patient relations


I went by my mailbox the other day to clean out the usual accumulation of useless fliers and advices from the administration (a new administrator; a new policy; a hospital picnic), and was astonished to find a card in the box.

It was from a woman whose husband’s hand I had sewn up back in March. It wasn’t the most horrible injury I saw that month, but it was certainly sickening to people, like the man and his wife, who hadn’t seen anything like it before. It had taken me some effort to talk him into letting me take my time and do things carefully. Once I got the anesthetic in it hadn’t been that bad. I think the previous ER where he’d been had tried to do a digital nerve block and failed. I got it right (for the first time ever, to my own surprise; but I didn’t tell them that), and then he let me cut and sew as I saw fit.

Anyway, the card was to say that his hand was working well, and the doctors thought the nerve would grow back in time, and it was nearly as good as new. This was not a short card; it was a big hallmark card, filled up with writing. I think I started crying in the hallway. I’ve had people say thanks before, but to take the time and effort to write a whole card and mail it to the hospital – unbelievable.

A few days later I ran into the wife of the man with really the worst injury I saw that month, the one that I could barely stand to look at. (Broken bones turned all wrong-side-out really turn my stomach.) I didn’t recognize her, but she stopped me and started exclaiming about how well it turned out, and how the plastic surgeons in the office had said I’d done the right thing, recognizing how much tissue was viable and should be repaired, and removing what wasn’t salvageable.

I don’t know what to say about any of this. I’m disturbingly surprised to hear that my hand surgeries turned out well, and touched by the patients’ gratitude. Getting this feedback is even more satisfying than simply looking at the hand when I was done and thinking I had done well. This is what it must feel like for the attendings in their offices, to have people come back and say that they’re better and the surgery helped them. This could be fun to keep doing.

Since I’m handing out advice right and left (I think I’ve run out of intern advice, though; maybe next year I’ll have some things to say about annoying interns, of whom I’m sure I’ve been one), maybe I’ll throw out some for patients.

Although really these are more anecdotes about my favorite patients. Out of the whole year, I think my favorite, and best memory, is this one old gentleman who learned my name pat the first time I introduced myself. After that, every time I walked into the room (usually at 5am), his eyes would literally light up. “Dr. Alice! Thank you for coming! It’s so good to see you!” I was almost embarassed to be there, because here I was waking him up, and I hadn’t done a blessed thing for him yet, and he was so happy about it. Actually, I think it started because one of the first days I came to see him, his wound dressing had gotten all disarranged, and he was worrying that when the nurse finally came to change it, it would hurt a lot. I needed to see the wound for myself, so I just changed it quickly and fairly painlessly. Since then, although he kept coming back in with complications, he was always so cheerful and grateful that everyone loved talking to him.

Then there was another lady, who had what you might call a chronic hospital course. She’d stay for a few weeks, go home, come back in less time than it took her to leave, and stay a while longer. When I got signout about her, changing services, I got the phrase “pain issues,” which usually indicates a drug seeker that people have gotten tired of dealing with. For the first couple of days, that seemed to be all there was to it. She had had a lot of surgeries, which resulted in a lot of pain. She’d spent enough time in the hospital to be fairly tolerant to narcotics. But then I started to realize that if I came to talk to her at the times when she wasn’t in as much pain, she was a very nice lady. She wasn’t defeated by all that had happened to her. She worked hard with the physical therapists, and could be often found up moving around by herself. Finally, I realized that she had the same goals we did: despite her complaints of pain, more than anything else she wanted to move away from iv narcotics, and get out of the hospital and back to being independent. At that point it became easy, and she and I worked together as a team to wean down the doses.

Basically, don’t make the doctors and nurses afraid to come in your room. The people who smile when they can, say thank you every now and then, and speak politely, will have nurses come quickly when they call for help, and doctors who come to check on them frequently, and are willing to spend a while discussing plans and alternatives; whereas the patients who make it unpleasant to come into their room will get much more grudging service all around. Unfortunate, and despicably human on our part, but there it is. A little politeness will go a long way towards making your hospital stay smoother and a little more pleasant.

I am now on the vascular service, which is probably the busiest surgical service in this hospital (as at most). There are enough attendings operating that I will probably get a few cases a week – of course, the ones no one else wants: ablation of varicose veins, amputations, simple angiography.

This service also tends to pick up a lot of pointless consults: our favorites are femoral pseudoaneurysms as a complication of cardiac catheterization (which a priori means that if the patient eventually requires surgery, they’re going to be a very poor cardiac risk), and generally whenever anyone is bleeding. Somehow, to the ER and ICU doctors, bleeding means vascular surgery should be able to help. Sometimes it’s interesting; most of the time, our advice is to hold pressure for a lot longer.

Anyway, after a few days’ worth of consults like this, I’ve learned not to be concerned about blood in reasonable quantities. I spent an hour holding pressure on one of our patients and practicing my calm, this-is-perfectly-normal voice. He was very pleasant, and not disposed to panic anyway; and I think my smoothing voice is getting better. Next time I’ll just remember to take my white coat off before getting close to arterial puncture sites. We got to talk about books, politics (noncomittally; I do know better than to start firecracker conversations with people whom I have to sit with for an hour to keep them from bleeding to death), and crafts.

The bad thing about this service is that they regularly have patients admitted in the evening for hydration prior to angiography/procedures the next day. Somehow, these patients always come right at signout, so we usually leave an hour or two later on this service than on others. Ah well, that’s how it goes.

Once again, more studying got done than my brain can really stand. Learned all kinds of things about the biliary tract, including, in detail, what to do if you injure the common bile duct during a laparoscopic cholecystectomy. Which is actually fairly irrelevant, since although I’m afraid such an event may be in my future (incidence stable at 0.5% for the last several years), hepatobiliary surgery has never crossed my mind as a specialty, so I am sure I will not be in a position to repair the injury adequately. The general tenor of the lengthy textbook discussion was, interspersed with detailed instructions on how to repair every variety of injury, admonitions to refer such patients very early on to a major center and an experienced hepatobiliary surgeon. So mainly I learned something else to try very hard not to do; of which I already had a long list.

I’m still not happy with my moral position during conversations which I disapprove of. But at least I resolved, again, to try very hard not to say anything I wouldn’t say if the subject of the conversation were in the room. Maybe I can’t help what other people say; but I don’t want to contribute.

I really love this type of patient conversation:
Me: “. . . So basically everything that brought you in to the hospital has been corrected, and you are ready to go home, although you do need to continue taking these medications.”
Patient: “Great, I feel fine, I was ready to get out of here yesterday. Let’s go.”
Spouse (with the most suspicious tone of voice you can imagine): “You’re not kicking him out of here again, are you? I’m sure he was deathly ill with this xyz the last time you discharged him, because he was sick immediately [although we didn't come back to the hospital or talk to any office staff for a month].”
Me: “Ma’am, I understand your concern, but I assure you that there were no signs of this problem the last time he was discharged. And anyway, right now [laundry list of tests] have all been completed, and show that the problem is completely under control. The best thing is for him to get back home and on the road to recovery, and you just let us know immediately if anything concerning comes up.”
Spouse: “They should have listened to me the last time. . .”

Which is such a horrible note to close on if, as there’s a decent chance given his underlying disease, the poor fellow gets sick again and has to come back. But right now he’s fine, and he wants to go home, and I want him to go home, so please, try and give some credence to the long list of negative test results. Some people do seem to feel better after you explain it all in detail; but this lady had our negligence firmly in her head, and she wasn’t listening to reason. Ah well. I’m sure we can resume the discussion at the next admission.

The other day I got to watch the chief doing a laparoscopic cholecystectomy (gallbladder removal). For him it was easy. He only took the case because going in we were concerned about a lof of inflammation and scarring, which turned out not to be there.

As a student, when I watched laparoscopic cases, there was a fair amount of boredom involved. On one hand, I could see everything much more clearly than during an open case, when only the two people directly operating can actually see what’s happening, and not always easily even then. On the other hand, I have a strong propensity for falling asleep whenever the ambient lighting falls below a certain level; even holding the camera didn’t always keep me from drifting off.

Now that I’ve done a [very] few lap choles myself, it’s another story. I was very interested to watch the chief’s every step: how smoothly he peeled the gallbladder off the liver, and swept away the adhesions, how precisely he dissected down to the cystic duct and artery. No wasted steps, no fumbling – every move went exactly where he intended and moved the procedure forwards.

————

One of my patients last week was just about perfect: young enough to recover very quickly, with a disease that absolutely warranted surgery, but shouldn’t affect her much once she’s gotten over the surgery. Her family was supportive, practically living in the hospital, attentive, but not smothering. She herself asked intelligent questions, exactly the things she needs to know and ought to be concerned about, but not too many silly questions or impossible ones – and she seemed to understand the answers. We don’t often meet such ideal patients. Everything went smoothly in the hospital for her, and with as wonderful a family and an attitude as she has, I expect she’ll do very well at home, too.

Ok, this is scary. We actually had a workplace shooting incident turn up at our trauma center lately. I comforted myself with the idea that people come to the hospital after such incidents. Remind me to check and see if our security guys have guns. I think they do.

The service has slowed down a bit. When one of our members goes on vacation in a few days, leaving me twice the work, things are scheduled to speed up. I love how that works out. I’m sure it happens whenever I go on vacation, too. That’s why I feel guilty about being away even for one day. Something invariably happens when the team has fewer working members.

There was a lady last week who absolutely drove me crazy. I’m sorry to report this, since she was quite nice, and so was her son. But somehow they were terribly aggravating to talk to. All her previous care had been at an outlying hospital, so we had minimal records. The conversation went something like this:

Me: “Well, ma’am, since you’ve been admitted with a probable pneumonia, do you have any coughing?”
[and please don't ask me what pneumonia was doing on our surgery service; my attending loves his patients, what can I say? or maybe he just wanted to increase our skill in internal medicine, since this lady seemed to be a walking textbook]
Patient: “What’s that? I don’t hear so good these days.”
Me: repeat three times, enunciating till I feel absurd
Patient: “Oh no, I’m not nauseated at all. In fact, I’ve been eating real good lately.”
Son (yelling): “No, mom, she said, are you coughing?”
Patient: “Oh no, not coughing at all; just my usual, you know, every now and then.”

Some time later, having established that she coughs about five times a day for the last year, not really productive, certainly no blood in it, we’re on to the next topic.

Me: “You’re not coughing, but are you having a fever at all?”
Patient: “Oh yes, I burp a lot. Do you know anything that could fix that?”
Son (yelling): “No, mom, she said, do you have a fever? No, doc, she hasn’t had a fever.”
Patient: “Except for that time, my temperature was up to 100.8. Does that count as a fever?”
Son: “She means last December. Mom, that was when you had the UTI. The doctor means right now.”
Patient: “Oh, no, no fever now.”

A good while later, having established a complete lack of symptomatology, I proceeded to get a past medical history.

Me: “Do you have any medical problems, ma’am?”
Patient: “Oh, no, quite healthy, dear, quite healthy.”
Son: “Mom, you have cancer.”
Patient: “Oh, yes, I do have cancer. It was diagnosed last summer. You see, my legs were feeling a bit swollen, so after my husband and I went on our usual vacation to South Carolina – we go to South Carolina every year. Charleston is such a beautiful city. Anyway, I went to see my family doctor, and he was concerned that I might have a blood clot or something, so – “
Son: “Mom, she wants to know about what’s going on right now. Tell her about your pacemaker.”
Patient: “Oh, yes, I have a pacemaker, and my heart is doing great, I just got it checked last month.”
Me (sensing a disappearing glimmer of light): “And why did you have the pacemaker put in?”
Patient: “Oh, my heart went a little fast.”
Me: “Was it irregular at all? [to the son] Did she have atrial fibrillation? Do you remember ever hearing that name?”
Patient and son together: “Oh no, not irregular at all. Just fast.”

A long time later, having elicited a medical history containing a disorder in every single organ system, I asked for a list of medications.

Patient: “Don’t you have them in the computer?”
Son: “I don’t have a list, but I know them by heart. Not the dosages, though. She takes lasix, aspirin, coumadin – “
Me: “Coumadin? Why does she take that?”
Son (with great patience): “It’s a blood thinner. She takes it to thin her blood.”
Me: “But why is she taking a blood thinner?”
Son: “I have no idea.”
Me: “She must have atrial fibrillation. Isn’t that right, ma’am? You have atrial fibrillation?”
Patient: “Oh yes, but it’s been just fine since they put the pacemaker in.”

That was the longest surgical history and physical I’ve done since I was a medical student. Apparently lately all my patients have been either coherent, or so demented that their children were obliged to be intelligible. I’d forgotten what it was like to have a patient too alert to ignore, but too forgetful to be helpful.

Much later, the chief came by to check on her. As he wound up his explanation of our plans and headed for the door, the patient smiled at me from the bed and inquired, in an unconcerned voice, “So then they think it will need surgery?” Since under no circumstances would we do surgery for pneumonia, nor could I imagine what we had said to lead her to that conclusion, I threw a wild glance at the son. “I’m sorry, I have to run, could you please explain it to her?” And dashed ignominiously out to keep up with the chief, who was escaping to see our ICU patients.

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