Truth about Lies

            “Do you smoke?” I asked my forty three year old patient. As the anesthesiologist I was interviewing the patient for her upcoming mastectomy.

After a moment of delay he said ‘I quit’ avoiding my gaze.

I love to pursue faltering answers. “When did you quit?”

“When I left college?”

“And when did you leave college?”

But her husband entered the room, didn’t give a chance for the patient to speak.

He said,”Doc, she just finished college day before yesterday.”

It is interesting how patients sometimes give deceptive information. Anybody would have assumed in a woman of that age that she must have quit smoking a long time ago if that was when she quit college.

Some patients don’t tell the truth, others tell half truths and still others distort the truth. I always wonder what makes the patients not tell the truth. I believe in case of history of smoking, drinking and drugs, it is they want doctors to appreciate their good habits. They do not want to lose self-esteem by revealing their drawbacks. Few of them believe they won’t get good care if they reveal their bad habits.

Studies show one in four occasional patients deny they ever smoked.

There may be fear their illness might be blamed on the habit of smoking, drinking or drugs. Lastly, the illness may be looked upon as self-inflicted and self-inflicted illnesses rarely invite sympathy from doctors. Imagine a man gets drunk in the middle of the night and is brought to ER because of a motor vehicle accident. Who will feel sympathetic toward this guy?

A few days back, I had a patient who was scheduled for the same day surgery, meaning he was supposed to go home after the surgery within a few hours, when the effects of the anesthetic dissipate. She looked disheveled. A nurse who had talked to her before got the information and told me the patient was recently divorced and is going through a difficult period in her life. She also had a bad headache. As an anesthesiologist I thought her anxiety level must be high. I examined her, re-assured her and walked off. That day I happened to work with a resident who came to me telling when he went close to her to start an IV he smelled alcohol on her breath. Feeling ashamed how I missed this I returned to her.

“You said you drink wine with dinner,” I said. “Do you drink every day?”

“No, no, no, no. No. I don’t drink every day.” She glared at us.

“Madam, we smell alcohol on your breath.”

Everything seemed to fall into place – her disheveled appearance, possible reason or response to divorce, her red eyes and the smell on her breath. Finally, she admitted she had a glass of wine with dinner the night before.

“Madam, if you had only one glass of wine it wouldn’t give the smell of alcohol on your breath. She must be heavily drunk last night.

Since alcohol, in combination with anesthetic drugs can prolong the recovery and increase the chances of the patient getting sicker, I canceled her surgery.

Tobacco, alcohol and drugs can have important interaction with medicines that doctors prescribe but this is seldom appreciated by the patients. While chronic alcoholism can increase the anesthetic needs, acute alcohol intake can make them very sensitive to anesthetic drugs. Cocaine use spikes up the dose needed to produce the state of anesthesia.

Because of the anxiety about the operation many patients can’t sleep and resort to take sleeping pills. Anesthesiologists need to know this. If the patient has a hangover from the sleeping pill, the dose of the anesthetic may be decreased.

We, as doctors, need to recognize problem patients by going deeper into their history.

Last week, I asked a man, who was a lawyer by profession about smoking.

“I don’t smoke cigarettes,” he said.

I noticed a tiny bit of tensing of his shoulders when he said it. So I asked him, “what do you smoke and how much?”

“Doc,” he looked at the ceiling. “I only smoke when I drink.”

“What do you drink and how much?”

“Not much, doc. It’s only on weekends.”

His daughter sat next to him. She blurted out, “his weekend starts on Friday. He drinks all those three days.”

The way man looked at her, I thought he would strangle her.

Anesthesiologists are supposed to instruct their patients not to smoke for at least twenty four hours before the operation so that they have a better circulation; their blood picks up more oxygen too. I do tell them. Most of my colleagues don’t because they say patients don’t comply. I still persist. I go beyond the situation at hand and advice them quit smoking forever. Even if one patient listens, among a hundred, it’s worth it.

Yesterday I had two such patients.

I asked my first patient. “Do you drink alcohol?”

His wife sat next to him. He made a face and said, “Only socially, doc.”

His wife butted in. “The problem is, doc, his social life is very busy.”

I am now wary of the vague terms like ‘socially’, ‘once in a while’, occasionally’, ‘only in parties.’ I dig out for exact answers in order to take the best care of my patients. ‘Two times a week’ may be a binge drinker with liver dysfunction that is important to know.

My second patient was a 53 year old male sitting with his wife.

After his medical history I asked, “Do you drink?”

‘Only on special occasions.”

His wife said, “He is telling the truth, doc, but every sunset is his special occasion.”