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.
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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 pati...