patient relations

I really do not understand the way my patients think.

This one lady, for instance, had surgery. She has pain from the surgery. So for the last two days, she’s been asking every doctor who walks into the room why her right side hurts more than her left side. We’ve all given her, repeatedly, essentially the same explanation: there’s a larger laparoscopic incision on that side, and a little more manipulation was done there.

This morning, the same question again: Why does the right side hurt? I mentioned that there had been a larger trocar there, and she said, what’s a trocar? Well, I guess that’s a fair question; I have no idea of the etymology, myself. So, having not much to do this morning, I stopped and explained the mechanics of laparoscopic surgery in some detail: one site, in this case supra-umbilical, for the camera to go through, and several others, spread around the abdomen, for various instruments. Her surgery had required a stapler, so a larger port had been needed on the left. Thus the larger incision, and more pain from the acrobatics needed to get the stapler oriented correctly.  I thought I did a pretty good job: no words longer than two syllables (except “laparoscopic”), layman’s terms, openings for questions, and so on.

Half an hour later, the attending walks in. Same question: Why does the right side hurt more? I couldn’t believe it. What did I miss? Did I give her too much information? Doubtful, since for her elective surgery, I knew she had received several explanations of the precise anatomy, including diagrams. Was it too early in the morning? But it was 6:45am; that’s not horribly early (is it?). Did I use more technical terms than I recognized?

It seemed to go on all morning. I had an attending covering, so the patients weren’t really his. On such occasions, the attendings expect the residents to have everything neatly bundled up before they arrive. When covering on weekends, the attending cares even less for the details than usual. But my patients seemed determined to quiz him about all the minor details that I’d already addressed on pre-rounds. I guess some of them think that the big tall male attending will give them a different explanation than the small female intern. Maybe. But by their conversation, a lot of them seem to think I’m a partner with the attendings; so rank differences can’t be the only thing.

I am coming to suspect that people in the hospital are never very close to rational. Perhaps it’s the narcotics. Perhaps the element of irrationality in almost every patient I’ve had all year (even the nicest still seem to fixate on some irrelevant point here and there) is due to the drugs, and I’ve just never recognized it before. Either that, or the American non-education system has truly succeeded beyond Dewey’s wildest dreams, producing a populace incapable of proceeding from A and B to C. But outside of the hospital, once properly dressed, and returning for follow-up visits, most of these people seem much easier to talk to. Nevertheless, I’m starting to think that it really doesn’t matter how carefully I explain things, because so much of the time none of it seems to stick. The fact that I did stop to talk does seem to remain though, so perhaps simply the lingering impression of friendliness and helpfulness is worth the efforts at coherence and simplicity which seem to fall so flat.

We’ve now arrived at that peculiar time of the month, when the service is drawing to a close, and I am divided between sadness to leave the patients I feel responsible for, and attendings I’m now slightly comfortable with, and eagerness to move on to something new. At the beginning of the month I was disappointed in the high hopes I’d had for this rotation, but in the last week or two I’ve enjoyed the work that I actually am doing, rather than focusing on what isn’t going to happen. At last, with only two days left, I dare to recognize that I’m actually doing a good job. Which in the world of an intern means that it’s time to switch to a new subject about which I know nothing.

But perhaps it is time to move on. Today I was utterly disgusted to discover that, like every other intern by this time of the year, I hate my patients. Underneath all the other motivations and emotions, I hate my patients. I had about five or so lined up to be discharged today. One after the other, either while I was checking on them during pre-rounds, or later when the attending came around, they all discovered ways to stay in the hospital another day or two. I hadn’t previously felt much animosity towards any but one of them, but by the end of my list, I was seething. How dare they? “I think I’d just like to stay another day.” “I don’t feel quite up to going home yet.” “I don’t like the nursing home that has a bed for me; we’ll have to find another one.” The attendings, of course, blithely accepted these excuses, and even came up with some of their own: “He’s a little queasy today.” “Let’s have her work with physical therapy another day.” “The family’s not comfortable with the plan.” And every single one of the five is another ten minutes that I can’t sleep tomorrow morning, which I could have done if they would have left the way I wanted them to. 3:30am, again.

 So I’m disgusted with myself. I calmed down, of course, and said what a splendid idea it would be to keep five or six extra people on the list for another day. (They’ll leave tomorrow, but tomorrow is an OR day, so the list will still grow, despite my discharges, so the next day will be no better.) I went around later in the day and checked on them politely, and didn’t even flinch when they observed that they won’t have a ride till tomorrow evening around six, or maybe a little later (so I will be frowned upon for allowing my patients to loiter so late, occupying beds that could be used for new patients). Maybe I should dispense with my polite formulation about how we don’t evict people from the hospital, and just frown outright at such weak dilemmas?

Yes, definitely time for a new month. Or maybe a new year? I think definitely I’ll feel better in, say, July. Then, I’ll just have to get my patients out of the unit, and then the intern can worry about them.

I think 8:30 is the latest I have ever stayed in the hospital yet this year. It felt kind of crazy, walking around to check on the patients, saying “goodnight, I’ll see you in the morning,” and considering that “morning” means 4am, less than eight hours away.

But I don’t particularly mind. I picked up a case in the ER, and got to take it to the OR within a few hours, and do a lot of the procedure. Quite satisfactory. Of course it was another one of those ugly, boring cases that no one but an intern wants; but I had fun.

That took till the end of the afternoon. Then, I got called to the ER for an intubated patient. I was trying to figure out what could cause a surgical patient, no vascular issues, to present, intubated. That’s not usually the scenario, when you’re not on trauma. Often enough we have to re-intubate people post-operatively; but to come in like that?

Turned out to be a nice old gentleman, holding his daughter’s hand and nodding at her, in spite of being intubated. His blood pressure was too low to handle any sedatives, and his mental status was poor enough, so he was on hardly any drugs at all.

I got a surprise walking into the room. I started to introduce myself – “Hi, I’m Dr. Alice, one of the residents. . ” – and the daughter interrupted me. “Oh yes, Dr. Alice, I know you!” She’d been identified as a respiratory tech, so I assumed she worked at the hospital, and we’d been together during some crisis or other. I couldn’t remember any crisis involving respiratory which would lead to such a warm greeting, but the patient was in too much trouble to spend time on reminiscences.

Half an hour later, one of her remarks finally clicked. She doesn’t work at this hospital, she’d been here as a patient on one of my previous months. She’d been one of the nightmare patients (the way healthcare professionals often seem to be when they do get sick): the nurses used to argue about who would have to take her, and the senior residents sent me to her room by myself, until something major required their attention. The catch was that I could never relax with her, because she actually was sick, and every so often one of her “crazy” complaints turned into a really serious problem. I learned a lot taking care of her. By the end, though, I did dread getting called by her nurse; but apparently I masked that feeling pretty well.

The whole time that a group of surgery residents spent in the room, working on her father, she kept smiling at me, directing all of her answers at me, and remembering things we’d talked about in the past (when I was being conscientious, and stayed in her room to chat). One of the chiefs was there, big, tall, impressive guy – and she didn’t pay any attention to him, just Dr. Alice.

I feel so guilty. I really didn’t like her at all when she was a patient, and I did my best to stay away from her. She seems totally different, quite a reasonable person, now that she’s better, and taking care of a sick relative. On one hand it’s good that I behave professionally enough for a patient to like me even when I didn’t particularly like them; but I feel bad about being on the receiving end of such good feeling, when I didn’t reciprocate it at all until I felt flattered by her memory and shocked by the difference in her behavior.

Today was a Friday kind of day. Some of my patients were angry at me again (maybe I need to start thinking in terms of borderline personality, although I hate that psych nonsense; it would make their vagaries easier to take). Everyone declined to be discharged, and my attendings seemed to be scouring their offices for people to admit. I somehow found myself in the ICU with a sick patient for part of the morning, which also threw off my plans to keep the floor in order. The senior residents were struggling too; somehow it’s worse all around when no one on the team is on top of the game.

The lab produced terrifying results to some lab tests, which sent me scurrying all afternoon to take care of the people; and then the repeat labs came back stone cold normal. So I called the lab and asked them whether I ought to be worried about the originals, things like massive leukocytosis and hyponatremia, or whether I ought to be concerned about their machines being broken. They were still thinking about it when I finally signed out.

One of the seniors used some obscene colloquialism, and I had no idea what he was talking about. He repeated it about five times, in context, until by his laughter I figured out what he had to mean. Then, just when I understood enough to want to drop the subject, the medical students realized that they didn’t understand, and started asking questions. The resident was doubled up with laughter. I’m glad he thinks I’m funny; I wasn’t trying to be.

I’ll be working all weekend, so “Friday” doesn’t mean much to me; but everyone else in the hospital will feel good after the weekend, so hopefully the gestalt of the place will improve.

First time ever: I felt obliged to go spend some free time in the library, reading Mastery of Surgery, a massive set of two volumes which combines discourses on the pathogenesis, presentation, and diagnosis of every single surgical illness, with lengthy instructions and illustrations on how to perform every procedure which could possible be desired – and many which are now only of historical interest. Senior residents have told me that when dictating a procedure for the first time, one could simply read passages of this book out loud, and be correct.

I have read this book before; but today was the first time that I finished reading a chapter, and was immediately paged to go see a patient with that problem. I felt extraordinarily intelligent while talking to him, and to the attending. I shall have to repeat the experiment.

On the other hand, it seems as though my well-behaved collection of patients has fallen apart. All the nice ones have been discharged, and every one who is left is miserable, and angry at me, and at the nurses, and at the whole hospital.

You have to understand. For all that I’m six months in, I’m still very understanding and compassionate, even gullible, towards patients’ complaints. I usually will give as much pain medicine as you could want, as long as there’s the slightest reasonable evidence that it’s warranted. I’ll listen to your complaints about the attendings not talking to you, or not answering questions, and apologize for them. I’ll accept complaints about dietary services. If you need something straightened in the room, I’ll do it, or find someone who can.

But today, it was just too much. Every single patient was furious, about food (or the lack of it), and pain medication (or the lack of it). And again, I feel that I’ve failed to take proper care of my patients if they have to call night float for pain meds. I should be able to adjust things during the daytime, or at least talk through it. But tonight, I signed out in a bad mood: “This one, give her whatever she asks for, it’s not worth fighting. This one, and this one, are going home tomorrow, regardless of what they say, so don’t under any conditions give them iv medications. This is the only happy one on the floor; please be polite to him.”

We had progressed through all the floor patients, and were in the ICU, having a fairly interminable discussion about one of our sicker patients. (I don’t understand physiology the way it’s handled in the ICU at all. I know theoretically what CVP and SVR and CO are (central venous pressure, a measure of intravascular volume, systemic vascular resistance, which affects blood pressure, and cardiac output, which could be low for a lot of reasons), but the medical and surgical ICU residents throw these words around, and derive logical arguments from them which I cannot follow at all. I need to find a book which teaches this the way it’s actually practiced.)

A patient was wheeled into a nearby room, and the nurses started doing their preliminary assessment. As soon as they put the thermometer in his mouth, he started screaming at the top of his voice, and cursing out everyone in the vicinity in the foulest language. Somehow you don’t expect that from nursing home residents. I remarked, “If he does that just with a thermometer, imagine what he’d do if you touched his belly.” Meaning, since he seems to have nonspecific pain, or is just delirious, an abdominal exam would certainly appear positive.

Teach me not to say things like that. Half an hour later, I got paged. “We have a consult for your attending; he was just brought in from a nursing home, febrile, they think he either has cholecystitis, or urosepsis, or possibly ischemic bowel. He’s in room 23, and he. . .” I stopped the nurse. “You mean the guy who’s cursing at the top of his lungs?” She dropped out of her official report mode. “Yeah, that’s him; we just gave him some haldol, I don’t think it’s making much difference.”

I knew my senior was not going to believe this. I went to see him, and sure enough, as soon as I touched his belly, he started screaming. Not that he’d really ever stopped. The haldol wasn’t touching him at all. The nurse was just working on her records; she’d given up trying to talk to him at all. On the other hand, if I touched his hand, or his shoulder, he screamed too. Also if I didn’t touch him at all.

The attending was thrilled when we called him.

It got back to me through the grapevine that my chief told someone, “Alice is a decent intern, but she’s just too nice to be a surgeon.” Which is a compliment coming from medicine people; but from my chief, who is good but not nice, I’m not sure. Anyway, as long as she thinks I’m doing my work semi-competently, it’s fine; she is good at what she does, and I respect her, but I don’t want to be good the way she is. I want to find a different way.

 The other day I discharged the loveliest little old lady. This is the one who thinks I saved her life; at least I was present on the occasion. She reminds me so much of my grandmother: a tiny delicate little bird, perched in a cocoon of blankets, with wavy white hair and sparkly blue eyes. Like most of her generation, she hardly ever complained except when she was nearly dying. She always woke up with a smile when I came in at horrible hours of the morning. (It’s awful, but I’d rather wake the older patients up first on my pre-dawn rounds; they’re more likely to be pleasant about it than the younger folks.) On the day of her discharge, I finally made time to sit down and ask about her trip to Israel several years ago. She described how her son had bought her the tickets for her birthday, only a few years before he himself died. We reminisced about places in the Holy Land: the Mount of Olives, the Temple Mount, the banks of the Jordan, the hills of Galilee. What between her son, and Israel, and her rather unexpected recovery, and me missing my grandmother, we both ended up crying and hugging each other. (Contact isolation is for the birds, anyway. Especially when she’s being discharged.)

(I hate contact isolation. Not only is it a horrible waste of time, putting that stuff off and on for half the patients every morning, but you can never connect to someone the same way if you’re trying to hold their hand through a rubber glove. Explain all you like about disease prevention; those gloves and gown still say, There’s something wrong with you, I have to stay away from you, I can’t touch you. I’ll wash my hands in every room, I do believe that much about these bugs; but I want to touch my patients.)

I didn’t expect to . . . like – love? –  my patients so much. Now that they’re mine, even though I’m scurrying in and out of their rooms so fast every morning, I care about them. I hate seeing them sick. I don’t like them staying longer, and having to be rounded on every morning; but I also hate to see them looking miserable. For the first time in a while, I really dislike sickness. I wish there were some way I could cure them all. If wishing would do it, I’d have cleared the hospital out already. It didn’t bother me as much when I was a student, somehow. Maybe the patients at this hospital are sicker. Maybe I’m paying attention more, now that they’re my responsibility.

That’s the problem with surgery (ok, one of the problems). If your patients recover, it’s fast and wonderful. But if they don’t recover, it’s a nightmare: months in the ICU, months on TPN, months of fistulas draining, wounds having to be changed and dressed; months of trying to create hope and optimism for patients to whom every day seems to run together with pain and sickness. Now that they’re mine, I can’t block their suffering out the way I did in medical school.

Anyway, today was good. I talked so fast I persuaded the senior attending to let a lap chole patient go home immediately, without staying overnight. I set him up with plenty of medicines, because if he calls the attending tonight, I’ll never hear the end of it. The patient is happy to get out of the hospital, and I’m happy to have one less person to wake up tomorrow morning.

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