Cardiac panel’s okay. Chest x-ray looks like early emphysema. We need a repeat 12-lead. How’s his pain right now? More importantly, how’s his mood?”

“Well,” I say wryly, “with a little gentle prodding from Yours Truly, he’s moved from Denial, to most of the way through Anger. We may even be nibbling at the Bargaining stage right now.”

“Well, go get that 12-lead,” Doc chuckles, “and we’ll see if we can tag-team him into Acceptance.”

I’ve left the EKG machine attached in anticipation of doing more 12-leads, so all it takes is a press of the button to acquire another one, perhaps an hour after the one we took when he first walked in. The report rolls off the printer, with Lenny Robichaux watching suspiciously the whole time. From where he’s sitting, he can see the words ***Normal ECG*** printed at the top of the report. He sighs explosively, but says nothing. The relief is palpable on his face.

I walk back to the nurse’s station and wordlessly hand the report to Doc. He looks at it, grunts and stands up. “Well, that’s good news. No heart attack.”

“No heart attack now,” I qualify. “We may have averted something.”

“Right you are,” Doc agrees. “That’s why I’m going to recommend he stay overnight for serial EKGs and cardiac enzymes. Come on with me and we’ll face the dragon togeth-“

Right then, he’s interrupted by the ward clerk, pushing a woman in a wheelchair. She’s gasping for air, and her hands are retracted into gnarled claws. “Gotta woman who can’t breathe!” the clerk announces unnecessarily.

I sigh, pointing to Room Three. “In there. I’m right behind you.” I turn to the Doc. “I’ll take care of this new one. Good luck. He’s a hardheaded bastard.” Doc nods understandingly and goes into the room alone to tell Lenny Robichaux the Good News and Bad News.

My new patient has nothing more than an anxiety attack and hyperventilation syndrome, but by the time I’ve given her oxygen, dimmed the room lights, sat by her bed and soothed her, coached her in slowing her breathing and convinced her family that she’s not dying, twenty minutes have passed.

I find Doc back in the nurse’s station, filling out AMA papers. “Your unstable angina patient in Room One is leaving against medical advice,” TAN informs me matter-of-factly.

Damn. And I thought I had gotten through to him.

I look at Doc expectantly.

“Don’t look at me,” he protests. “I’ve been arguing with him for fifteen minutes, but he’s adamant. He doesn’t trust doctors. You can give it a try, but I’m all out of arguments.”

Damn. Double damn.

I walk back into the room to find Lenny sitting with his legs dangling off the bed, ripping off the monitor leads. He looks up at me defiantly, but says nothing. His wife and kids are crying.

“So I take it you’re leaving? Nothing I’ve said to you makes any sense?”

“Doc said the last EKG was normal. I ain’t hurtin‘ no more. I told you all it was just a false alarm.”

“Maybe, Lenny. This time. But all that means nothing if you don’t listen to the signs your body is giving you. If you stayed here, you could see a cardiologist first thing in the morning. A good cardiologist, and he comes by here twice a week.”

“I don’t need no cardiologist. I ain’t hurting no more, and the Doc said all my tests were normal.”

Damn, we’re right back to Denial.

“Ever stop to think that the reason you’re not hurting is because of the nitroglycerin and oxygen you’ve had for the past hour and a half? Which, by the way, usually only works on someone with genuine cardiac problems. That should tell you it’s your heart.”

He wavers a bit. “All the cardiologist is gonna do is tell me what to do with my life. Tell me to stop smoking. Tell me I cain’t work. Tell me I cain’t provide for my family.”

“No, what he’s more likely to tell you is stop smoking, and recommend a few things to do to make sure you can keep working and providing for your family. All you have to do is follow his advice.”

“I like smoking,” he says plaintively.

“As much as you like being there for your kids? Hunting and fishing with your son? Working in your shop? Are a few cigarettes worth all that? You’re making this into a smoking issue, and it’s bigger than that. We both know it.”

“I ain’t staying in the hospital,” he says adamantly, holding out his arm. “Are you gonna take this fucking IV out, or do I need to rip it out myself?”

I meet his gaze, shrug and start removing the IV catheter. After I’ve bandaged the site, I try one last time.

“It’s four o-clock. Still time to catch the cardiologist in his office. Let us at least make an appointment for you.”

“I got too much stuff to do this week,” Lenny shakes his head. He sees the scorn in my eyes, and relents a bit. “Okay, if you give me his number, I promise I’ll make an appointment as soon as I can.”

“No you won’t,” I say, looking at him appraisingly. “You’re gonna walk right out of here, light one up, have a big old greasy burger for dinner, and keep on doing what got you in here in the first place. Don’t blow sunshine up my ass.” He knows he’s lying, and I know it.

“Look, I appreciate everything you done,” he says sincerely. “And if it gets worse tonight, I promise I’ll come back in.”

“Bullshit,” his wife spits, still teary-eyed. “I’m calling an ambulance next time!” I look at the address on his chart and sigh.

“You live in Hooterville, right?” He nods. “The closest ambulance to you is fifteen minutes away. If you go into cardiac arrest at home, no ambulance in the world can save you. I know, Lenny. I’m a paramedic. It won’t matter how much CPR your family does and how hard the paramedics try, you will die. If you have a heart attack, by the time they get you to the cath lab at Big City Memorial, you’ll have lost so much of your heart muscle that the life you’re living now will just be a fond memory. You’ll be a cardiac cripple.”

He says nothing, tries to meet my gaze, and his eyes wander away.

I shrug, and offer my hand. “Good luck, Lenny Robichaux. You’re gonna need it.” He grips my hand hard and walks away down the hall.

He’ll be back. I pray he’ll be alive when it happens.