"Sam*, can you at least take your antibiotics?"
"I'm not takin' any of 'em. Why should I? You weren't here."
He's had so many head injuries, that he's now a kid trapped in an adult body. His face is scarred and his body is scarred and his liver is scarred, and his heart hurts. Not his real heart. Sam's lonely.
"Sam, another patient needed me," I faltered, weighing HIPPA against his anger.
"It was an emergency, I didn't know how long I would be in the other room when I went in."
"I don't care. You were supposed to be here. You weren't. I'm gonna go smoke."
He doesn't understand waiting in line, or being told he can't do what he wants to do. What he wants to do is drink a lot of alcohol and smoke cigarettes and eat cinnamon buns until his glucose level is unreadable on the glucometer. He tells me the higher the number, the better. "Like basket ball scores."
Before they reach a certain stage in both their mental and emotional development children are unable to think abstractly enough to put themselves into another person's shoes, or to plan for the future, or to delay gratification.
Sam is a little like that. Unable to understand why a nurse would not be on time, or why he shouldn't cuss out the doctors, or why he should care about his blood pressure.
Just like a child, retarded emotional development doesn't mean Sam is a bad person. It just means he is where he is. Unlike a child, however, he's not going to progress. His brain is damaged. He may be able to learn behavioral modification - but he's not ever going to reach the next stage. He's stuck.
So whenever Sam is my patient I take my time to remember that and treat him accordingly.
"Hey Sam, you look nice today. I'm sorry I wasn't here for you earlier. Can you take your medications now?"
"No. I'm going to sleep."
Usually it's me who is called in to reason with Sam, some other nurse at her wit's end. Today, I'm the bad guy. Because another patient was vomiting and I was late with Sam's medication cup.
I'm putting out fires. Vomiting, hypotension, dressing changes, patients with frightening hallucinations. Pharmacy's on the phone asking about prescriptions never sent. Due to a "boil water" alert I'm rationing bottled water. I have three patients with persistent elevated temperatures possibly related to their illnesses but much more likely caused by dehydration. I am watching everything.
As I run around, Sam is in the background of everything I do. Standing in the hall. Sitting in the clinic. Riding the elevator. He takes his meds from me, quietly, an hour after refusing them. He says little all day.
Then, as I'm leaving, he's telling a respite aide:
"I had three cats," he said, "named Mud, Mud Junior and Mud the third."
His eyes glow with excitement as he continues, "and I used to feed those cats better than I fed me. King crab. Shrimp. They loved that stuff. I'd go buy it for them."
It is the first time I see Sam smile all day, talking about his cats and how he took care of them. How he loved them and they loved him.
He notices me listening and waves cheerfully, the morning forgotten.
I leave the building deep in thought, wondering how one would word a prescription for a cat.
*names, diagnoses, and situations have been changed to protect the privacy of patients and staff involved