Noose of suspicion

“I prefer credulity to skepticism and cynicism for there is more promise in almost anything than in nothing at all." - Ralph Perry

Friday afternoon of Grand Prix weekend. The city mayor has issued a decree - all persons found prone on the streets of the city are to be transported by ambo to the nearest hospital within two miles headed away from the racing streets. The rule seemed laughable at the time. Prone persons in the city streets? The ERs would be flooded.

Our patient lucked out, thanks to the decree. The circumstances of her pick-up and arrival were unclear, but since she was nearly full-term in pregnancy, she wound up in L&D's triage, completely unconscious and unarousable. Paramedics must have found an ID, because we had a name, leading to scant records in the system from a past ER visit or two, but little else. No prenatal records, because she didn't see any of our hospital-affiliated OB's for care. No significant demographic or psychosocial information. A mystery heightened by her incapacitated state.

Concern was mounting, however, because her baby was as unresponsive on its heart monitor as she was, and so the debates began. How long did we wait for the baby to wake up before we took her for an emergency c-section? How long did we wait for the mother to wake up and face our inquisition? Should we attempt an overdose-reversing therapy in the interim?

She had no autonomy of decision, because she was asleep and had no advocates, no one we could track down. She had a nurse who was increasingly concerned for the baby. She had a resident who was convinced she was a druggie, intent on getting a high even if it meant screwing her baby over along the way. She had another resident with a cool head, patience and an iota of faith. And all this before she awoke and had a chance to speak even a word in her own defense - not that it made a difference even when she did.

Resident #1 kept evolving her own opinions without ever meeting the patient. Meanwhile, the nurse, resident #2 and I spent 45 minutes trying to stimulate the infant on the monitor and on ultrasound. We managed to engage the patient in spurts of awareness, and piece together haphazard segments of her last 12 hours. Her urine toxicology came back positive for a handful of things, some of which she fessed up to and others that elicited a palpable, visceral shock.

Her grip came to bear on my wrist as tightly as the fetal heart monitor snapped around her abdomen, almost cutting off circulation. What was wrong with her baby? What had she done? In the months of her struggle with psychiatric issues, staying off medication to avoid harm to her baby; in the months of abandonment by her family; in the months of terror, tears and confusion; she had lost her way, more helpless than willfully destructive. And here in the hospital, where she should have been able to expect support and unbiased care, she had to fight not only against her psyche, but also against the ill-informed preconceptions of her own caretakers.

Even as mom woke up and became increasingly aware of her situation, the baby insisted on sleeping in, and eventually dragged its mom into the OR for an emergency c-section. Medically speaking, the situation ended as positively as one could hope - the c-section proceeded without any complications, and the baby came out looking fantastically healthy and alert. Now mom was left to deal with the fall-out, with the questions from social work and CPS.

Everyone was predisposed to believe the worst. Clearly she was a drug-addled woman, unfit to be a mother, callous to her baby's needs, constantly on the prowl for the next high. Never mind that she was scared to death of the possible harm she had caused her kid. Never mind that she was terrified of losing her baby to the system. Never mind that she felt demeaned because no one had the courtesy to treat her like a person and keep her informed - the most basic of courtesies, one could argue, when we hold all the cards and she holds none.

Who will advocate for her? The nurse who is annoyed by the barrage of questions from a perceived irresponsible mother? The staff who discount her incisional pain as the lure of a drug seeker?

I only have unfounded theories about what fosters this unshakable suspicion. Some have probably been burned countless times in the past for giving the benefit of the doubt, and having patients take advantage of their empathy. Some have lost their integrity of faith, maybe had it beaten out of them by the job or job culture. Some are just predisposed to cynicism from the beginning, and they are perhaps the ones we can never sway. I keep hoping I can find the necrosed root and chop it off, even while recognizing it's an impossible feat. At the least, I hope nothing can quash my idealism, however naïve it may prove to be.

Never have I felt this frustration more keenly. We have all, since starting med school, dreamed of the day when we are capable of assisting the nurses, putting in orders, answering patients' queries, and have constantly felt the pang of disappointment when we cannot fulfill any of those. But for the first time this weekend, I felt the hollow sink of failure, confusion from standing alone in my opinion of my patient's needs.

Was I a sucker for empathizing with her helplessness, for believing in her commitment to love and nurture her child? Honestly, the answer to that question is irrelevant.

This job is not easy. Of all the patients we will meet who struggle with addiction, probably 80 percent of them will attempt to exploit us for pain killers. To some degree, they cannot help it, nor can they recognize their helplessness; that task falls to us. Of that 80 percent, maybe 60 percent will claim they want to quit, they need help. And of that 60 percent, maybe 10 percent will mean it. It might start with 2 days clean, then 2 weeks, and for a handful of them, maybe it will graduate to 2 years, or even 20.

But we have no way of knowing who that handful will be, and who are we to project a perceived fate onto anyone? That falls outside of our purview.

We should be the torchbearers of faith, believing that any person walking through our doors could be among the handful. And if we nurture them as such, maybe that handful will grow. If we lose faith in them, who will they hang their dreams on?