I would lump myself into the Optimist category. But every now and then, I encounter a patient that overwhelms and defeats my optimism.
I worked with such a patient again yesterday. It was our second or third session together. Joe* is in his 40's, and had a significant stroke on the right side of his brain. (MCA CVA for those who like medical jargon.) The left side of his body is paralyzed, and his brain tends to ignore that it's there. (left neglect for you jargonists out there) So he'll start swearing about how much his left shoulder hurts. And you have to point out to him again that it's because he's sitting on his left arm. Now, most people can learn how to pay attention to their left side again, and they get much better. But his stroke has significantly affected his overall self-monitoring and error-detection. How do you fix a problem that you don't think you have? Why would you exert maximum effort in a therapy session to fix something that isn't broken? This definitely affects someone's rehab prognosis.
Joe doesn't understand how cognitively impaired he is. His mind jumps from idea to idea, seemingly uncontrollably. Sessions with him are exhausting. You can spend 30 minutes just trying to get him to read through his medication list. He won't do structured memory tasks, but I tried to work on his memory by helping him learn his lengthy list of medications. We didn't get very far.
My favorite moment from yesterday's session was a conversation that went something like this:
Joe: "I think I might need to fire my doctor and get a new one."
Me: "Why's that?"
Joe: "I was taking tons of pills at home, but he couldn't keep me from havin' a stroke. Shouldn't he have known I was goin' to have a stroke?"
Me: "Didn't you just tell me that you smoke all day long, eat nothing but greasy food, never exercise, do drugs, are diabetic, and until recently weighed almost 400 pounds?"
Joe: "Well, yeah."
Me: "I think your doctor's done a great job of holding off your stroke as long as he did."
Joe: "yeah, maybe you're right..."
And then he changed the topic again.
The part that makes all of this most difficult is his baseline pre-stroke personality. My co-worker describes his life as "chaotic." She's stating it nicely. Here are a list of things he's told me about his life:
- While he was in the hospital after his stroke, his mom had his new van towed and "crushed".
- She evicted him from the apartment he was renting from her because he didn't pay rent while he was in the hospital.
- He's taking her to court.
- His 17 year old son is in trouble with the law, and is wearing an ankle monitoring bracelet.
- He recently paid $1000 bail to keep his son out of jail. He's afraid his son will miss his court appearance and he'll lose that money.
- His 17 year old son told his teenaged girlfriend to get an abortion.
- He wants to "bust him in the mouth" for doing that. That's not what their family does, even if it was going to be a "mixed-race kid."
- Joe lives with his girlfriend and her 3 teenaged kids.
- She helps him with his medications and doctors appointments.
- They want to have a baby together.
- They just got a pit bull puppy.
- When Joe gets home, he's going to start running, playing basketball, and lifting weights every day.
- He's going to have a 6 pack and a body like you see on TV.
- He's going to go back to school and become an RN.
- He'll support his son and keep him out of trouble.
(Nevermind that he never does his homework exercises and can't support his own weight, and left the previous rehab hospital against medical advice, one of the best in the nation, because he just wanted to go home. Oh, and he didn't finish high school, and isn't really very literate...)
His personality is one that does not take constructive criticism well. This makes providing feedback in therapy sessions quite challenging. He "fires" therapists regularly. He yells and swears at the staff regularly. He yells at me for "cutting [him] off all the time." I consider it "redirecting him to task." Especially in the context of needing 30 minutes to read through his list of medications...
I love it when patients have big plans, with big goals. I'll never forget the 54 year old hand surgeon that had a cerebellar/brainstem stroke. Let's call him Larry*. His mind was intact. But he had severe ataxia - a lack of motor control. He had difficulties speaking, eating, walking, bathing, etc etc etc. Returning to vascular surgery was out of the question. And he knew it. But he specialized in reattaching fingers. Working on hand transplants. He successfully amputated a guy's big toe and used it to replace a mangled thumb so a patient could have a useable hand. And he and a friend had been playing around with a new hand prosthetic design. So he set reasonable goals for himself. He and his friend turned their attention to the prosthetic. He decided that he could continue his love of hand surgery via teaching. He just needed to improve his speech to be able to do it. AND HE DID. If I told him to do 20 repetitions of an exercise, he did 50. When friends came to visit, he told them to grab his therapy notebook and do exercises with him. He toughed it out through the most intense electronic stimulation treatments I've ever administered. He set goals for himself, and he just worked his backside off to reach those goals.
Larry fostered optimism, even in pessimists. And when he gave an intelligible lecture (with Powerpoint images of severed fingers!) to our medical and rehab staff, I KNEW he'd be fine.
But Joe... he's not a do-er. He doesn't set reasonable goals and work hard to achieve them. So even if he did wake up one day and realize that he had problems, I have no evidence that he'd set out to solve those problems. He doesn't have a history of being a fighter. Of being someone who doesn't take "no" for an answer. Someone who will sacrifice towards a bigger goal. Because he does drugs all day long. He creates drama wherever he goes. He doesn't play by the rules. He lives in a different world than I do. One of drugs, prison time, welfare checks, baby mamas, and street cred. And I"m having a hard time seeing it as an environment that will help him recover and regain his own life, much less start a better one. He's ready to discharge himself from the rehab hospital so he can sue his mother. Can you imagine a guy like him in court? It's going to be a nightmare.
So I need help being optimistic on this one. I've never had a patient's situation upset me so much. I know that miracles can happen. There is still room for a miracle in his life. And he needs a miracle more than anyone I've ever met. No, I take that back. His son needs a miracle. His girlfriend's kids need a miracle. Because the sins of the father will be visited upon those kids and direct their future more than they can even imagine. He's going to be a handful to take care of...
Pray for Joe. And pray for my optimism. Thanks!
*Of course I"m not using their real names. The HIPAA police would come after me.