Late in the afternoon, the effects of my midafternoon cup of coffee were dwindling. I picked up the chart of a new patient with the chief complaint, “Needs a home health nurse.” He sounded like a good patient for Melissa, the nurse practitioner student who was working with me, to see and sort through the
concerns. In the meantime, I saw two other patients.
Melissa emerged from the exam room. “You better sit down for this one.”
“Be as concise as you can,” I said as calmly as I could.
The patient, eighty-seven years old, had not seen a doctor for twenty-five
years. Retired from farming, Mr. Gains and his wife lived alone in a farmhouse
outside of town. Their son worked the land, and their daughter ran the dry
cleaning store in town, just minutes away. The daughter said she cared for them
twenty-four hours a day, made their meals, bathed them, everything. It was
getting to be too much. Two days ago, her father quit walking and eating. Her
mother used a walker. They needed someone to come in and help.
Melissa and I entered the exam room. The daughter, a middle-aged bottle
blonde, who was generous with her makeup, rose from her chair. I introduced
myself and told her that Melissa had filled me in. “What’s your main concern?”
“It’s getting to be too much. I need some help. I thought maybe a nurse once
a week,” she said as she moved toward the door.
Mr. Gains was frail, wearing a feed cap and overalls. When I addressed him,
he made eye contact but didn’t say much. We learned that he spent most of
the day in a reclining chair, that he was usually incontinent at night. He never
had much of an appetite. Both the daughter and son checked on the couple
throughout the day.
“Dad doesn’t have insurance, so my brother doesn’t want much done,” the
daughter said tapping her toe on the linoleum floor.
“But he’s over sixty-five. He should have Medicare,” I said.
“Neither of my parents have it.”
Strange, I thought, and asked the daughter to step out of the room while
Melissa and I did an exam. She was reluctant to do so, so I walked her down
the hall and reassured her that we would bring her in as soon as we were done.
“Please, they don’t have much money,” she told me.
I reiterated that we would do the best we could.
When I returned to the room, Melissa had helped Mr. Gains onto the exam
table, which was low to the floor, making it easier for elderly patients.
“Pretty unsteady on your feet, aren’t you Mr. Gains,” Melissa said.
“Do you hurt anywhere?” I asked.
Mr. Gains shook his head.
I asked the usual questions about vomiting, fever, chills, diarrhea. . . . Mr.
Gains denied all. Finally, I inquired, “Is anyone hurting you?”
Again, Mr. Gains shook his head. As we removed his flannel shirt, I noticed
a layer of brown oily scum around his neck and under his arms. His odor was
pungent, not like urine, but similar to that of overripe fruit. His T-shirt was
gray. His lungs were clear, and his heart rhythm was regular. No murmurs.
We removed his overalls; they were clean, as were his undershorts. The brown
scum was also accumulated at his beltline and in his groin. Melissa removed
his threadbare socks. Near his ankles were two quarter-sized bedsores.
(Excerpted and used with the permission of the author, published in The Country Doctor Revisited, KSU, 2010)
As health care professionals–nurses, doctors and social workers– we are mandated reporters of suspected abuse for adults in most states and for child abuse in all states. These are always difficult situations. This one was particularly complicated. Read the rest of the story. When I talk to students about managing families who are living with abuse, I always remind them that as a physician it is not my job to decide who is right or wrong, but to link the family with support and the people who can make that decision.