Sometimes it is the quite moments that speak the loudest.  I was leaning against the door frame to patient’s room in a nursing home. The thought of crossing over the threshold kept my position in check.  If I moved the little energy I had left in me would drain away.  I would somehow meld into the doorframe that had been sliced too many wheel chairs and the dead and near dead.  As I stared across into the room and saw a man, or what used to be a man, laying in a bed of sorts my mind wandered back to the door frame.  Did each notch represent someone or what I just being a tired old asshole?

I decided the asshole thing seemed the most likely.  After all, one of the great lessons you learn in medicine is that everything changes, no one is special, there are no magical escape routes, and life sometimes just really sucks.  It boils down to that very simple concept - life can and does suck.  Sometimes life can twist or play out as planned and still be horrible.  Other times the twist turns you around and you find footing on new ground.

But standing and staring at this patient was not really a “horrible” moment; it was a sadly inevitable one.  The human clump lying on the starched sheets was simply waiting for his ride home.  He was dying; there weren’t any more magic pills or promises.  Now it was all dim lighting and morphine.  The only sign of life left in the room was the blinking light on the morphine pump telling me that it was slowly pushing in the pain killer.  I said a silent prayer hoping he was getting more than enough. 

I have often written that death and I are very old and well acquainted “friends”.  It does not mean I like it.  I just have to accept the fact that the path I walk is sometimes strewn with bodies.  But what I have come to realize over the years of working in this constantly imploding neutron bomb we call the AIDS epidemic that death is not always the worst thing that can happen to a person.  Dying by degrees or seeing a person’s soul melt is worse.

I straightened up and cursed the tiny rips in my shirt that the door embedded as I walked over to Rob.

When I first met Rob he was newly diagnosed and had tossed his well mannered life out the window for the great god known as crack.  He ditched his family, friends, career and fortune as the disease of addiction replaced his dignity with chemicals.  It also made his a pain in the ass.  No one really wanted to bother with Rob.  He was bounced from one medical practice to another.  He became known a “frequent flyer” at the local ER always seeking pain medications. 

Before he even walked though my office door the very first time I had heard more than enough stories to make me box him into the “JPN” category.  (“JPN” is the inside medical slang for “Just Plain Nuts” and that means trouble.  JPNs can range from colorful to living nightmares.  Nothing satisfies them.  They lie.  Sometimes they steal.  Often they simply break people down into tears. JPNs rarely find a stable medical relationship.  Something always happens and it is never their fault.  So they boomerang from clinician to clinician and knock people over like bowling pins. Rob was a first class JPN.)

About three years ago I had asked Rob to find another provider.  I had foolishly made a promise to myself I would not let him become just another JPN in my clinical life.  But he finally did.  I don’t even recall what the breaking point was, but I do remember it was final.  A time when both the patient and provider know that it is over.  Both sides simply surrender and walk away.  It feels like leaving the scene of accident with witness that can identify you.  It feels like shit.

Yet here I was staring at him on a mattress crumpled into a ball.  He was my patient once again.  The hospice team had admitted him to a nursing home I cover.  When I saw his name on the new admit list my vision blurred and the veins in my head pounded.   As I looked at Rob I recalled our first encounter when he came back into my life. 

I was looking through some charts at the nursing stations when Rob appeared in front of me talking non-stop like the three years we had not seen other did not mean much.  I suppose it didn’t to him or even to me really.  When I was an active drunk and user the only thing that was important was how I was going to get my drugs and alcohol today.  Nothing else was even on the list.  So Rob’s barrage at me was more than understandable.  I had done it myself many times before I got sober.  Being in recovery really only means I am on slip away from falling down the rabbit hole again.  It is a lesson I have seen too many people forget and then never climb back out.  I was grateful for the painful reminder. This is where I heard the God voice in my head say clearly“ ”This is the wisdom part where you have been granted the knowledge to know the difference.  Now, don’t fuck it up."

Yes God, I said to myself, I will not fuck it up...with your help.

So Rob hammered at me and I shut down.  Nothing he was saying penetrated my brain.  It hardly made sense.  It was JPN Rob doing his JPN best at the very end.  I was just about to say something to Rob when he looked at me and I could see the energy of the fight just stop dead.  He turned slowly and pulled him morphine pump behind him and said, “Just don’t fuck up, okay?”

So God and Rob had come to the same mandate.  I was not to fuck up. 

As Rob slumped away the intern sitting at the nursing station just looked up at me and said, “He is going to pain in the ass, isn’t he?”

"Oh, yea.  A big pain in the ass." 

“Fuck,” she said to the air.

"But remember. He is also a big pain in the ass that is going to die. He has always been a big pain in the ass all of his life.  However, this is his first time dying."

The intern just stared at me.  “Give him what he needs and don’t let his behavior be an excuse for you to be a bigger pain in the ass than he is.”

The intern leaned back in her chair and was pissed.  "It this supposed to be one of those wonderful moments in my medical education when I hear wisdom from above or what?’

"Hell I hope not because I am still waiting for mine to happen.  I’d be really pissed if you somehow got your golden moment before I got mine."

She was not taking kindly to my banter.  I could see her eyes laser in on me.

“So I guess the gossip mill is correct about you,” she said with a sense of satisfaction that only those who know their truth to be gospel.

“I sure hope so.”  I smiled brightly and slipped my stethoscope into my back pocket.  “I hate it when they get it wrong.”

She slammed shut the chart in her hands.  "So you’re a drunk with AIDS just like that jerk.  Expect you have a fancy title and lab coat."

I leaned over the top of the desk and said. "Correction.  I am a grateful recovering drunk with AIDS and I never wear a lab coat or ask anyone to call me by anything but my first name.  You see one of the biggest problems in medicine is that we try to separate out from our patients.  We put up barriers so we can hide behind them.  It is a lot harder to treat everyone as an equal.  It upsets that imbalance you have been brainwashed with."

I just smile and head down the hall.  I don’t even turn around when I hear her yell after me. 

“I suppose THIS is magical moment I am supposed to remember all my life.”

I keep on walking without turning back to her.  "Nope.  But I do think you watch too much TV."

The elevator doors open and I step in and turn to select my floor.  The intern was on the other side of the doors and staring at me.  I smiled, flash her the peace symbol as the elevator doors closed.