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Emergency Medicine News:
doi: 10.1097/01.EEM.0000393515.16389.95
Second Opinion

Second Opinion: Jim-Bob's Terrible Confession

Leap, Edwin MD

Free Access

Cast: Mama, 40; Daddy, 42, Chastity, 19; Jim Bob, 17.

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Setting: The family is sitting around the table in their subsidized housing discussing the future. Mama is microwaving dinner, as Daddy pops an Oxycontin, which Chastity eyes with interest. Her back has been hurting, too.

Background: Jim Bob, ever the black sheep of the family, is on edge. He has news to tell the family, but he knows it won't go well. Chastity knows about it, and is being a typical big sister. A typical big sister, that is, who refuses to work, loves to party, and has seriously considered a career in government-sponsored childbirth.

Mama: How's your back pain, honey? Any better?

Daddy: Naw, I think them Oxycontin aren't gonna help anymore. I need something a little stronger. That lousy ER doctor offered me Lortab. Can you imagine? Might as well give me Pez!

(Laughter from all.)

Mama: He tried that on me, and I called the patient advocate. I got him in all kinds of trouble! By the way, your Aunt Treena's birthday is coming up. Next time someone offers you Lortab, think about the family before you storm off, OK?

Daddy: As always, honey, you're right. (Turns and smacks her on the backside, but winces in pain from the effort).

Chastity: My boyfriend has some methadone. You want me to ask him if you can try it?

Daddy: Sure, sugar. There's a nice girl! See if you can borrow a couple for your old man. What's Ricky take them for?

Chastity: Well, you know he fell out of that tree stand a few years ago. Ever since then, he has headaches. And pretty bad ....

All: BACK PAIN! (Laughter, but nervously from Jim Bob.)

Daddy: How's his application going?

Chastity: Lawyer says he'll have disability in no time. Then we can think about ...

Jim Bob: Getting married?

(More laughter from Chastity and her parents.)

Chastity: No, stupid. You're such a goody two-shoes! We can think about having a baby! I'll get Medicaid, and he'll get a check. Why, the sky's the limit!

Mama: (beaming) I always knew you were the one who could find her way in the world.

Daddy: Good job, sugar. He's a low-life, but I think y'all can make it work! I got arrested with his daddy one time. His grandpa knew how to file a lawsuit. What a man. (Wistfully, with admiration.) How about you Jim Bob? Graduation is almost here. What are your plans? You recovered from that car wreck? I mean, that's your ticket right there, you know!

Jim Bob: My ticket? Chastity was driving! And she was stoned on Xanax and Adderall! It was her fault!

Daddy: Well, there's fault, and there's fault. You know that soccer mom that hit her will settle up, just to stay out of court.

Jim Bob: (Appears disgusted.) I do have a plan, but...

Chastity: I know a secret! I know a secret!

Mama: Hush, you, and let your baby brother talk.

Jim Bob: It turns out I got a scholarship to go to the university. I want to study construction science, and build stuff like great-grandpa.

Silence, as Chastity snickers and plays with her nose-ring. Mama spins around, and wipes a tear from her eyes with the dish towel, then rustles in her apron until she finds and takes a Xanax. She repeats it a minute later.

Daddy: (Looks hard into his son's eyes.) Did I hear you right? You thinking of going to college? (He tries to stand, but can't due to his medication and back pain.) I ought to walk right out of here. Look there! You've made your mama cry. (Looking into his son's eyes.) Just what makes you think you're better than everybody else?

Jim Bob: Daddy, it's nothing against you. I love all of you! But I just want more than disability, Medicaid, and pain medicine. Can't you see that?

Chastity: He wants Hannah, the checkout girl at WalMart. She's going to nursing school.

Mama: (Sobs.) Her papa is a preacher. I can't face this! They'll bring...casseroles! And there won't be anything but punch at the reception if you get married!

Daddy: Why don't you two just shack up? Or get hitched if you have to? WalMart is a fine job for her. And you can, well, you can just go work until you get hurt or something.

Jim Bob: I can't! It's dishonest! Can't you see it? Granddad would have agreed with me.

Daddy: Granddad never knew his place. Why, he kept working years after he could have quit! Stubborn fool!

Jim Bob: But he died happy, didn't he?

Daddy: Chastity, get the car. I'm going to the ER. My nerves are tore up, and your mama's is, too. Now, remember, you got pelvic pain, Mama heard that somebody was dying, and I got hurt in Iraq. We have got to have something else to get us through this trial. What we did to deserve a son like you, I'll never know! I knew you were different, boy, but I never took you for a prodigal.

Chastity: Told you they'd be mad! (Sticks out her tongue, with tongue stud.)

Mama: Jim Bob, please think about it. You don't know what might happen to you, to our family, if you take such a sordid path! Oh, and if you're out, can you get me some smokes?

Jim Bob: I think I'm going to the library. Sorry to be such a disappointment.

The family storms out and lays rubber on the road in leaving. Jim Bob, resolved, opens a book to read.

Sure, it seems harsh. And it's fictional. But it's based on years of observation. Anyone who has worked in an ED for any period of time, actually seeing human beings, will at least understand how this came to my mind. People seem to choose disability, addiction, dysfunction, and generational incapacity. Does it seem focused on rural America? Maybe, but that's where I practice. I grew up and practice in Appalachia. Sadly, this sort of life is all too common.

I fear that those kids who want to rise up, to escape, often face an uphill battle against ingrained culture and a mindset that diminishes the value of success and education unless it comes by luck, such as a lottery, or by deceit and crime, such as false disability or illicit drug sales. Is this only in Appalachia? Hardly. The inner cities experience similar problems.

But the greater problem, and perhaps the greater tragedy, is that many of those in positions of influence — in medicine, politics, education — know it. But they're afraid to point it out for fear of being branded judgmental or unkind. I think not telling the truth is the unkindest cut of all.

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