Chuckie, Donna, and Dory

He knew his birthday, but not how old he was. He couldn’t remember the year or the date, but he was aware of the season. He remembered his own name but couldn’t remember the name of the doctor he saw the last time he came into the office for a checkup. He thought he had a blood pressure problem, and maybe had something wrong with the prostate, but he couldn’t be sure of his history. He was  absolutely sure, however, that he hadn’t taken blood pressure medication for months—maybe even more than a year. It could have been a pink pill, or maybe a pink one along with a blue one. He remembered that, yes, he used to take two pills. He was annoyed. Why didn’t I know these things? Why did I even need to ask? Wasn’t I the doctor? (Despite my attempts to explain my role as a nurse practitioner, he insisted on calling me "Doc.") He wanted a full checkup, but he didn’t want to be examined.

And he was tired of the medical profession—the doctors, the nurses, the technicians, and all the lab tests—he had seen all of them and completed all the tests before, and they had never solved a single problem for him.

No, he didn’t need all of that stuff done to him again. He just needed to see a new doctor. He wanted to see someone who was good, someone competent, a doctor who would tell him what was wron  and how to fix it. A doctor who would tell him why, after all of these years, no matter how hard he tried, he couldn’t remember things. And, by the way, I was not that person. I was just there because he wanted me to send him to another doctor, someone who would know these things. He didn’t need an exam and he didn't need to answer any questions. Those questions I asked were just prying, anyway, and it was getting on his nerves. The note from his previous visit described him as confused, a poor historian, obviously with a dementia of some sort. And, the note continued, the patient was extremely hostile. He refused all exams and was not interested in a workup. It was difficult to say why he was there, what he wanted, and what kind of help he would accept.

The patient's son, who accompanied his father to the visit, was rather detached and distant, grunting from time to time in response to a direct question. Most of the time, he was rockin' to his iPod, and the music was loud enough for all of us to hear. In fact, at times it was so loud that it made it difficult for me to hear his father’s muffled responses to my questions. But in an odd way, I found the beat of the music comforting. It filled the room with a complicated rhythm, along with a jazzy cacophonous melody that seemed to complement the mood of the visit perfectly. The music somehow helped me transcend my frustrations and lifted me to a new level of hope. I persisted.

I then asked the patient’s son, “Do you know which medicines your father used to take or what kinds of things are bothering him today?” The son barely removed his iPod earbuds as he  repeated my question to his father—almost like a translator—but the father didn’t answer him either. So he reinserted the earbuds, only this time, interestingly enough, he put one earbud securely in place and left the other one partially outside his ear, apparently so he could listen to both the music and me….well, maybe.

Next I said to the patient, “I know that you don’t want an exam today, but would you mind if I just check out a few things? Maybe I can help you figure out why you can’t remember things.” He laughed and said, “Well, maybe.” So I helped him onto the exam table. The son was now singing along to the music while simultaneously reading a magazine that he’d brought with him. The father immediately became irritated with my attempts to examine him, so the checkup was extremely brief. His blood pressure was high, but I couldn’t get him to cooperate for a neuro exam or much of anything else.

I asked the patient to get off the examining table and return to the chair, with the hope that he would feel more comfortable and in greater control, and that he might therefore be more receptive to my desire to help. I told him, "I can see that your blood pressure is high, which can interfere with the flow of blood to your brain. It can affect your thinking. Would you be willing to take a pill to lower your blood pressure?" "Oh, yes," he exclaimed. "I think I've taken one of those pills before." I then asked the son if he would be able to help his dad remember to take the blood pressure medicine. I suggested that they use a pill organizer. "That's not necessary," said the father. "I’m fine with it all." The son agreed to remind his dad to take his medication.

I assembled some forms for the patient to get lab work and some other initial diagnostic studies done. Then I asked him what kind of doctor he wanted to see. He responded, "The thinking kind." I asked, "You mean like a memory doctor?" He was starting to get edgy again. "Of course that’s what I mean." Now the beat of the iPod was really pounding; I could almost feel it. The beat calmed me down again. "Okay, I’ll give you the name and a referral so that you can make the appointment." The father said, "He has to be in Camden. Is he in Camden?" "Yes," I reassured, him, "the office is nearby. Do you want us to help you make the appointments?"

Much to my surprise, the son looked up from his reading and said that he would actually take his father to the building where the lab and doctors’ offices were located because they didn’t have a telephone at home. "It would be much easier to just go over there and schedule the appointments." Well, that sounded like a good idea. I volunteered, "You could get the lab work without an appointment and do it on the same day that you schedule the doctor's appointment. You wouldn't need to schedule two separate visits." They liked that idea, but still weren’t too impressed.

It felt like time was running out; the father was getting tired and losing whatever patience he had left. The visit was just too much for him. "You know," I said, "we could probably avoid unnecessary testing by sending for your medical records." I asked the son if he had the name and address of his father’s previous doctor, but his father interrupted, saying, "You don’t need to do all that. That record won’t tell you a thing. A real doctor would be able to understand everything without the old record." I almost tried to explain but thought better of it. Besides, the music was filling the room because his son had turned up the volume as he was standing up and preparing to leave.