Tuesday, 8 May 2018

In shock-the doctor as the patient

As a doctor I've long be interested in what it is like to be on the other side of the desk. In other words, what is it like to be a patient? And since personal experience of being a patient may lead to a more empathetic way of practising the art (see chapter 8 'Seeing the world through patient's eyes' in my book The art of General Practice), I would suggest that it is a good idea to read what other doctors have learned from their illnesses. Such a one is Dr Rana Awdish who tells all in In Shock: How nearly dying made me a better intensive care doctor
It is a salutary tale of serious illness which not only affected Awdish's physical well being-indeed she came within a whisker of dying- but also during the many times when the health professionals attending her said the most hurtful, unhelpful and thoughtless things, and consequently her stress and sadness were magnified.

One particular example was the occasion when after the giving birth to a still born baby. Awdish herself was only just recovering from nearly dying as a result of severe haemorrhage, a stroke, renal and liver failure. A nurse from the Neonatal ITU visited Awdish, it's a long quote but worth the time,
'The baby, she told me, was evacuated from my uterus still encased within the amniotic sac, and the placenta fully separated. A complete abruption, which has the distinction of being the worst-possible scenario. The connotation was that at some indeterminate point earlier in the evening, the placenta had detached from the uterine wall, depriving the baby entirely of any blood supply. The baby was delivered already" dead. They attempted to place a breathing tube, and were successful, which she appeared to be proud of, but the baby didn’t respond to their efforts. The baby weighed less than a pound. She spoke with precision and an intentional gravity. She reminded me of the military officers that would arrive on the doorsteps of widows.

“Do you want to see the baby?” I recalled the last time I had seen the baby, with her motionless heart on the monitor in the triage area. Did I want to see the baby? “No,” I replied flatly. “Well, I think that’s really sad,” she stated, visibly disappointed. I was surprised by her reaction. It hadn’t occurred to me that there was a right answer. I attempted to explain that I knew the baby had died prior to entering the operating room. I also felt that as a physician, I had some working concept of death, and I didn’t believe that I needed to see the baby to be able to grieve the loss. I stopped there, not understanding why I even felt it necessary to justify this choice to a stranger. It struck me as unnecessarily cruel to ask me to hold a baby that had been dead in my mind for days already. “Well, you won’t get another chance.”

Interesting tactic, I thought, resorting to threats in an attempt to provide her version of compassionate closure on a failed pregnancy. As if to further drive home her point, she added, “You know, I don’t want to be too graphic, but after a few days, their skin, it’s very fragile and it starts to … um, break down, so you won’t be able to change your mind later.” I was rendered speechless by her apparent need to provide a description. I wasn’t going to change my mind, I assured her, wishing she’d leave. She looked at me with an expression of pity, the way one might look at a child who has broken his favorite toy in a fit of spite. “A baby deserves to be held by her mother at least once.”

I stared back at her, silently imploring her to leave. I thought I would have done quite well to have avoided this whole encounter entirely. I agree, in principle, that a baby should have the experience of being held by her mother. But in my mind, that baby would ideally be alive. This baby was not alive. This baby stood to gain nothing from this imagined interaction with its mother. I felt as if she were asking me to submit to some act of self-abuse that she bizarrely construed as constructive. As if she were asking me to bare a wound she had neither the intention nor power to heal.'

I guess the length of the quote prompts me to say my one critique of this devastating and fascinating account of a doctor and her illness. I believe the book could have been half as long and just as powerful, its not that it is a particularly long book, just longer than needs be.

There was insensitivity, not only the neonatal nurse quoted above, but also the hospital that sent a bill for the unsuccessfully resuscitated 27 week baby, on what would have been her birth date (thankfully not something that would happen in our struggling NHS).
There was skepticism shown by her doctors when she clearly required stronger pain relief, and so felt guilty for asking since they thought she might be an opiate addict.

 At times she seems obsessively reflective and self analytical, and I suspect would be a rather challenging patient to manage. The detail she records is at times encyclopaedic (in the acknowledgments she thanks at least 50 people by name) and somewhat repetitive, but there is so much to learn here for the practicing doctor. Alas the books length may put my fellow medics off-I hope it doesn't.

Good grief!

After this beautiful Bank Holiday weekend I suspect not everyone is feeling sunny. And looks can be deceptive.

In the extraordinary short story,  A perfect day for  bananafish, J D Salinger (he of Catcher in the Rye) depicts a tender encounter between a sweet little girl called Sybil and a much older man, Seymour, who gently, and innocently takes her out on a float in the shallows of the sea off Florida. Sadly Seymour is not as carefree and happy as the story at first appears. But I won’t spoil it for you! There are many Seymours around us.

I think of a bereaved widow I know who’s world was shattered by the sudden death of her husband. She would greet me with a timid version of a smile that hid a mountain of sadness. But smile she would.

That splendid GP educational organisation Red Whale helpfully sends out updates from time to time, and a recent one was on the subject of  grief and abnormal grief. It’s a helpful reminder of how all pervading and bewildering the experience is. Summarising 2 recent BMJ articles it reminds us that grief has many faces, and can be subtle in its effects.
 Impaired functioning: within the family, socially, ability to work/go to school.
Intense yearning and sadness, emotional and physical pain. There may be physical symptoms of anxiety. Mental fogginess, difficulty concentrating, forgetfulness.
Loss of sense of self or sense of purpose in life.
Feeling disconnected from other people and ongoing life. Difficulty engaging in activities or making plans for the future.
That disconnected person who just can’t get themself  going maybe hiding a grief unknown to those around. And since grief has many causes,  although it has death at its heart, this may not just refer to physical death. There can be death of status through loss of job, by illness, redundancy, retirement or divorce. Loss of a dreamed for future is a kind of death which may only be known to the afflicted.

I'm thankful that there is increasing emphasis on the need for resources and attention to be drawn to mental health issues. I recently re-read Reasons to stay alive by Matt Haig and felt again the sympathy that is due to the sufferer and the sheer sense of   physical pain that low mood can produce. It is indeed agony.

I recall an old patient of mine whose dog had died. The old chap was single, disabled and his dog was his life. The dog died in the middle of the night and my patient called for an ambulance to move the dog onto his knee. Fortunately the paramedics took pity and obliged. I suspect our NHS accountants are less than impressed. But grief is grief whatever the source and is equally shattering.  Lets try to be aware of each other's grief, whatever the cause.

A message from the other side

No, not that side! But thank God got through surgery ok yesterday. And thanks to all for love support and prayer.