Wednesday 27 November 2019

A Geriatric Night in the Emergency Room.

There was hardly anyone in the emergency room that night. We sat in the sparsely occupied emergency department that looked like a bus station at 3 a.m. waiting for the triage nurse to assess my wife. It was six o'clock an I guess everyone was having their supper, including the staff. My wife had fallen down the basement steps and for all they knew could have been hemorrhaging to death. Still, after only half an hour or so sitting dazed in the wheelchair, someone came out to triage her. The girl looked about sixteen and I asked her if she was the triage nurse. No, she said. She was the student triage nurse. She did a good job. She asked the routine questions that I won't bore you with right now and then politely vanished into the night without further comment.
Ah, good, I thought. My wife will soon be seen by the Doctor. We sat and sat. An occasional patient drifted in, otherwise nothing seemed to be happening apart from an occasional patient drifting out. Not like any emergency department I had worked in, and I had worked in quite a few. We hadn't had any supper so I bought an exorbitantly priced bag of potato chips from a vending machine. After that my wife needed a drink (I needed one too, but not of water!). I found a water-vending machine. A small bottle of water cost only $2.95. (A similar sized bottle in Costco is 25c! ) Outrageous - in a hospital yet!!
After only an hour we were called out of the waiting area to have the whole history taken again by the triage nurse as well as a cursory medical examination. This was the real one, not the student! We were ushered back into the waiting room as the triage nurse had identified that my wife was still alive!! The same few patients were still sitting there - none looking as though they needed an emergency room. It was approaching nine pm, my wife and I were getting restless and irritated.   "I'm leaving here and going home if I'm not seen by nine pm." said my poor battered bruised wife who was now exhausted by being in a sitting position for three hours. She had once several years earlier been in the same ER following a severe accident resulting in facial fractures and had insisted on leaving after waiting many hours before being seen, regardless of the consequences. At least on that occasion the ER had been very busy. On this night there was nothing happening apart from an occasional patient drifting in and out.
At about one minute to nine we were again called into the assessment area. This time the young man who assessed her was the medical student. The history and medical examination protocol was again followed. After only a further hour my wife was seen and examined again, this time by the medical resident. After this she (the resident) assured us we would be seen shortly by the Emergency Room Physician. By now my wife was lying on a gurney in a cubicle in the ER, three of the four walls of which were a thin curtain, so that every word of the discussions taking place in the bubble on either side of us seeped through the drapes. So much for the alleged respect for privacy that we hear so much about!
Less than an hour later, the ER Physician appeared in person. He was a pleasant man in his middle forties. The history and physical examination were, of course, repeated once again but this time concise and to the point.
"Looks like she is alright, but we better do a CT scan and a few X rays. Accidents like this kill old people," he said, not unkindly.
So, after shuffling around at home for a day and sitting in a wheelchair in emergency for several hours the patient was placed on a rigid fracture board and neck collar, so as not to transect her spinal cord, while the X rays were performed. In terms of subjective suffering that's when the acute phase
began. The scan and x rays took about an hour but she had to remain immobilized until the results were available and interpreted, which involved another hour. Those two hours were by far the worst part of the whole experience, both because of the acute discomfort of the hard board and immobilization and some temporary but very frightening visual disorientation and vertigo. Eventually the ER physician came back with the good news the CT scan and x rays showed no brain damage or fractures.  
At twelve thirty am, six and a half hours after our arrival, we were on our way home. We knew the game had changed, permanently.

Come back here for further episodes of 'geriatric adventures' in the near future .

Friday 15 November 2019

"Doctors, get your affairs in order!"

   "Doctors, get your affairs in order!"
       Screamed the op ed piece in the my favourite newspaper, The National Post.   Because I have spent much of my professional life training physicians, I read the article with considerable interest.
   The article was written by an unfortunate journalist whose wife died of a very aggressive malignant melanoma.  Treatment options were very limited and the tumour metastasized relentlessly to her brain.  The author was particularly outraged by the Radiation Specialist who they had never met before.  He came in to share the MRI results with him and his wife.  He gave it to them straight -a little too straight.  Unlike Drs in the past who often avoided the discomfort giving bad news always causes, by just not giving it, physicians understand nowadays that patients want and are entitled to the truth.  There is no way to make bad news sound like good news, but there is such a thing as beating the patient over the head with the truth.  Even the most unpleasant truth can be conveyed with compassion.  "Get your affairs in order is not such a message."  Such a statement is not necessarily arrogance, nor deliberate callousness.  It is often lack of communication skills in a technician who happens to be a health care specialist..   The specialist's opinion was that she had about four to six weeks to live without treatment, maybe three months with radiation to her brain.  After almost sixty years of medical practice, I know there is no way to make bad news sound like good news, but prognosticating in such a definitive fashion is often very inaccurate and decimates the sliver of hope a patient may be hanging on to.  A tiny bit of hope is better than none - and there is always a tiny bit of hope!        

   Patients recognize compassion when it is present and equally recognize its absence.  After delivering the catastrophic news, the physician added, "Get your affairs in order!"  The husband was enraged and insulted.  "Who are doctors to assume such arrogance to themselves?" was his retort.   He went on to say that the only affairs of his wife that were out of order were her medical affairs. 
   He was suffering greatly from a horrible, cruel, acutely painful and unreasonable situation.  Coming to grips with that sort of tragedy is inconceivable. But human beings in suffering, often feel that there must be someone or something responsible for their suffering.  We do look for somewhere to place the blame and often the doctor or nurse is handy. When the health care worker is less than skilled at communicating it compounds the problem.  It often makes them seem indifferent or even callous.  Not all people enjoy the gift of caring communication which in a health care worker is a particularly egregious problem.      The bereaved, in such circumstances cannot conceive of the physician or other health  care worker as being uncomfortable or even grieved and just not knowing how to convey the bad news to the unfortunate victim and/or their family.  Physicians used to be experts at communication with patients.  They spent hours listening, interpreting and explaining to patients the nature of their disorders, their significance, their management and the likely outcome in so far as they anticipated.  In other words Physicians and patients were at one with each other. They were on the same side. The relationship was not adversarial.  I never feared a legal suit because I knew most of my patients were on my side, just as I was on theirs.  There was no 'one complaint per patient', no ten minutes per visit, no 'appointment in six weeks', whether you needed it or not.  An annual 'complete physical examination', was a medium for the physician to become familiar with the patient as an individual and his individual complaints.  It was also an opportunity for the patient to get to know the physician and his/her approach and for them both to get the right match.  It was an indispensable component of thorough medical care, cost a pittance and we have allowed the administridiots to legislate it away. 
   All those things don't seem to matter any longer and we wonder why there is 'no service' anymore.  
   Perhaps it's time for the whole health care system to put its affairs in order!

   Comments welcome.