Of cigarettes and flat tires
============================

* Mukaila A. Raji

*   © 2004 Canadian Medical Association or its licensors

It is a balmy Monday morning, promising a typical Houston summer day. I arrive at the Ocean View Nursing Home a few minutes after 8 for my monthly rounds.

![Figure1](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/170/4/505/F1.medium.gif)

[Figure1](http://www.cmaj.ca/content/170/4/505/F1)

Figure. Photo by: Art Explosion

“Good morning, Dr. Raji,” the nurse says, hardly looking away from her computer.

“Good morning,” I reply, eyeing the pile of patient charts that she has set to one side. 

The nurse closes a data entry screen and looks up at me intently. “Mrs. Dean isn't feeling well,” she says. “She hasn't gone to recreational therapy for a month and always looks glum. Maybe she needs an antidepressant.” She picks up the first chart in the pile and hands it to me. “You should start with her today.”

I flip through Mrs. Dean's chart as I head down the long corridor toward her room. Seventy-nine years old, admitted to the nursing home 6 months ago with advanced chronic bronchitis, recent below-the-knee amputation of the left leg and increasing difficulty with activities of daily living. Husband died a year ago. Smokes a pack a day. Was tested with the Geriatric Depression Scale a week ago; scored 10 out of 15. Maybe the nurse is right.

“Good morning,” I say, knocking at Mrs. Dean's doorway. I try again, speaking louder. “Mrs. Dean, Dr. Raji to see you, may I come in?” No answer. I enter the room; there is no one inside. I retreat, heading back for the nursing station. Then I spot her moving fast with her walker along a side corridor that leads to the courtyard, an enclosure dedicated to 30-minute smoking breaks. Many nursing homes do not accept active smokers; Ocean View, a squat red-brick building renovated from an abandoned military dormitory, is one of the few with a “supervised smoking program.” I head down the hall after Mrs. Dean; I can see her moving through the sliding glass doors into the courtyard outside. I follow her as far as the doorway and stand there, peering through the glass.

The Smoking Coordinator is a woman of about 60 with white, thinning hair and thick bifocals. With a cigarette delicately balanced between her brightly painted lips, she presides over the fifteen men and women assembled in the courtyard. She carries the packets of cigarettes, each labelled with the name of a resident. “Jim, you're out of ciggies!” she says, shaking an empty packet. “Can I borrow one from you?” Jim says.

Mrs. Dean is the one who answers. “You never returned the last one,” she says, and everybody laughs. Eventually, Jim gets his smoke from Malcolm, a wiry resident known for missing the 40 years he spent in jail. “Life was more fun in the big house,” he is fond of saying. “Plus, the food was better.” Raucous laughter punctuated by coughing spells interrupts what appear to be animated discussions and playful teasing. The smokers exchange stories, exaggerated and real, serious and light.

At half past the hour, the residents file out of the courtyard, their faces drained of interest, their affect flat, shoulders drooped. A few curse at an aide. It is time for recreational activities, which today involves live music. The residents sit with bored expressions, half asleep, while the Director of Activity and Entertainment or DAE (pronounced “die”) strums her guitar to the song “I feel lonely.” She follows with, “Rescue me.” A resident snores.

My patients seen, my notes written, I gather my charge documents into my bag and head toward the door. 

“Aren't you going to prescribe something for Mrs. Dean?” the nurse asks me, waving my progress note in front of her.

“Look at the back of my note,” I reply. I have written: “Diagnosis: Loneliness and boredom. Plan: Encourage group activities with peers.”

As I walk to the car, my beeper rings. Message: “Your 1 pm patient is ready.” I notice that my driver's-side tire is flat. A nail, perhaps. I crouch down to inspect it, wondering how I am going to cope with this delay. I make a brief call to the clinic about running late. I open the trunk, looking for the spare tire and other tools, aware that I am probably being observed by any residents sitting on the screened patio outside. 

“I'll change that tire for you, Doc!” It is Bill, one of the residents and a retired mechanic with years of experience. He races down the driveway toward the parking lot in his wheelchair. A nurse rushes after him. “No, no, you can't do that,” she tells him. I thank Bill for his offer as the nurse pushes him back up the driveway.

Dripping with sweat under the midday heat, I fumble with the flat tire. Thirty minutes later, with a spare tire on my car, I wave goodbye to Bill, who is sitting on patio with a flat expression, his shoulders slumped. The wind picks up strands of his thin grey hair. There is no smile, no wave in return. 

I pull my car out of the parking lot. Bill's face lingers in my rear-view mirror and then disappears as I merge into the lane of pulsing traffic. 

**Mukaila A. Raji** Geriatrician University of Texas Medical Branch Galveston, Texas