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Mindful Practice

The question

Smith, Jordan PA-C

Author Information
Journal of the American Academy of Physician Assistants: February 2019 - Volume 32 - Issue 2 - p 1
doi: 10.1097/01.JAA.0000552722.83241.02
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“Those ones are fine,” she says, as she unabashedly pulls back the bandage and shows me the ulcerations on her arm.

I can see her study my face while she shows me. Her empty brown eyes scan my features, though I'm not sure what she's looking for.

“How long have you been using for?” I ask.

“Ummm....” She looks away, not to avoid my gaze but to search for the answer. “Around 3 years,” she replies, in a voice that shakes slightly but contains no emotion. Purely factual. A passerby might have thought we were discussing this over a warm latte.

She hesitates, then slowly reaches down and pulls up her right pant leg, revealing a thin knobby leg. She begins to pull back the wound covering.

“This one, though,” she says timidly, with a pause.

I can smell it before I can see it, like a wave washing over me.

I look up at the scrawny, unkempt, wisplike girl lying in front of me.

She's no longer looking at me.

I can see the fear splayed across her face as she stares down at what lies on the inside of her calf.

“Am I going to die?” she asks.

I look down at the angry and blackened ulcer.

Born of habit, in a moment my subconscious quickly assesses the size, contour, and surrounding tissue, ticking off a list of differentials that might possibly pose an immediate threat to the life in front of me.

“Not going to kill you,” I say.

But yes.

I want to say yes to the almost skeletal 21-year-old who lies sprawled on the examination table in front of me.

And for the first time, I allow myself to fully take her in.

I take in more than the borderline BP, more than the way her heart ticks away rhythmically yet frantically, more than the slight wheeze in the base of her left lung, even more than the notable piloerections along each forearm and the slight fasciculations of her hands, indicating the early stages of withdrawal.

To take her in as a person might.

Plain, fair-complected, thin... and on death's door.

No medical expertise is needed for that assessment.

In and out of rehab and prison too many times to count.

A regular.

She returns again, faithfully, unable to shake the forceful call that brings her to this state over and over.

I calmly explain the procedure, shielded behind my gloves and mask. Behind my wall of medicine. To protect her or to protect me, I'm not sure.

“It is going to hurt?” she asks.

“Yes, it will hurt, but we need to do it,” I say.

I inject the lidocaine into the already-dying tissue to anesthetize the area. The same thing she has used up all the veins in her spent body doing. The same pursuit she has been ravaging her life for.

She grabs the nurse's arm as I begin to incise, then looks up and says, “I'm sorry. I'm just scared.”

How can so much emotion come from someone whose eyes are so empty?

She pulls away at times, and I pause to make sure the numbing is still in effect, then continue on methodically, detaching my brain from what my hands are doing.

Detaching my emotions from my thoughts.

After we are done, she thanks me feebly and shuffles out the door. All that's left is her imprint on the examination table paper. I cannot fathom how small it is. How frail it is.

Her first dose of antibiotics is already in, and the withdrawal protocol has been initiated.

I place her on the sick call to be rechecked early tomorrow and explain my concern to the nurses who will check on her.

I know that she will be well taken care of, that this ulcer will eventually heal. But there's something nagging in the back of my mind.

The fact that I've failed her.

I can't shake the fact that heroin wins.

The fact that I've lied to her.

And the answer to her question, truly, is yes.

You are going to die.

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