Quenched
1960, Parkland Hospital, Dallas
Before Parkland Hospital was catapulted into world history with the 1963 assassination of John F. Kennedy, I was roaming the halls as a junior medical student getting my first taste of patient care.
The first two years of medical school were like college: classroom and lab courses in anatomy, physiology, and similar. Patient contact was non-existent. We practiced physical examinations on one another and learned how to collect a medical history by interviewing volunteer patients with real diseases who had been coached how to answer scripted questions we had been coached to ask, a poor substitute for pulsating drama of diabetic acidosis, heart attacks, and cancer surgery going on next door at Parkland. Private patients wanted air conditioning and private rooms, neither of which Parkland offered.
Care was delivered by a team led by a professor, who bore final responsibility. Next in line was a resident, a specialist-in-training, in this instance one in internal medicine. The resident made most of the important decisions. Then there was an intern, someone who had graduated from medical school the previous year and supervised bedside care and monitored patient progress. The lowest lump in this pile was the medical student, me. My job was to start IVs, draw blood, fetch charts, track down missing lab results and x-rays, collect urine and other specimens, and do whatever other “scut work” was required.
Miss Quench (not her real name) was one of my first patients. I was 23 years old.
She had curly red hair, freckles, and a pleasant, round face, but from the beginning she was a trial.
First, she smelled to high heaven. Second, she was demanding, insolent, ungrateful, and combative. Before her stay ended, I was exasperated near to screaming and filled with dread at having to visit her several times each day. Before her stay ended, I had no greater wish than that she would somehow get off 6-South, out of Parkland, and out of my life.
But she had good reason to be there, appearing in the Parkland emergency room complaining of chest pain, a symptom taken seriously in any patient. Most such patients were older men with underlying coronary artery disease complaining of the distinctive symptoms of angina pectoris—literally pain in the chest; a heavy, achy, suffocating, alarming sensation—but not exactly a pain. She was a woman in her mid-thirties, not the type to have clogged coronary arteries. On the other hand, she was short, fat, and had diabetes and high blood pressure, a dangerous triad that frequently leads to heart attacks.
Records indicated numerous previous visits to the emergency room. Typically, she would show up loopy from out-of-control diabetes, blood pressure raging. Her chart was thick with exasperated notes about bad attitude and poor compliance—she didn’t keep appointments and didn’t take her medicine. Most of the time she languished for hours, IVs dripping, while insulin and other medicines slowly coaxed her systems back into balance. But this time the emergency room resident couldn’t exclude the possibility of heart disease, so despite her youth and gender he put her in a bed on 6-South.
As bad as things were for her, they were good for me; too good, perhaps. I was well on my way to becoming a doctor, and I stood near the top of a class filled with high school valedictorians and cum laude graduates from major universities. My academic performance puzzled and thrilled me because it was coming so easily. I’d had a mediocre high school record and had struggled the first year and a half in college, until my father’s death, merciful for him and for me, freed me from worry. Good grades and good fortune plopped into my lap like fruit falling from a tropical tree. I was a lucky beneficiary as the Universe worked out its purposes. It was heady stuff. I studied, but it was fun, not a chore. I read voraciously—novels, biography, history, newspapers, magazines, you name it. I even had time for a bit of social life, though my financial means were limited. Prestige and new vistas beckoned. Especially intoxicating was the new power I was discovering—license to invade bodies and probe minds, to ask questions not allowed in any other context, and to command others in the name of an altruistic cause. On the last point, however, medical students labored in a vale of shadows, but I could see the sunny higher ground where white-coated authoritarians experienced immediate compliance with their orders.
The new patient protocol for medical students required us to do a thorough history and physical exam, never mind that residents and interns had done a focused history, physical exam, lab tests and x-rays in the middle of the night. It was all there for me to read and done better than I could ever hope to do.
Nevertheless, in observance of expected ritual, I asked her a zillion questions from a standard form—“Miss Quench, has anyone in your family had hemorrhoids?”—and poked around in anatomy that had no relevance to the problem at hand—“Miss Quench, I’m going to do a rectal exam to be sure you don’t have a cancer in there.”
This nonsense did not sit well with her. It was clear that she’d seen enough of Parkland to know where the power lay, and it was not with me. I dutifully asked irrelevant questions.
“Miss Quench, do you ever have headaches?”
“You give me a headache.”
“Miss Quench, has anyone in your family ever had colon cancer?”
Silence. She stared at the ceiling.
Her disrespect was palpable. My inclination was to quit. I could probably skip filling out the form on her and no one would care.
But I was on an academic roll and didn’t want to break my momentum. I slogged on.
“Miss Quench, tell me about your chest pain.”
Animated for the first time, she levered up on an elbow and spoke directly to me.
“It’s like a band going around my chest,” she said, using her fingers to draw out an imaginary band a few inches wide. She was quite precise.
“It starts here, goes around this side,” she said, pointing under her right arm, “and around my back to here,” she added, pointing under her left arm, “and back to here,” she concluded, pointing to the middle of her chest.
“I have another band going around my stomach,” she added, using her fingers the same way.
I had dutifully read about heart pain, and this was not the way it was supposed to be. It should have been dull, diffuse, and difficult to describe—an unpleasant sensation, not really a pain, but more like a strong fist pushing in on the breast bone. Sometimes it extended to the left neck, jaw, or arm.
“None of that,” she said with finality and returned to the bands of pain. It was like she was describing barrel hoops.
Violating technique, I asked leading questions.
“Is the pain sharp or dull?
No answer.
“Does the pain cause a feeling of pressure in your chest?”
Silence.
“What . . .” I began another question.
“Will you leave me alone!” she shouted. “I’ve told every one of you what’s wrong with me. Why don’t you just give me some medicine to make it go away?”
With as much dignity as I could muster, I closed the chart and walked out, angry, and humiliated. I wrote in the chart what she’d told me even though I knew it made no material difference.
This was my first encounter with the problem of pain. The ability of patients to describe pain is necessarily subjective and more dependent on intelligence and linguistic skill than any other aspect of patient complaints. Pain is a singular personal experience, so difficult to communicate that it is akin to trying to describe color to a person blind from birth. The average patient, let alone someone like “Miss Quench,” is poor at describing pain. Maybe her pain really occurred as bands around her chest and belly, or maybe if she had better control of language and better self-knowledge, she might have described the pain in a way that would have convinced us that she had heart pain. But she didn’t. There is no solution to the problem. Science will never get into someone’s mind to determine the “true” nature of pain.
Later in the day she was the subject of much discussion among our team, but it was too early to come to any conclusions other than the strange way she described her pain, how rude she was and how awful she smelled.
The next morning as I was about to turn into her room, I heard a loud argument between her and another woman.
“I’m telling you; it’s not working. You must find someplace else to live,” the new voice said.
“You can’t do that! I’ve paid my rent!” Miss Quench shouted.
“I don’t care. You’re not coming back.”
“Go to hell. Parkland is a lot cleaner than that filthy hole you call a room. You’ll never find anyone else stupid enough to pay the rent!”
Insults flew and her visitor, a rail-thin, middle-aged black woman, stormed out of the room. I decided there were other things I needed to do.
The next day I tried again. My goal was to ask cleverer questions, maybe I could get an answer to the riddle her peculiar pain. I would get to the bottom of the mystery by persistence if nothing else. But she stuck with her description of the bands of pain.
Her reputation among the staff had spread. Nobody could bear to deal with her, even after an aide had given her a bath, which eliminated the smell.
Nobody believed her odd description about the bands of pain. It sounded contrived. The blood tests, electrocardiogram and other tests were inconclusive. The idea began to build that she was making it all up. At evening rounds the collective judgment was to send her home. We couldn’t find evidence of heart disease; we needed the bed; and she was likely malingering, probably to avoid an unpleasant home environment. But to be complete, we asked for a psychiatric consult to see what the shrinks thought.
The next morning a psychiatry resident came for a visit and left a useless note about personality disorder and situational stress. Afterward, it was my chore to tell her we were sending her home.
“Miss Quench, we are going to discharge you this afternoon. You need to call someone to get you,” I said.
“Y’all are crazy,” she fumed. “I’ve been here nearly a week and you haven’t done a damned thing for me. I’m still having these pains. I’m not calling anybody.”
Not knowing what to do, I retreated and passed the problem to the resident.
“That woman may be the end of me!” he said and disappeared down the hall toward her room.
In a few minutes he came back, madder than ever.
“Now we’re going to have to get social services involved. She says she doesn’t have a place to live and nobody to call. We’ll never get that woman out of that room. She likes it here.”
It took Social Services a few days to find a place and it fell to me to give her the bad news that she had to leave. Dreading every step, I marched to her room.
“Miss Quench you must get dressed to go home,” I said with all the authority I could muster.
“I don’t have a home. You know that,” she said. “Are you throwing me out on the curb?”
Then, to my astonishment, she sat up in bed and slid her feet to the floor. She looked at me blankly for an instant, her gown and hair a mess.
“I’m having the pain again,” she said.
That’s it, I thought. She knows the system. She is going to manipulate us into keeping her here.
In a final act of desperation, she threw herself on the floor.
As calmly as I could manage, I said, “Get up. This charade is over. You must go home.”
She stayed on the floor, making little movements.
“Get up!” I said. “We’ve had enough of your nonsense.”
She would not get up. I went closer and poked my toe into her ribs.
“Get up!” I said again. No response.
She was turning blue. I bent close and pried open her eyes: they were rolled back. Foam bubbled through her lips with a gurgle. I felt her neck for a pulse: nothing. I shouted for the crash cart.
In the ensuing pandemonium I faded to the periphery, thankful no one had seen me poke my toe into her ribs. Never had I felt such shame, not the red-faced shame of embarrassment, which suffices for the public glare of social faux pas, bounced checks, and speeding tickets, but a cold, soul-blanching darkness.
After the bedlam and failed resuscitation, to which I was a dazed spectator, I retreated to the hospital library and sat for a long time, pretending to read a textbook, and rebuking myself. I kept running the loop of our final interaction, which always ended with a still-frame: my toe in her ribs. I tried rationalization. Everyone else had failed to make the correct diagnosis, too, but it brought no solace. None of them had been angry with her and poked her with a toe. Nothing could explain it away. All I could think of was how utterly I had dehumanized her. I had compounded scientific failure with indifference to the human condition, out of which springs all manner of evil, from torture to terrorism.
The next morning, I went to the morgue to watch her autopsy. She proved to have severe coronary heart disease and evidence of old and fresh heart attacks.
Epilogue In the ensuing years I’ve revisited this episode many times, trying to understand how it came to be and how it might have played out another way. Humility would have helped me. She was faultless. I was of a mind, without realizing so, that I was right and could not be wrong. In retrospect it seems scripted. I was myself; she was herself, and that was the problem.
If her hospitalization occurred today, it is a near certainty that tests would have produced clear evidence of heart disease and her odd description of pain would merit nothing more than casual interest. However, as good as today’s technology is, it is not so good that it can save us from ourselves. In one way or another this scene from long ago is replayed every day in modern medicine.
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