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The Art of Medicine


Godfrey, Alexandra MMS, PA-C

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Journal of the American Academy of Physician Assistants: July 2016 - Volume 29 - Issue 7 - p 58
doi: 10.1097/01.JAA.0000484315.50050.91
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Her skin tells the story. The dirty needles, the years of abuse, the infection in the crook of her elbow. Her chart tells me about the years of addiction, the days in detox, the high days when she was abruptly awoken by Narcan. The psych access nurse tells me she is homeless. She lives in a tent in the woods. She shares an orange tarp with a friend called Mike. He has hepatitis C. Sometimes they share needles. She sleeps with him because he keeps her warm and she likes the sex. She may be pregnant, she may not. She has no idea when her last period started or finished. On good days Mike kisses her, making her feel like a princess. On bad days he beats her.

She comes to the ED in ripped jeans, a gray hoodie, and socks that don't match. I see her toes poke out at the end of her pink Converse sneakers. She smells stale, a miasma of urine and parking lot stairwells. Around her neck is a purple crocheted scarf. Maybe she crochets in the stairwells or under the bridges or when Mike isn't around to share needles. By her side is a shopping bag from Walmart, filled with essentials like Tampax, pencils, lipstick, a bottle of Mountain Dew, and some plastic bags for her shoes. It is raining and there's no place to dry shoes in the woods. She carries a brown envelope filled with old visit reports, unfilled scripts that she never could afford and some bus ticket stubs, I think. It is hard to tell.

She tells me Opana is her friend.

I drain the abscess in the crook of her elbow. I watch the pus trickle down her arm and run between her fingers. I wipe it away with gauze. I know 2, maybe 3 weeks from now, I will see her again. There will be another dirty needle, a different abscess to drain, perhaps a baby growing in her stomach. She tells me she cannot afford birth control. I look carefully at her body. Mike left no bruises this time, but next time he might. She wrinkles her forehead when I ask her about Opana and how this started. She tells me she broke her ankle and took Percocet. The Percocet led to OxyContin, and the OxyContin to addiction. She lost her insurance, her job, her children, her home. She switched to injecting Opana. No doctor would write her drugs anymore.

Opana for the pain. Opana crushed, boiled, drawn into a syringe.

She has track marks everywhere. Her veins are shot. She would need an external jugular venous catheter for IV access. Not today though. But she might tomorrow or next week if the bacteria runs through her blood stream and settles on her tricuspid or mitral valve. Then I might see splinter hemorrhages or white spots on her tongue. She would need admission and a valve replacement perhaps. Today I give her pills. I tell her to come back if she feels worse.

She says she is fine.

But when she goes back to Mike, he hits her in the stomach, knocking her to the floor. He is annoyed she left him. He pushes Opana into his veins and holds her as he injects it into hers, telling her how much he loves her. He stands up and kicks her in the head. She is too high to care. He hits her face, her stomach, her arms. She laughs then cries. No one hears. She is a druggie, people think. She did this to herself. Who cares?

She looks normal when I next see her. She has a baby in her stomach. And another abscess on her arm. I drain the abscess. No splinter hemorrhages yet. I see bruises on her back. I ask her if I can help. I rest my hand on her shoulder, taking her hand in mine. She tells me she is fine. She will have a baby in the tent with Mike and she won't use Opana anymore. She won't file charges or make a report. I offer her safety, a shelter, prenatal care. She waves them away.

She goes back to him. Maybe she crochets a pink blanket for their child; a child who will be born in a tent in the woods to a dad who beats his woman and to a mom who shares his needle.

Four hours later, it is raining. All I can think about is pink crocheted blankets, a piece of canvas in the woods and whether she has plastic bags on her shoes. I wonder what hope this child has and if I can save her.

I wanted to talk to Mike, to tell him to stop beating her, to give up on the Opana, to stop sharing needles. I thought about driving to the woods.

All I did was give her vitamins, instructions about pregnancy and drug abuse, and a promise (or a plea) that she could come back any time.

She waved me away, saying she was fine.

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