Working in the Fishbowl

[Ann Emerg Med. 2010;55:125-126.]

“I have a confession to make.”

This is my favorite part of the history. It’s also the part I understand the least. It typically occurs after I’ve asked questions I wouldn’t ask my mother. After I’ve inquired about the medical history, perused her potential illicit drug use, plumbed the depths of the sexual history, examined all the parts the patient wouldn’t show strangers on the beach or even a spouse in the bedroom. This is the part where I find out the secret nugget of information in whose context everything that has happened up to this point needs to be placed. This is where it will all fall into place and make sense. It’s the moment when I believe the patient knows I want to help and is showing some trust. I don’t understand it because the confession so often seems less intimate, less personal, less critical than everything else I’ve said, heard, and done in the room. But it’s my favorite part, because it has a sense of sanctity to it, a mark of the physician-patient covenant. It doesn’t happen every time, but I like it when it does.

I sit back down on the lid of a trashcan, so she knows I’m not in a rush. I’m superficially familiar with the studies about sitting when you’re talking to patients and I’m a fan of both sitting and evidence-based medicine, although I’m not sure if any studies address where you sit. I avoid the biohazard bin as a sign of respect for what might be in there (I am also a fan of signs of respect), but the trashcan is the perfect height. It also has a big lid, so I feel less unstable on it than on a stool, which is really only good for pelvics and procedures.

“Tell me what’s on your mind.”

By way of background, this woman does not see doctors. Period. She hasn’t seen a doctor since the birth of her last child 30 years ago. I am aware that I feel a little honored that she has chosen to see me, because I know this isn’t easy for her, and she wouldn’t be here if she didn’t think she needed to be. As a corollary to this, she is not insured and has no money. She is about the age of my mother, and I wonder if maybe she’s thinking all the things my mother thinks of my appearance. I try to sit up straighter and arrange myself more ladylike on my trashcan. I cover my dozen earrings with my hair.

She is here for a rash. It’s on her left buttock and has been spreading for a couple of days. She’s starting to feel unwell, with chills and fatigue. It looks to me like cellulitis, and she doesn’t seem ill enough to warrant admission. This makes her happy. I was about to write her some prescriptions, but she has stopped me from leaving, and now I am perched waiting for her confession.

“I take fish antibiotics.”

Fish antibiotics. I turn this over in my mind, trying to look at it from all angles. Is this actually a psychiatry patient? Does she think she’s a fish? Is she saying she can only take fish antibiotics? Maybe asking me to prescribe fish antibiotics? Do you need a prescription from a fish doctor to get fish antibiotics? Is she familiar with the common metaphor that the ED is a fishbowl? Is she making fun of me and my job? Is this the kind of day I’m going to have? Is my next patient going to take reptile antibiotics? Will he think he’s a dinosaur? Suddenly, my rapport with my patient teeters vertiginously on the edge of the chasm of my judging her.

“I’m sorry. What do you mean?” I can hear my tone has changed, and hope she doesn’t hear it.

“I’ve been taking fish antibiotics. You know, from a pet store. I thought you should know, because I’ve been taking fish amoxicillin for 2 days. I’ve done it for years, but this time, I’m not getting better.”

Suddenly, I understand. Aquarium drugs. The loophole of the United States prescription antibiotic system. I remember treating my own home aquarium with an antifungal tablet, and how many choices there were for antimicrobials, no prescription necessary. So she’s been on amoxicillin of some formulation or other, intended for a goldfish. I am no longer irritated or judgmental. This woman is resourceful. She has no insurance. She has no doctor. She has needed drugs over the course of 30 years and has researched what she thought she needed and treated herself to good effect up until now. She has never been to the ED before. She likely would have made a better choice for herself if she had had more information on community-acquired MRSA, and then she wouldn’t have presented for care this time, either. I wish patients didn’t do this, and I wish it wasn’t an option for them, but in the same situation, it’s something I can see myself doing. In some ways, it is what I do for myself. I decide what I think I need and prescribe it.

“Um, ok. Thanks for telling me. That’s really helpful information to have. Do you mind if I ask you how you dose it?”

“I take one tablet. I figure I’m about the size of a 10-gallon tank.”

I quickly do the math. 80 pounds. Not even close.

I write up a prescription for doxycycline and some generic discharge instructions. I add in, “It would be a good idea for you to see a primary care doctor, as this is safer than you trying to figure out what infection you have and buying antibiotics intended for an aquarium. If you do buy antibiotics for an aquarium, remember you are the size of a 20-gallon tank.” I hope this will help her make a more informed decision next time.