Saturday, August 30, 2008

Losing Patients

One of my friends lost a patient some time ago. It happened during the induction of anesthesia. Just as aviation disasters often happen during take-off or landing, operating room codes or emergencies often take place as anesthesia is being administered or terminated. His patient was terribly, terribly ill, chronically with diabetes, heart disease, kidney disease, and vascular disease, and acutely with other things. She had been through many operations already. He prepared the anesthetic with meticulous care, spoke to the patient's family about the risks, but despite all his efforts, his patient was too weak to tolerate this one last anesthetic. He labored for over an hour to resuscitate her, to no avail. It was the kind of case every anesthesiologist hopes never to have to face.

Unfortunately, it's also the kind of situation that comes to every anesthesiologist's table sooner or later, regardless of his or her skill and experience. My anesthesiologist friend asked me a very thought-provoking question after he told me about his experience. He asked, "Are you willing to continue in a career knowing that this will happen to you someday, if it hasn't already, and you're going to have to deal with it and live with it and not give in to grief and self-doubt afterward? Do you love this work and believe in yourself enough to keep going? Because if you don't, you need to get out now while you can."

These were sobering reflections. If I left my work as an anesthesiologist now, what would I do? Where would I go?

I can only imagine what he went through. The indelible image of his patient's face seared into his mind. The questions he asked himself.

  • Did I do everything I knew how to do to care for this person?

  • Was there something I missed, something I should have changed?

  • What will happen now? Will the family blame me for the consequences of their loved one's frailty? Will I lose everything I worked for even though I did the best I could?

  • If the hospital or the family wants me punished, how much punishment will be enough, since no punishment could possibly bring their loved one back?

  • If someone else had been taking care of her, would things have been different?

  • Even if I am a good physician, will this forever color people's ability to recognize that and their willingness to hear my opinions and advice?
  • Whom can I talk to who would actually understand?

  • Even if losing this patient wasn't my fault, will this churning of thoughts ever heal, this ache ever go away?
Doctors grieve. Doctors shed tears, seen and unseen, over patients, for many different reasons - at least, the ones who care do. I know this to be true. Seen it. Done it. But doctors also can't be debilitated by grief or doubt or regret for too long. Other lives hang in the balance. The question is, how do doctors heal?
Addendum 1/27/09:
Just read another brilliant post by Bongi of other things amanzi on the subject of post-traumatic stress in doctors who face the loss of a patient and had to reproduce its well-wrought final sentence here: "When we fall off the horse, most of the time before we can even shake the dust out of our hair, we are shoved back on and the horse is given a hard thwack on the rump." So true.


rlbates said...

Yes, we do, T. Thanks for this post.

todo es cambiable said...

As a 4th year med student in Chile, I´ve encountered many difficult and painful clinical scenarios while doing rotations in our "very improvable" public healthcare system.

Even as a student, I can't help but wonder if outcome would be better if I had done this or that.

The vast majority of time it's the system's fault and not ours though. The aughful and rigid system messes good intentions up for no particular reason, without a wiz of empathy.

Replying to your post, I don't really think we heal from these situations.

We take them into account for our future patients, teach students hoping they learn from our experience, and save a sad story for our grandchildren.

A lot of good actions can result.

Congratulations with your awesome blog by the way. I'm a dedicated follower, ha.


Emily said...

Time helps, but perhaps we're not meant to truly heal, but rather, to learn. When someone is "callous" I take it to mean that they have distanced themselves from the lesson by so many layers of scar tissue that the effect of the teaching is not felt any more.

One last thing, that I heard during a lecture talking about the Dalai Lama. Here is a guy who talks about being gentle to ones self, about non attachment, all of those pillars of Buddhist thinking,etc. He was asked about lingering feelings, or if he had any regrets, and he relayed the story of an old man who came to him for advice as to whether he should (if I remember correctly) continue with yoga practice, even though the pain in his joints made it nearly impossible. The Dalai Lama counseled him to refrain from his practice, and that night, the man killed himself. The person who was interviewing the DL asked, "How did you ever get over that?" and he replied, "I never did. I just live with it."

These flecks of pain temper our experience and bring about huge dimension to our decision making and introspection. I, for one, understand this implicitly in my relationship with the medical profession, and thank the multitudes of people who continue to help my loved ones (and maybe me, too) live on what could be considered borrowed time.

T. said...

Emily, thank you so much for your beautifully-written wisdom on this tough issue.

ChangeEverything, muchisimas gracias. Me alegro!

And Ramona, as always, I appreciate your understanding. said...

One more reason to be thankful for my not-terribly-high-paying but certainly not life or death sort of job.

Sorry you all have to deal with this, but I am extremely grateful some are willing to do so. (I'm not smart enough to be a doctor, so there's that problem too ... I couldn't have done it even if I had the desire!)

Thanks for the post.

Ann of the Incredible Gift said...

How do doctors heal?

The same as the rest of us, I'd imagine. You're never the same again, but over time it becomes easier to function. You pay attention to the important things, and grieve on your own time. And, as Emily said, you live with it.

Doctors are human beings first. All the education, the training, the internship and residency, and the other bits that go into making you a doctor (and me not) is layered on top of your basic humanity. Your profession puts you in the way of being present and in charge when someone is just too fragile to revive. Much more so than my profession (mom).

You probably already know that Moms ask themselves the same kind of questions when something goes wrong. Substitute "child of mine" for "person" in "Did I do everything I knew how to do to care for this person?" and you will have exactly the question I asked myself when my daughter died. I questioned my competence as her mother, care giver and advocate and gave myself nightmares.

How, you may ask, do I feel about my daughter's physicians? I believe every single one of them to be excellent doctors, and caring compassionate people. I do not blame them. I will continue to listen to them, and take their advice where applicable. I am thankful that she had the benefit of their combined expertise. They gave us the gift of time to get all available family members, and several friends, together to say "I love you" one last time, and then give her a loving sendoff. I looked up once and caught tears in the Chaplain's eyes.

My daughter was medically fragile - unrepaired complete AVSD rastelli C, Eisenmenger Syndrome, oxygen dependent - and admitted with severe respiratory distress. I think her problems were viral to start with, but an opportunistic bacterium took advantage of her weakened state, and ravaged her lungs. Where might she have picked it up? Anywhere. They're extremely common. And resistant to antibiotics.

Would things have been different if someone else had been taking care of her? Yes. She probably would have been lost almost immediately without the specific supports she received.

I really appreciate the time her doc took with me to explain what a delicate balance we managed to maintain with her health. Maybe it's a good thing I didn't know exactly how fragile daughter was. Or maybe I did know, and put the knowledge aside as something that was not helpful, and might drive me crazy with worry if I let it.

I was impressed by her doctors, and I think they were impressed by her family, too. We'll all heal.

I hope your friend is well, and I'm glad there are skilled and compassionate people such as you, he and daughter's docs in the profession.

Thank you.

gelci72 said...

Dear Ann, I am completely blown away by your visit and your words, which moved me very deeply. I am terribly sorry for your recent loss. I have a daughter too...I cannot imagine what you have gone through, and the fact that you continue to give of your heart to others - even a stranger like me - shows me that your daughter - and indeed, all your children, and your husband - have in their presence an "incredible gift" - you - which brings blessing to their lives. I have no doubt - no doubt at all - that you did do everything you could for your daughter and continue to do so for your family, because it strikes me from this brief message that that is simply who you are.

Thank you, again, from the bottom of my heart.