My dad was once a physician for the coal mines in Yorkshire, England, where I grew up. It's been decades since I accompanied him on his rounds, and fifteen years since I moved to the States and began to practice as a physician assistant in the Appalachian Mountains of North Carolina. But I still vividly recall my childhood days and the Yorkshire dialect we spoke.
Somehow, the seventy-three-year-old woman sitting in my exam room takes me back to that time.
She's coughing violently--hacking thick yellow mucous into her tissue, spraying the floor with spittle--just as my father's patients did.
Despite their blackened lungs, the miners were stoic. Whenever I'd say, "How are you?" the reply was always the same:
"Ah's just middlin' my'sen, Miss; but thank ye for asking."
Their warm words contrasted starkly with the challenges they faced every day, working to support their families--toiling long hours in confined spaces and risking death or injury from noxious dust, gas explosions, collapsed mineshafts and runaway fires.
My father was on call for them round the clock. When his pager sounded, he'd pull on his orange overalls, grab his medical bag and head down those burning, falling mineshafts. We'd wait for him--my mother hovering by the phone, the news playing on the television, the empty space in our driveway reminding us that he might never come back.
I drag my attention back to the woman before me.
Sophie, for that's her name, has come to the emergency room complaining that she can't sleep.
"This cough is driving me insane--it keeps me up all night," she croaks. "It's been more than two months now; I'm exhausted."
I hand her a glass of ice water. She sips it and frowns.
"Sometimes I get breathless and wake up in a sweat--" she breaks into more coughs and high-pitched, whistling expirations.
I start her on oxygen, then study her intently.
Short and squat, she wears a seedy mauve sweater. Her black pants, though well-cut, are baggy at the knees and coated with animal hair. Her dirty gray hair is pulled into a straggly bun. Her red eyes water, and lines of worry etch her face. At first, her expression seems impassive, but underneath, I see sadness tinged with fear.
In her large, open paisley purse, I glimpse a horrible muddle of pill and perfume bottles, keys, nail clippers and broken-tipped pencils. Amid the rubbish, a single pearl earring glimmers.
Overriding everything is Sophie's terrible smell--a penetrating stench like that of a bus-station restroom.
It reminds me of my grandmother amid the depths of her depression. For months, Gran wouldn't shower or change her clothes. She left dirty dishes festering in the sink, food rotting on the counter, trash cans overflowing--and she smelled. Back then, I didn't understand it; but I loved her anyway for the good days, when she'd give me fresh-baked shortbread biscuits, and milk in pink polka-dot cups.
"I don't want to make a fuss," says Sophie apologetically, pulling me back into the present. "I know you're terribly busy."
"Let's see if I can help," I say. I roll up her mauve sweater and listen to her chest. Her heartbeat is normal, but her lungs crackle loudly. Fleabites dot her back; ringworm mottles her flanks.
"Do these itch?" I ask, running a finger over the marks.
"Yes, ma'am," she says meekly. "Sometimes I scratch until it bleeds. It's from the animals."
"Cats--I've got six. Six cats and six dogs."
"They must be hard work," I say.
"Not really," she answers, then smiles. Her eyes glow; all at once, she seems warm and capable. "I like every sort of cat. People started bringing me strays and feral kittens. At first I felt I was doing some good, saving these animals and loving them." She pauses, and her smile vanishes. "When my parents died, I took in their cats. A year later, I lost my brother to cancer. I took in his dogs. Then I couldn't stop...."
"Pets are fine," I say, "but they can be overwhelming. How many did you say you have?"
She sighs. "Sixteen, I think. I don't really know--I've lost count."
A hopeless look crosses her face. "I don't know how to go on. Sometimes I don't want to. I used to have a career. Once, I was an editor for a major newspaper. I had friends and went out to dinner and to the theater. Now I'm a mess--just look at me!"
She leans towards me.
"And I stink," she whispers, shamefaced. "It's awful. My bathroom doesn't work. I can't have people visit my home."
Her eyes well up. "I don't even have a bed to sleep on. I bought a new couch, but even that's soaked in cat urine. I'm so desperate inside, but I never show it--I'm always cheerful."
Tears fall from her lashes. Her hands tremble. In the silence, I swear I can hear her heart beating--or is it mine? I so want to fix this, to give her hope for a better future.
"I'm sorry, Sophie." I say. "That must be overwhelming. I think we can help, though. We have excellent resources available through our psychiatric nurse and social services. Are you comfortable with my referring you to them?"
"Yes, ma'am. I would appreciate that," she replies tearfully.
"Okay," I say, putting a hand gently on her shoulder. "But first, let's see what we can do about this cough."
Sophie's chest X-ray shows severe pneumonia--and a suspicious mass in her lung. Is she, like so many of my father's long-ago patients, suffering from a malignancy? Apprehensively, I admit her to the hospital for treatment and further testing. While she's there, we notify animal control, who find twenty-seven cats and six dogs crammed into her one-room house.
Sophie's story ends more happily than I feared it might. Her home is condemned, and the animals taken to a shelter--but her lung mass turns out to be benign, and she's discharged to an assisted-living facility, where she acquires one cat: an affable tom named Elliot.
When I call Sophie to touch base, she'd just returned from a shopping trip to get ingredients for a dinner she's cooking for a friend.
"I have new friends," she says. "I don't need so many cats anymore. My old friends visit me here too; they can sit at my table. I have a bed and a bathtub and Elliot--there's room for him and me to sit together on the couch. We both have a place. That's enough."
Hearing her tranquil tone, I'm reminded again of my childhood dialect. I can almost imagine Sophie describing her life nowadays as "just middlin'. " And I reflect that in this case, perhaps, just middlin' may be just right.
About the author:
Alexandra Godfrey is an emergency-medicine physician assistant with Wake Forest Baptist Health in rural North Carolina. "My experiences in emergency medicine and in life have challenged me to find ways to understand trauma. I started writing after the loss of my baby son during pregnancy back in 2002. A deep love for language along with a passion for medicine have helped me find comfort in the medical humanities. Writing helps me 'hold center.' " She has written for Confluence, Cell2Soul, The Yale Journal for Humanities in Medicine and the Journal of the American Academy of Physician Assistants and writes a monthly In Practice blog for the New England Journal of Medicine.