Chance Encounter ("Paradoxically" Part II)

The more people you encounter as part of your routine ongoings in medicine, the more people you forget (inevitably, due to statistical likelihoods and all..). Every now and then you meet someone memorable and sometimes find yourself thinking, "I wonder what happened to..?". This is particularly the case, I think, in emergency medicine where the duration of a patient encounter will total a few hours, if that, and then the patient is transferred to someone elses' care, discharged home or (as the case has been for several of my patients), taken from us by the Almighty upstairs. So, this afternoon at the dentist's, I was presented with a chance encounter of the fateful type - I was reunited with the wife of the gentleman who died of a cardiac event a few months ago while I was doing a night shift in ED.. the one whom I had informed of her husband's passing on that tragic night. She recognised me before I had even noticed her standing there, and then when I looked up and saw her looking at me, all she had to say was, "my husband.." for that night to come rushing back. It wasn't an unhappy encounter and not completely awkward like you would expect it to be, but there was certainly an air of unease as we exchanged our greetings and how do you dos. I found it hard to tailor my body language appropriately to the situation - should I smile? should I sigh? should I just nod curtly to everything she says? How on earth does one converse to a deceased patient's family members, many weeks post-mortem? She talked about his death and how the hurt hadn't eased one bit - certainly her affect and tone were as sorrowful as that night, and the painful self-imposed guilt was still there: "if only we'd gotten him to the doctor sooner, if only...". We also talked about the coroner's insistence on an autopsy despite the family's wishes for an immediate burial and other smatterings of small chat, as you do. She cried, I listened and offered her the untested advice that it will get better one day. So then we went our seperate ways, wished each other well and hoped for another chance encounter. A small step towards closure that is often missed in this profession, a little poetic too, don't you think?

Handbags

There's something about patients' handbags which remind me that before me is a person, and not just a body. You can put all sorts of things that signify life and existence in this world in a handbag: keys, wallet, tissues, mobile phone, diary, random hard-boiled candies wrapped in clear cellophane... you get the point. A few weeks ago, a dear old lady in Ward C passed away. Her handbag was always at the foot of the bed. After the arrest call and proceedings, as the people in the room started to clear away, I noticed that her handbag was still there by the foot of the bed. And then I couldn't help but wander about how her family would feel taking it back home without her. It made me feel quite sad at her passing, even though I'd only seen her a few times during ward rounds. She was a person, with a handbag full of worldly things that are of no use to her in the next journey. And by then, neither are we...

Paradoxically...

Saturday morning, 3.30am, overnight shift in ED. I had just gone into the on-call room for a shut-eye when one of the interns popped in to let me know that the ambos were bringing in a middle-aged male in cardiac arrest. There was six of us in ED: an ED physician, 2 interns, 2 nurses and myself. Did I want to see it? "Hell yeah!" I thought, this is the only medicine worth seeing as far as some med students are concerned. Things are somewhat different on the other side now, you'll see what I mean.

He looked his age, but a little worse for wear. He'd been intubated by the ambos; and had defib pads on his bare chest. I stood back to watch as the scene unfolded, wanting and unwanting to be involved... it's a hard feeling to describe. A few minutes in, one of the interns told me to grab a pair of gloves and get ready to take over chest compressions. "Wha..? Err, okay.." I took over after from the start of a new cycle - and in that instant, I crossed the line; I became involved, in more ways than I wished to be, as events would later unfold. I'd done CPR before - on a 90 something year old already half-dead, dying old man in Fiji, just because protocol dictated we do so. At the time, I appreciated the practice, felt kind of sorry that I broke his rib cage, and was secretly grateful when they called it. This was so different, so much more intense, so much more involved... I'll keep coming back to that word. It was an intensely highly-sensory experience: I could smell the patient's sweat; hear the ventilator beep, puff and whirrr; feel the crunch beneath my hands as we'd surely broken his ribs; and see his empty eyes staring up at me. If anything, the eyes gave it away - he wasn't going to make it, even I knew that. In hindsight, I wish I didn't have that initial hunch that he'd already left us - I wonder if I would've compressed harder and more wilfully on his chest if it weren't the case? I wonder if that would have made a difference? Several rounds of compressions, a bolus of atropine or adrenaline, stop and re-assess, rotate through and do it all again... we gave him a fair go. Initially because it seemed he was gasping for air though the ETT, and then when that had stopped, for closure. And then we called it, just like that. Machines turned off, ventilator detached. Time of death: 04:05.

We stood back for a few moments to quietly reflect on what had happened and pray to whatever we believed in that he was is a better place now. Then one of the nurses looked up at me and said, "he's from a Middle-Eastern Muslim background, I think the family would really appreciate if you're there when Noel (the ED physician) tells them." It wasn't a suggestion, they all nodded in agreement and it was decided. Nothing in the world can prepare you for delivering the information we were about to. Nothing at all. We lead them into the family room - his wife, kids, brother and sister in law. Typical Arab-style, the extended family were all in the waiting room. Noel started to ask a few questions about how our patient came to be: straight-out-of-a-text-book heart attack presentation - so classical, it was heartbreaking. His wife recognised he was having a heart attack and urged him to go to the hospital. Shit! If only... ? Or maybe it wouldn't have made a difference... ? Who knows... ? Noel asked a few more questions, before finally putting it out there that, "we tried very hard..". The message passed over them. Noel looked at me and I said in a faint voice in Arabic, "God has taken his soul, may He have mercy on it".

The rest is of inconsequence. Life happens when you least expect it and people react in ways that they know how best to. The outcome is the same, no matter who delivered it, but I hope that being there in this sensitive moment made the situation a little bit easier for them. For me, suddenly, everything else in the ED that night seemed so trivial...

To be honest, I hated being the bearer of bad news to this family - worst feeling as far as the future doctor in me was concerned; more so than losing the patient I think. This family could have been mine, easily; the situation was so eerily close to home after what had happened with my mum last year. I was involved in a way I haven't been in a very long time, or ever even, with a patient and their family. But there's a lesson to be learnt in everything we do here. In the past few months before this happened, I'd noticed myself becoming increasingly blase about the people around me as patients and my role as a carer. A lot of the time I haven't even bothered asking the patient's name and I guess I've pushed this concern to the side thinking, "detachment in medicine can only be good", or they say so anyway. And then this. I won't deny that I've felt quite sad for the last few days, but now that the dust is starting to settle, I feel refreshingly at peace with the idea that I've at least felt something towards someone who I was looking after. It's paradoxical, I know. Guess I just didn't realise how much I missed it...

A rough patch on the greener grass

Half-way through my GP-rotation and the honeymoon period is definitely behind me. I never expected my GP-rotation to be so exhausting. This is really due to my main GP supervisor, who is just...so... mean! Today I cracked it. Today she made me cry. I'm too exhausted to write about in great lengths; she is simply just so exhausting! I wrote to the clinical supervisor/mentor of my home-base hospital asking for help:

Dear Mentor,

I hope you're well. I'm half-way through my GP rotation and wanted to raise a concern I had with one of my mentors. I have several GP supervisors that I work with in the practice - all of them are really wonderful and I love working with and learning from them. My main mentor, Dr X, however, is really quite harsh and strict. Her feedback is extremely helpful - don't get me wrong - she gives great advice about what you need to know to fill gaps in your knowledge; but her approach and mannerisms are quite destructive. If she asks a question and you don't know the answer, she pulverises you in front of the patient and makes you feel like a failure. I don't know if I'm just a little soft in that regard, but some of my experiences with her have been extremely stressful and quite frankly, just downright hurtful. I've been too scared to say anything to her about it because, all things standing, I think she means well and it's certainly not personal. On the contrary, I have thanked her for her feedback and am doing my best to remedy these gaps in my knowledge. But I still feel really upset about her demeaning approach and I'm not sure what to do. I know we're half-way through and if I can disregard any of my personal response to her approach, there is a lot to be gained from the wisdom she is offering. I was wondering if you can offer me any advice on how to approach this situation? I really want to learn from her; but at the same time I don't want to go home crying every night.

Thanks for you support,

Miss Purple Stethoscope


She replied straight away and told me she'd call me tomorrow to have a chat about it. Very, very grateful for her support; but still feeling stressed-out that this chat will come after a day spent with Dr X and God knows what sort of damage she'll have done to me by then. Thinking of having a mental health day tomorrow, but also feel deep down that it will be like admitting defeat. I know it seems excessive, but I've been tipped over the edge. And I'm a fairly tolerant person... if that's saying anything...

GP-Land...

... is a happy place, with candy-cane and fairy-floss; oh, and no ward rounds or running around a hospital trying to find people: the patients come to you - fancy that?! ... bliss!

***

*Snap out of day-dream for a bit*: I just found out this morning that one of the students doing the John Flynn Program has been placed in the Cocos Keeling and Christmas Islands! OmG! Extremely jealous!! I do love my rural community of Mudgee very much, but c'mon - outback NSW vs Islands in the middle of the Indian Ocean?! Hmmm, at least I now know it's a rural area of need that I can (and will!) venture to in working off my rural bondage.

OK, back to daydreaming...

Dear FMH,

I miss you everyday.

Come up to meet you, tell you I'm sorry
You don't know how lovely you are.
I had to find you, tell you I need you,
Tell you I set you apart.

Tell me your secrets and ask me your questions,
Oh lets go back to the start.
Running in circles, Comin' in tails
Heads on a science apart.

Nobody said it was easy,
It's such a shame for us to part.
Nobody said it was easy,
No one ever said it would be this hard.

Oh take me back to the start.

~ Coldplay, "The Scientist"

Learning how to be a doctor, one step at a time

Saturday night; interim weekend between two rotations. I've just finished the first of my two Surgical blocks (plastics and ortho) - the next one (gen surg) I will do later this year - and am about to start my General Practice block next week. Surgery was pretty awesome, plastics more so than ortho. Despite the early morning starts, the day went quickly as there was lots to do and we normally didn't stay past 5pm (though the surgeries would go past 10pm most nights). There was a pre-med student from the USA doing an "internship" in orthopedics during our time there and she was such as eager beaver, coming in very early and staying late every day; which made us look a bit bad, but hey, it's not as cut-throat here so we don't really feel the need to exert ourselves to excel. My supervisors in both plastics and ortho gave me really positive feedback in my competency assessment form; I feel quite accomplished that after 2 years of getting mediocre marks, my hard work is finally getting some recognition! On a personal level, I feel like I achieved what I set out to do in this rotation in the way of practising my hx and ex skills as well as some basic procedures, particular to a surgical context. I now feel more confident with a lot of bread and butter presentations/skills that I will no doubt encounter again in internship and beyond. Small steps, long way to go.. but I'm getting there, I'm learning how to be a doctor and look after people. Damn it feels good!