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Black Pump Independence

woman holding knee

“And just why do you need this blood test?” the elderly woman demanded in her fierce quiet voice. She glared up at me past elegant, hand-drawn eyebrows.

This was her third day in the hospital; my third week as an intern. We had had this conversation before.

Mildred refused to allow her blood to be drawn without a full explanation. If I wanted it so much, she told me on the first day we met, I’d have to draw it myself. And if I expected to ever get another drop of blood out of her again, I better come and tell her the results of those tests as soon as they were available. It was her blood, drawn to treat her medical problems, and by God she was not going to be the last to know what was going on.

When I told my resident, he told me that those kinds of demands weren’t acceptable. We have people whose job it is to draw blood. And, he added, they are probably a lot better at it than you are.

I sent in the lab techs to draw her blood. Didn’t work. Rather than admit failure to my resident, I drew her blood myself. I didn’t mind. It was good practice. Plus, I could kind of see her point. It wasn’t her fault that some of the work of her care had to be delegated or deferred. But from her perspective, it was her blood, her body. She got to decide who did what.

Mildred had a lifetime of high blood pressure but had consistently refused to take any medications for it. Her grandmother had “pressure,” never treated, and she lived to be almost 100. Her daughter had “pressure” too. She’d taken all the stuff she’d been given and died at 40. You don’t have to be a genius to know which side of that equation to be on was Mildred’s ready refrain.

But now Mildred’s kidneys were failing. She’d come to the hospital because she worried she might be dying. She had no appetite, had lost 30 pounds, even though her legs had swelled up to twice their normal size. When she couldn’t get out of bed one morning she finally called 911. In the Emergency Department they told her that her kidneys weren’t working. She might even need dialysis. She didn’t want to hear anything about it. She had friends whose lives revolved around the 3-times-a-week unpaid job of dialysis and, no thank you. Not even if it was temporary. Not even if her life depended on it.

She was admitted to the intensive care unit so her heart could be monitored as they brought her potassium down and started intravenous diuretics to get rid of the fluid. She was transferred to my service the following day.

When I went to meet her that first time, she laid down the law. I was not to think she could be treated like some sack of potatoes to be handed about, peeled and boiled and sent home when she was all done. Because that’s not how she rolled. And if she couldn’t have it her way, she was going home.

So each morning I arrived just a little earlier than usual. I pre-rounded on my other patients, then gathered the equipment needed to draw her blood. Her east-facing room was bright with the glowing dawn those summer mornings. She was always awake when I arrived, sitting up in bed with her robe from home draped around her shoulders. I pulled up a chair and tightened the tourniquet around her arm. “One try you get. Just one try,” she always said. So far, so good, but after she’d been on the diuretics for a couple of days her blood vessels—once so fat and easy to find—had flattened out. I imagined them under her skin, wrinkly as a deflated balloon, like her legs.

The cords of tendons lifted, showing themselves sequentially beneath her skin as she flexed and gripped her hands to inflate the blood vessels. At the crease of her elbow I could feel the soft linear bulge of a vessel, but couldn’t see it. I gripped the butterfly wings on the needle, making certain the bevel was facing up. I steadied my hand against her arm, and tightening the skin with my other, advanced the needle slowly into the vein I hoped was there. A flash of blood appeared then stopped. I pulled back a hair and slowly, blood filled the clear thin tubing. I snapped on the vacuum-sealed container and a narrow stream reddened the glass tube. When it was full I popped it off and put on the next. Two tubes in the morning. One at night. As the second filled I pulled off the elastic band with a sigh of relief. I think you’re getting better at this, she growled. And about time, too.

After 5 days she was ready to go home; her blood pressure, well controlled; her kidneys working, though not great. Her legs almost back to their original shape and size, though I could still leave a fingerprint if I pushed hard enough on her shin bone. On the windowsill of her room sat a pair of shoes from home, a slender pair of black pumps. This was her own test, she told me: when she could fit into those shoes it would be time to go home. On that fifth morning, I helped her sit up and she slid her foot into the shoe. It was a tight fit and I could see the indentations of her still-swollen foot spilling out over the top of the pump. One more day? I suggested. No, she asserted. Today.

When she left that afternoon, I handed her several prescriptions. Are you going to fill these, I asked? What do you think?, she snapped. I wasn’t sure what she meant. I wanted to think that our conversations about her blood pressure and her kidneys had made it clear how important it was. Sure she’d heard it before. But this time she was so sick that she’d had to spend a week in the hospital. And she hated that. So maybe she’d take them. This time.

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-Lisa Sanders, MD

This article originally appeared in the June 2017 issue of The American Journal of Medicine.

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