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The Art of Medicine

A god of all things

Katers, Laura MS, MCHS, PA-C

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Journal of the American Academy of Physician Assistants: March 2016 - Volume 29 - Issue 3 - p 58
doi: 10.1097/01.JAA.0000480582.54239.8f
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A woman with brown skin and blue eyes leaves the port of Seattle every 4 months for 3 months at sea. She leaves behind her friends and family, her patterns and behaviors and, most of all, solid ground. She boards a vessel with a crew of 15 and heads to the North Pacific. She works as a fisherman, or fisherwoman, on a commercial fishing boat—often cited as being one of the most dangerous jobs in the world. At age 39 years, she creaks with pain. A bulging disk at the fifth lumbar vertebra and osteoarthritis fill many movements with grating discomfort. She lifts more than a person of her 5'2” stature should. She works alongside men 200 lb heavier, muscled, younger, but her workload is the same as theirs. “You pull your weight on the boat,” she says, “or you don't.”

Her hands are rough and leathery. Her lips are worn thin, and her face rests in a sad yet determined frown—the face of someone much older. “I am always cold,” she says. She sometimes wears gloves to protect her hands from the frigid seawater, but the gloves make handling fish too slippery so she often forgoes them, leaving her hands subject to microtears from fish scales and barbs.

When I was younger, I fantasized about Alaska and the commercial fishing industry. I even went so far as to apply online to work a 2-month stretch. I was reeled in by the promise of $10,000 a month, the romanticism of lighthouses, 360-degree sunsets. But I had other options—an education under way and a family to fall back on. The day I meet the fisherwoman, she registers at my clinic using her first and middle names only. I know she has asthma and seasonal allergies, but there is no other medical history. I don't know where she was born, what she likes or dislikes, or how she ended up on the boats in the first place.

What I do know is that she is charming. She isn't here for screenings or prevention or healthcare. She sought me out for one reason, and it has to do with a few letters after my name, a license to practice medicine that cost me $100,000 and 3 years of my life. I have cures to some things, placebos for others, but I also have the good stuff, the “pain pills.” I have the power to write for prescription medications.

I try to get to know her, pry out the story. I see a character with rough edges who plays the game well. She doesn't want to appear desperate.

“Everything I need,” she tells me, “you have.”

I believe in her pain. She goes back out on the boat tomorrow. But still I state the research on chronic pain management, discuss a thorough treatment plan that will increase physical function while reducing the need for medication. She stops listening. What she needs isn't more medication, I realize, but another existence—one where she doesn't have to work on the boats to make money, another means of survival or a different life she could pursue and accept.

I fail. Because there is no one who wins. I'm from a predominantly white, blue-collar community. No matter where I go or what I do, that is where I came from. I have never been in a boat on the way to Alaska, but I have been to Alaska and it was beautiful. I have worked hard to be where I am, but I have never had to call the street my home. I've never had to beg for anything from strangers or pretend I am someone I am not. I have never stood under a net full of writhing fish in a gale-force wind 3,000 miles from home.

Only one thing will work for the fisherwoman. It is derived from the opium plant, and it has become the god of all things. I face the next 30 minutes with two hands I could play: 30 minutes of empathy and a “no,” with fury as a repercussion; or 1 minute of empathy and a prescription for hydrocodone.

She gets ready to leave, the charm gone. There is no discussion about asthma or the myriad of other things we might discuss to keep her healthy at sea. She says I am sending her to the dealers and the marijuana dispensary, places she will now have to visit to ease her suffering. I am leading her to addiction, to further abuse and to potential harm. It is all on me, she says.

I did not ask for this power. I am not comfortable with it, am not responsible for this woman's pain. Or am I? I had fish for dinner last night.

“Am I god!?” I ask finally, hands up, desperate, earnest.

The answer to my haphazard question is burned into her resolve. Her shoulders, briefly squared, sag.

In this moment, I fear, I am everything.

Copyright © 2016 American Academy of Physician Assistants