Winters in North Carolina are always unpredictable. Mild but short summerlike days alternate with cold fronts that seem to bring new batches of colds. Crisp early-morning frosts harbinger an early flu season that strikes with such rapidity its victims know only that the timing is incredibly inconvenient

Goldstein, A.O.

Carolina Digital Repository

Social... SecurityWinters in North Carolina are always unpredictable. Mild butshort summerlike days alternate with cold fronts that seem to bringnew batches of colds. Crisp early-morning frosts harbinger an earlyflu season that strikes with such rapidity its victims know only thatthe timing is incredibly inconvenient. The winter holiday tempera¬ment is equally capricious, as family stress competes with family re¬unions, and gift-giving mingles poorly with the realities of recession.In the community health clinic where I work, I establish routinesto deal with this seasonal uncertainty. In such processes, though, na¬ture more often wins, as I discovered one recent morning. Arrivingat work, I was immediately informed that one of the other physicianshad himself come down with the flu. Would I mind seeing six to tenof his patients in addition to mine? I consented while acknowledgingthat I would be running very late throughout the day and might rushpatients, the staff, and myself, during a season and economic timethat call out for patience, compassion, and understanding.I was 60minutes late for Mrs Walker's appointment. Her anger wasnot initially alarming. I knew that an apology and brief explanationwould be sufficient for us to proceed. MrsWalker, though, was waitingat the open exam-room door, and although angry, she seemed less soat me than at something unknown. "You know, the pharmacy closes in20 minutes, and last time I couldn't get my medications for almost twohours," she blurted out as we both sat down. She turned her eyes awayand assumed a guarded posture, seemingly shutting the door to furtherconversation almost before the exam-room door itself had closed. I im¬mediately reassured her that because of my colleague's illness, thepharmacist had agreed to stay open throughout lunch.I was taken aback by this initial exchange, and what followed waseven stranger, one of those rare pauses in the clinical encounter. It wasnot one of those moments when we wait impatiently for the patient torespond to our multiple questions, but one of those times when weourselves are unsure of what we are going to say. Normally, I wouldhave asked Mrs Walker what seemed to be her main problem, but forsome reason, the question that finally came was not a question at all."You seem quite anxious and upset," I said as I leaned back slightlyin my chair.A piercing glance fixed me in my place as she said, "My head hurts,an awful headache I have. My whole head feels like it's going toexplode. The pressure, that is, on the whole side ofmy neck, it's so tightthat, that..., there must be a blockage of something. I thought mypressure must be up, although the nurse said it was OK. I think I'mhaving TIAs, that's my problem."As she spoke, what she didn't say was more disturbing. Mrs Walk¬er's dark eyes were truly angry, and her voice was sharp, accusatory,and wild. Her hands, opening and closing in opposition to one another,displayed anguish and anxiety. And her neck muscles sharply definedthemselves anew with every sentence, seeming to bulge at the word"pressure.""What's been going on in your life lately?" I asked. "Everything, justabout everything," she replied, as she began to cry. This time, the pausewas hers to break. "Well, you see, my husband died a little over a yearago ofprostate cancer, and I was so depressed_They say it gets bet¬ter, ... but it doesn't. I'm no better now... I'm so alone,... so lonely.""Do you have any children?""Yes, but they all want what little money I haven't got anyhow.""What do you mean?""Well, my husband left me a little Social Security, but with bills,medications, and the such, who's got any money left over, and my sonneeds a loan. I don't have money for him. I feel so guilty_Besides,there's my daughters' medical bills.""Tell me about your daughters.""Kelly, she's an alcoholic, always has been alwayswill be. Rachel's theone needingmoney; she'sgot three kids and just got out ofprison herself,for selling drugs, of all things. Patty, she's my daughter-in-law, thoughshe's just like one ofmy own. She ... she was just diagnosed with lungEdited by Roxanne K. Young, Associated Editor.cancer, only 44 years old...(crying)... smokes two packs of cigarettesadayand anurse,... how stupid!... Do you think I could get somethingto help me sleep? I can't sleep at all. Can I get some more ofthat XanaxI had last year after my husband died?""Well, let me first examine you," I said hastily, as I handed her a boxof tissue, took a deep breath, and tried to collect my thoughts and dealwithmy own anxiety. A little empathy had gotten me in overmy head.Was I feeling uneasy from hearing partial stories, knowing ofparts pur¬posefully put off, or from an uncertainty ofhow to proceed? I was acutelyaware that I had not yet started a physical examination despite beingwith Mrs Walker for 15minutes and havingmany more patients to seethat morning.I was beginning to understand that Mrs Walker's headaches and"TIAs" were likely the final manifestations of unresolved stress. I hadno idea, though, how far back her anguish went. Proceeding with thephysical, I said, "It seems that youmust be apretty strongperson to...""I'm tired of being strong," she blurted out, cutting me off as her ownvoice trailed off. "It's OK," I reassured her. "It's OK."I examined her eyes and ears, head and neck, all ofwhichwere normal,as was the rest of the exam.With my hands returning to touch the sideof her neck once again, I said that I needed to step outside for just aminute.There I made my assessment. Mrs Walker was severely depressedas well as acutely anxious. In addition, she was strapped formoney, un¬employed, lonely, angry, and tired and had a host of conditions she waspoorly prepared to handle. Realizing thatmy own sense ofcontrol feltthreatened, I decided thatMrsWalkerherselfneeded some control overthe events in her life.Returning, I told MrsWalker what she obviously knew, that shewasseverely depressed and anxious. After inquiring about suicidalthoughts or plans, which she denied, we discussed the relationship be¬tween her headaches, pressure feelings, and unresolved stress. I toldher I would try to help her start feeling better, and we agreed to anappointment with a mental health professional, for her to discuss herproblems with a close friend, to start taking a low-dose antidepressantthat might also help with sleep, to return in one week for a follow-upappointment, and to talk with one another over the telephone in twodays. Mrs Walker then left while I returned to a backed-up morning.Meaning often remains unclear. As healers, we try to heal our pa¬tients' wounds, whether physical ormental. Mental wounds are harderto heal, because it's often difficult to clearly identify the "lesions." Theyare uncovered slowly, if at all, for their home resides deep in the soul."Bleeding" may go unrecognized for a long time.MrsWalker appears to be such a person.With hermind speeding outof control, she doesn't know how to stop. Her brief disclosures conjureup images of an unfair and cruel life. And I, of course, want to justifythe often unjustifiable. In an hour's time, I share the anger and sorrowof an older woman's lonely struggle.The nextweek she returns, headaches, pressure, and cryingepisodeslittle improved, but her feelings ofanxiety less severe. New issues ariseas she fills me in on old ones unresolved. "My first husband, you know,he killed himself 20 years ago!" Even with such a disclosure, her affecthas perceptibly changed. She appears less out ofcontrol. And I feel lessthreatened. A brief smile ends our session, and we agree to see eachother in one week.Seven more days. The headaches are slowly improving and sleep hasdefinitely improved. Mrs Walker will talk with her minister this week.A fragile control is returning for both of us. Our conversations amidstthis chaos affirm life worth living through the currentmisery, suffering,and pain. Such morsels may feed and nurture our spirits until our ap¬petites return."But I'm still so depressed," she says, as we try to remember life'swonder with its tragedies, unpleasant pasts with future unbridledpromises. Balancingpainwithpleasure, wewill touch each other in waysunknown. Even as we grieve, we endure and move forward.Adam O. Goldstein, MDChapel Hill, NC

Social ... Security.

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Social ... Security.

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