Sunday, November 4, 2007

Pain and Suffering II: a confession

I’m haunted to this day by what I consider one of my worst moments as a physician. It’s hard for me to talk about or write about, because it’s about failure, a moral failure to live up to my own ideals.

In my first year out of med school I was an intern at a tertiary care center where the pediatric ward had a large population of children with different kinds of cancer. 3 North was for the younger kids, 3 South for pre-teens and adolescents. These wards no longer exist; the hospital has since expanded and undergone an enormous renovation, and it’s now one of the most physically attractive and impressive pediatric centers I’ve visited. The renovations were just finishing up the last time I dropped in on the hospital with a good friend who stayed in the program after I left to do my anesthesia training, and my friend was able to open the door to those old wards just a crack so I could see them before they disappeared entirely. It was eerie to see them empty, like a ghost town, and a torrent of images appeared in my mind, faces I remembered from my days as an intern there. [Photo: Poa_Pan-milk, private collection, released into public domain by Matthias Sebulke]

One of those faces belonged to a baby girl – I’ll call her Ana – whose parents brought her to us one night after they found that one of her arms had gone completely limp. Just the day before, Ana had been a happy baby, crawling around her home, active, playful, but that day she was completely different, listless and strange, with that alarming arm weakness.

Ana’s parents spoke mostly Spanish, though her father could speak some English as well. By the time they got through the E.R., with interpreters, consulted with a couple of specialists, and came up to the floor for admission, it was 1 or 2 in the morning. I was on call and I had been up since about 5:30 the previous morning. I had been on my feet almost all day with no end to stressful tasks, phone calls, procedures, paper work etc. that I had been working on for hours, between patient visits and admissions. Ana’s parents deserved to have a reliable, kind, sympathetic physician to help them through this unimaginably difficult night, but they got me, and I was at the end of my rapidly fraying rope. I had a mountain of charts in front of me that all needed updating and a floor full of cancer patients who needed their blood drawn before the pre-morning work piled up. All I could think about was sleep.

Ana needed an MRI, and I needed to accompany her to radiology with her parents so she could get one under sedation. For some reason it worked out that between the morning line-up of cases and the things that were going on that night, we could only squeeze her into the schedule at 3 or 4 in the morning. By this time I was crazed with fatigue – the kind that makes little kids cry irritably, but you can’t do that, or scream, either, when you’re a full-grown adult, so my coping mechanism was to speak as little as possible and just get the tasks done.

While Ana was in the MRI suite I set about trying to catch up with the endless amount of work that I just couldn’t seem to make a dent in. My eyes were sore. My whole body was tired. I felt like crying because I just wanted to be allowed to crawl into a bed and sleep. Every once in a while I put my face into the crook of my arm over a desk top but stress over getting through my to-do list would yank my head back up.

As Ana came out of the MRI Ana’s father approached me and politely asked, in English, “Excuse me, do you know what the test shows?” I looked at him incredulously, not processing at first the fact that he had no way of knowing that I would not have the MRI report for hours and wasn’t qualified to read the actual MRI myself. And I was barely processing, though I too was a parent of small children, the fact that this is the first question any loving parent would ask about his baby girl after a procedure like that. I must have stared at him blankly for a moment as these hazy thoughts tried to make it across my sludge-like mind. I could hardly think and felt like dropping to the ground to sleep, right then and there. Or setting my silly pile of charts on fire, one or the other.

“I have no idea,” I said finally. Perhaps curtly. I don’t know; I can’t remember. He didn’t ask me any more questions, and I don’t recall being terribly conversational. But I know I wasn’t the calm, helpful, warm, kind, gentle self I try to be for patients who are deeply anxious over something that could change their whole lives. This was, in fact, one of the most terribly important times in Ana’s parents’ lives, and I failed to be totally present to them for it. I wasn’t rude, I hope, or unkind, and I couldn’t help but be affectionate with Ana herself, but I wasn’t particularly supportive or actively kind to her parents. And from one day to the next her parents’ lives had changed forever: Ana had a tumor at the base of her skull that was encroaching on structures in her neck as well as her brain, robbing her of the use of her arm on one side.

Ana received the best care we could provide medically, and during subsequent admissions to the hospital I tried to be more attentive to her parents, but I felt I could never redeem the way I failed to make them feel less alone the night Ana was admitted for the first time. I had been physically present, but spiritually absent. I'm still sorry about it, as I was back then, but it's too late - and it was back then too. Eventually Ana died.

I saw lots of children come and go that first year. Most recovered from their illnesses and did well. Some lingered in their suffering - a little boy whose babysitter had bashed his head into a wall, an adolescent with little or no mental capacity, a number of children with stubborn cancers or metabolic disorders. Some died – a 5-year-old with rhabdomyosarcoma, a nine-year-old girl with an unpleasant attitude, a 13-year-old boy who was looking forward to seeing his grandfather in heaven and whom we sent home to die, a 16-year-old with leukemia and developmental delay whose memorial service I attended, a 2-year-old boy whose death from smoke inhalation was the first I ever had to pronounce officially. And Ana.

Of all those whose death I was somehow connected to, Ana is the one patient whose suffering I felt somewhat responsible for, not because I caused her condition or worsened it medically in any way, but because I wasn’t “there” for her parents when there was literally no one else around to help them. Because I was so tired that all I could think of was going to sleep. It seems weak and silly and selfish now, because now with some distance I can only remember that I felt overwhelmed by the fatigue but not how taxing it actually felt. But there it is – one of my weakest moments as a doctor. There have been others, certainly, but I always go back to this one, maybe because it happened early on, and because it showed me the disappointing truth that all it takes for me to fail to be generous is a minute amount of my own so-called “suffering.”


rlbates said...

T, finally got to read yesterday's and today's post. Both are wonderfully written. Thank you.

I actually got to meet and watch Dr. Paul Brand operate when I was an intern at Earl K Long Hosp, Baton Rouge, LA. He ran the "leprosy" colony in Louisiana. It was taking care of patient's with that disease that spurred him to write the book mentioned--The Gift of Pain (alternately titled Pain: the Gift No One Wants) by Paul Brand and Philip Yancey.

On today's I think every physician has a patient (family) or two that "haunt" them. I know I do. I think they make me try harder.

Susan said...

As a parent who went through the diagnosis of cancer - I can say that during our son's diagnosis we didn't have any body there for us. I was told by a physician and then she had to leave to get her children. I had to tell my husband when he arrived and we spent the night sitting on the floor of his room in the dark.

I guess I never thought it could be different than that. The diagnosing doctor was an orthopedist, not an oncologist. She had children at a sitter's house she needed to get. Life goes on... Physicians are human. I bet you they never felt rebuffed by you. I imagine they would be surprised to find you feel that way still.

I can say that you sound like a very caring doctor and that all your current patients are probably lucky to have a physician like you. I rarely ran across an anesthesiologist who would take 30 seconds to answer my questions about my son's sedations.

You might appreciate the joke he told me once while getting ready to have a bone marrow biopsy. The anesthesiologist was drawing up the propofol (sp?) and my son (6 at the time) said "I know why it is called propofol!"
Me: Why?
"because when they give it to you it makes you FALL asleep and then you wake up and try to walk and you FALL down." He had a LOT of propofol over his 4 years as a cancer patient. He loved it!

T. said...

Susan, thank you so much. Your thoughtful comments and your son's wonderful sense of play made my day!

I'll always smile when I look at my vials of propofol now... :)

Anonymous said...

Oh, my friend, they still haunt me, too.....
-The sassy 12 yr old girl who celebrated 4th of July with you and me when we were interns
-The cell-phone collecting boy
-The one who died on Christmas name but a few.
And I think of them all whenever I hear the PINK song "Just Like a Pill."

T. said...

Yes! That P!nk song was THE theme song for that year, and every time it came up on the radio I'd blast it.

It's because of friends like you that I didn't feel totally alone our intern year and was able to get through it more or less intact. You were also one of the few friends that stood by me when I broke my arm that year. I think I still have the children's books et al. you brought over to my house...

Hope we can catch up in person soon...before your big move!

Anonymous said...

Wouldn't it be nice if Docs didn't hae to go thru that horrible "boot camp" type experience which feels like it desensitizes you to the point of barely feeling, if not acting, human? Just what is that supposed to accomplish? To make you tougher? Hone your skills? It's nuts. Docs, and nurses, should not be abused in the interest of taking care of sick people. It's not right and furthermore it doesn't work that well anyway.

Anonymous said...

Allow me to balance this husband had the same oncologist for 10 years, treating his unusual cancer, his odd side effects, his other problems... for 10 years. I have never met another doctor like this man and so many of the others we encountered were disappointing as this oncologist had set our bar so high. Lastly, when my husband passed away, his oncologist called and left a message for me; he of course extended his sympathies and told me to call him at any time,and then he said, "I can say that I loved the man."