Members of the medical community all know that patients shouldn’t smoke, but are there exceptions?
During my internal medicine rotation, a wiry young man with a long, scraggly beard had decided to discharge himself against medical advice. My attending had told us that this patient was there for “drinking too much.” As I was attempting to interview him, he was taking off the clothes the hospital had placed him in and changing into a Guy Harvey shirt, cargo shorts and flip flops from his drawstring backpack. He took out a lighter and flicked it to see if it still worked. As his hands were trembling, he took out a pack of cigarettes. As his voice began to rise, he told me he was getting out of there because he needed a cigarette “right now.”
I tried to distract him by saying we could see about that. In the meantime, I tried to talk to him. He had been diagnosed with schizophrenia although he didn’t believe the diagnosis. He had a tumultuous relationship with his mother, and he drank everything … everything: even cooking sherry as the salt didn’t bother him anymore. Through the changing of clothes, he made the transformation from patient to civilian, albeit for the IV hanging from his hand, and began to shake more violently. “If I don’t get a cigarette right now, I’m going to punch someone,” he said.
“Okay, I understand. One second.”
At that point, I got my attending. I was panicked by this uncertainty of what to do as this was the more human element of medicine that I wasn’t as explicitly taught in my pre-clinical years.
“Let him have a cigarette … Just watch him,” my attending said.
The head nurse watched him and me warily as we walked the stairs out of the hospital. “You make sure you come back with that thing in your hand!” she said skeptically. He assured her he would.
When I was a pre-med and even as a first-year medical student, I never thought I would spend part of my rotation making sure a patient didn’t run off with an IV in his hand to get lost in the hospital to end up with a nasty infection. He smoked his cigarette and came back so calm I almost wouldn’t have recognized him. He was ready to continue being treated after being shown a little kindness, some trust and a little lee-way for smoking a cigarette, which is often viewed as a hard stop in medicine.
If my attending hadn’t let him smoke that cigarette, the patient could have followed through on his promise and assaulted someone or at least brought chaos on the ward with his state of agitation. He could have walked out regardless of what we told him with the IV still in place and never returned or returned in much worse condition.
Sometimes, as a medical student, I wish medicine would simply allow me to follow the guidelines, removing the messy situations like turning a blind eye to patients sneaking cigarettes. It would be so much easier. I sometimes forget that medicine doesn’t exist in a vacuum and neither do my perceptions of patients or theirs of us.
Undoubtedly, tobacco and nicotine use is detrimental to one’s health and not recommended by anyone in the medical community. However, even though smoking a cigarette was not in the patient’s best interest, it was the best decision my attending physician could make for the safety of everyone on the unit. In this instance, flexibility in the ever-changing face of human suffering seemed to be the best panacea. Like the smoke from the cigarette, the permission given for this patient to use nicotine, which is a black and white issue in medicine, showed me just a little bit of grey.