Careful with what you ask for
“Only the devil believes a sick man who eats and pisses” said Mr. Iturbide, “That’s what my grandmother used to say”. Agustin Iturbide was admitted to the hospital with intractable abdominal pain and nausea, and had an extensive history of comorbidities that were not helping his case.
Agustin was a short man, of thin complexity, but with a noticeably distended abdomen, evidently due to the reason of his hospitalization. He was somewhere in his late 50’s but looked ten to fifteen years older than that. When I first met him, the day I took care of him, his plan of care involved a paracentesis, which meant draining built up fluid from his abdomen using a needle, which was causing him the pain, and daily hemodialysis to get rid of excessive fluid in his body.
The paracentesis relieved Mr. Iturbide’s pain, but only temporarily. The pain and nausea came back the following day, despite medication and repositioning like sitting on a chair, standing up, and walking around the unit. Nothing seemed to help, he was just miserable. I would try to linger around in his room, striking conversations to distract him from how he felt, but that only helped for some time. During the conversations we had, I discovered Mr. Iturbide’s sarcastic sense of humor. As he came out of the bathroom, he repeated an old saying his grandmother had, which meant that if a sick man is eating and urinating, there is nothing wrong with him. I feel his current situation was by far exempt from his grandmother’s judgement. Mr. Iturbide would often make me laugh with some joke he had, but rarely did he laugh himself.
After several days off work, I returned and, although he was not my patient, I visited his room. It had only been a few days, but the thin man I had met was now noticeably malnourished and excessively underweight. His arms looked even smaller by the pulsating AV graft on his left bicep used for dialysis. He had a nasogastric tube connected to suction going up his nose and down to his stomach, a wound vacuum on a surgical wound in his abdomen, and was lying in bed with his eyes closed. He did not look good, he actually looked worse than the last time I saw him. He opened his eyes, shook my hand and we began talking. Although Mr. Iturbide seemed to be in worse shape than before, he explained he no longer had pain or felt nauseous, and because of that, he did not mind all these lines and tubes connected to him; he could finally get some rest.
Later on, he told me a story of his own experience. A couple of years ago, while in Mexico, he had a ruptured gastric ulcer and was taken to a nearby hospital. “Worse than a jail!” He assured me as he began comparing that hospital with the one he was currently in. He continued, with a soft voice limited by the nasogastric tube and a sore throat, “The rooms were just walls with doors that were falling apart. There was no clock in the room, no television, no gloves, no hand sanitizer, no restroom. If you wanted facial tissues or water, your family had to bring them from home.” I have personally volunteered at hospitals and emergency rooms in Mexico, and have seen how rough it can be, but no restrooms or gloves? Perhaps he was at a small clinic in an underserved area, or due to the acuity of his illness at that time, he did not notice the restrooms and other details, such as gloves. I am not sure. The lack of television, falling doors, and prison-like atmosphere, I have no doubt about.
“I used to leave hospitals against medical advice,” he went on, at which point I wondered how many times he had been admitted into a hospital if he could say “I used to.” “But, what for? If I was back the next day in worse shape. Now I just behave and stay; I shut my mouth up” he said. When Mr. Iturbide was in that hospital in Mexico, they had him eating one small cup of gelatin three times per day, and the hours between each meal were “eternal”, as he described it, and wished he had more to eat at that time. In contrast, two weeks ago, when he had abdominal pain, nausea, and vomiting, “I could not eat breakfast because I would vomit, and then lunch came quickly, and dinner shortly after that, but I couldn’t eat. So be very careful with what you ask for.” He warned me. Although I do not believe that statement was fair for his particular situation, the warning itself has been repeated over and over again, and I am positive there is a similar saying in every culture.
It is not with every patient I take care of that I have talks like these. In occasions, it is a straightforward nurse-patient relation with minimal dialogue beyond the necessary. Sometimes, though, the patient feels comfortable enough with me to share their stories and feelings, as I with them.