His Service Ended, but the Battles Raged On

CASES
His Service Ended, but the Battles Raged On

By MARIANNA CRANE
Published: July 15, 2008
He tells me he wishes he were younger so he could fight in Iraq. “I enjoy killing,” he says.
He sits in my office in the veterans’ hospital, wearing a black leather jacket. A beat-up attaché case rests on his knees. His steel-blue eyes are unreadable. Wisps of light-gray hair frame a pockmarked face with a jaw disfigured by cancer surgery. A Vietnam veteran, he’s pushing 60 but looks 70.
Thin, nervous, his chest rising and falling quickly, he pauses to catch his breath as he speaks. “When I was younger and walked into a bar, everyone stopped talking. They never knew what to expect from me.” I catch a flicker of a grin. “My nickname was Mad Dog.”
I don’t question his past. I don’t want to know details. I want to know him, treat him as he is now.
The pain clinic referred him to me because I’m the spinal cord nurse practitioner, and he has an old spinal cord injury that doesn’t affect his walking, just makes me responsible for his care. I read the diagnosis of “alcohol abuse” in his record. He swears he has stopped drinking. I want to believe him. And I want to believe that he needs pain medication. In large doses. Until I learn otherwise, I write a prescription for the drugs, one month at a time.
Before his next visit, I get a call from his sister. They live together in a trailer two hours’ drive west of the hospital. “He’s still drinking,” she tells me, as I recall the conversation. A day later, she calls again. He has been admitted to the community hospital. She doesn’t know why. “Please get me the hospital records,” I say.
At the next visit, he hands me a sealed manila folder. He sits quietly as I read the notes from the doctor who treated him in the local emergency room. Unconscious. High blood levels of alcohol and narcotics. Given naloxone, a drug used for narcotic overdose. I find something else troublesome. He has had other admissions for the same thing. He can’t refute the evidence I hold in my hand. “Stop the drinking,” I say. “Detox,” I say. He agrees. Too readily, I think.
His sister is willing to drive him here to the veterans’ hospital and will make sure he gets to the emergency room. I find a psychiatrist who agrees to admit him to the detox unit. After he’s discharged, he will be scheduled for outpatient counseling.
The day arrives. His sister calls to tell me that they are leaving home. I alert the E.R. staff and the psychiatrist. Why am I tense?
In the afternoon, the phone rings. My breathing quickens. It’s the psychiatrist. She tells me my patient came in as arranged but when she was ready to admit him, he changed his mind. I hold my breath. She continues: “He pulled out a bottle of morphine and dumped the pills into his mouth without counting. I committed him.”
I want to reach across the telephone lines and hug her. At last: his destructive behavior is documented and he is hospitalized. The next day, I visit him in the empty dining room on the locked psych unit. He looks relaxed, resigned as if he wanted this all along. A safe environment. Someone to take the temptation of self-abuse away from him. I wonder if he took those pills in front of the psychiatrist in order to get admitted. Maybe he doesn’t have a death wish after all.
He’s discharged. I see him once a week. I renew his pain medication after counting out the tablets he has left over from the previous week. The count is correct. His tests are negative for alcohol and any drugs other than what I give him. He avoids his drinking cronies and gives his sister extra money to go back to school to become a certified nurse’s aide. As a bonus, he cuts down to four cigarettes a day, from two packs. His craggy face softens. He’s trying. After a month, he graduates from one-week to two-week visits.
The next time he comes into my office, he asks me to look up the results of a routine chest X-ray that he had before an ear, nose and throat procedure. He sits on the edge of the chair, facing my desk with a cardboard smile. On the screen I read: suspicious lesion, probable lung cancer. He decides it’s just a shadow. I let him think what he wants. He’ll get a biopsy. The truth will surface soon enough.
His mother, father, brother and oldest sister died of lung cancer. The odds are not in his favor.
He walks stiffly out of the office, carrying the battered attaché case in one hand, the black leather jacket tossed over his other arm. Mad Dog, out to do battle — a battle he will lose.

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