After 13 hours of almost constant work I got home and fell asleep at 11.30PM. At 1.30AM the phone rang. I answered, to hear about a patient vomiting blood in resus. He was jaundiced. This was going to be a variceal bleed, and I had to go back in. The thick nausea that accompanies interruption of deep sleep, with the last, hastily eaten meal still heavy in my stomach, brought out the worst in me. I had plans for the following day; I would be useless now. The night was gone. It would take hours to get in, get to theatre, do the endoscopy and get away again. I hated the patient for doing this to me. I imagined him – an alcoholic, no doubt, who had binged and taken another self-induced hit to liver. Now he was now suffering the consequences. In the middle of the night.
As I sped down the almost empty motorway and let cold air in to blast away any residual mental fog, I anticipated my attitude. It was going to be business like. No way was I going to be touchy-feely – there was a job to be done: get the patient anaesthetised, look inside, seal the bleeding point, get out, get home. Then sleep. Sleep.
The white-light glare of the resus bay rekindled any neurons that had not been required to drive the car. I read the casualty card notes and glanced across from the doctors’ station to the relevant cubicle. The curtain was drawn.
I walked in boldly. He was awake, but groaning. There was blood on his chin and in the bowl that he grasped to his chest. He had all the signs of cirrhosis.
“Hi, I’m Dr _______. What happened?”
“It just started doctor.”
“Have you had liver problems before?”
“Not like this.”
“But you’ve been told there’s a liver problem.”
“Oh yes, years ago.”
“Due to alcohol?”
“Any hepatitis infection, anything like that?”
“And… the drinking, have you been drinking recently?”
“Yes. Every day…”
Really? – I thought to myself. You know your liver is scarred and shriveled yet you carry on. I just don’t get it.
“How much, recently?”
“Two, three bottles a day.”
“Right. Well, I’m sure you’re bleeding from a ruptured blood vessel in your gullet, we need to put you to sleep for a bit and do a camera test.”
I presented him with a consent form, and muttered about the risks and the benefits. He signed, an uncoordinated scrawl. I walked away, but he had more to say,
“I knew this was going to happen. They told me. Ever since I started drinking, after the accident…”
And then he told me why. Why he had taken to alcohol. The industrial injury, the chronic pain, the enforced retirement, the gap… the gap in his life. My tiredness melted away and the focus, on my own discomfort, was re-directed. Just a few words was all it took. Context. The story. The reasons.
I approached the bedside and spent a little more time telling him what would happen. The possibility that things could go wrong when I was trying to seal the bleeding point, that he might have to stay on ICU, might be transferred for a shunt up in London, might die. He nodded. It wasn’t news.
“Got any family?” I asked.
“Yes. But not here.”
In the car on the way home, as dawn nudged its way under the edge of night, I felt good. The job was done. The sense of satisfaction was high. But for that hour after I was woken I did hate him, in a way. I wished he didn’t exist. But that was when I didn’t know him. He was a name in a cubicle half way down the motorway. At that moment there was no context, and therefore no empathy, only a natural and not unusual reaction to being woken up. It was the situation I hated, not the man. Before I arrived there was no man, only a problem.
So who’s interested in the reactions of a grumpy forty-something old who’s getting tired of being on call? You’re paid for it! You get a 5% supplement for being available to come in for emergencies. Get over it!
Well, it is important to examine the reaction to fatigue and disturbed sleep, because it is at these times that patients see the worst of us. The veneer (is just a veneer?) of compassion is often tarnished in the early hours of the morning, or with the hangover of a recent sleepless night still lingering in the system. The trick at such times is to know how to access the human in ourselves. For me, nowadays, such interruptions are rare and anti-social hours are few. Back in the day when I roamed the wards in the early hours I frequently transformed into a ‘technical’ doctor, asking closed questions, focussing on defined tasks and having no spare resources with which to make human connections. It is a biological inevitability – we are less human when we are supposed to be in bed. Yet a third of our patients’ lives are lived between midnight and 8AM. We have to find a way to be nice at those times. How to do this? In the case I describe it was by imagining a life disrupted by external events, and the undeserved downward slide into addiction. What if that happened to me? A window into another person’s unlucky life, mixed with a dash of imagination – two elements that when mixed can produce instant empathy.
Note: I have changed details in the patient’s personal history
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