The Clean-Up operation

clean up

 

Julia had told the story of the heartless consultant many times. How he, a paternalistic but highly regarded specialist, broke the news to a patient that he had cancer in an overly matter of fact way before walking away from the bed, and, within earshot, saying, “Hopeless!” to the rest of the team.

Julia, very junior back then, thought the patient, Mr Field, had probably heard the comment, or at the very least seen the slow shake of the consultant’s head that accompanied it. The patient stared across the ward, and seemed to be analysing the half-caught words and the potent gestures, trying to calculate their significance for him. Julia attended the rest of the ward round diligently, but was distracted by the thought that Mr Field must be in some distress. She wanted to go back and check; what did he hear, what effect was it having on him…?

So at the end the ward round Julia rushed back to Mr Field’s ward and asked if she could speak with him. He agreed of course. Julia pulled the curtain round and asked, in the most open way she could, what Mr Field had taken away from the ward round. He knew he had cancer, and he knew what this meant – it had spread, it was incurable if not untreatable.

“And did Dr ________ say anything that worried you particularly?” asked Julia.

“No, not really, though I’ve got a lot more questions. He was quite brief.”

Thank God! Relief. He had not overheard the callous comment. Now Julia found herself in a tricky position. She had come back to ‘clean up’ the mess caused by her careless consultant, but in fact there was no mess to clean up. And to be honest Julia did not have the knowledge to answer all of Mr Field’s questions about treatment options and prognosis. She cursed herself for interfering, and cursed her consultant’s behaviour for driving her to come back and check.

Julia was used to coming back to patients – for the ‘clean-up’. Answering or mollifying patients and relatives after a consultant’s cameo performance, a mixture of information-avalanche from a great height, bedside teaching, and a communication style that did not meet the needs of the patients. She didn’t mind… the consultant couldn’t really be expected to deal with every query and anticipate every nuance of his patients’ particular psychological or social circumstances, especially in a limited time-frame. His phone was always going off, he was always late for some committee, he had high level responsibilities in the Trust that clearly occupied his mind when he was supposed to be focussing on individuals. He wasn’t that bad… just a bit thoughtless during the one-to-one sometimes.

Nevertheless, Julia walked away from Mr Field’s bedside and swore that when she was a consultant there would be no such faux-pas.

Some years later Julia became a consultant. She made sure that her ward rounds were protected from other business and worked hard to relate to the patients. At the same time she acquired other responsibilities and developed as a clinical researcher. One day, eighteen months after becoming a consultant, she was on a ward round. A 72 year-old woman with advanced lung disease had developed an ‘acute abdomen’, likely dead bowel. The surgeons weren’t keen to operate, but she would certainly die without it. Julia, a chest specialist, reckoned the risk of dying after surgery, from lung complications, was 40-50%. A classic ‘rock and a hard place’ situation. Julia went to see the patient, who was alert and understood everything. Just before entering the cubicle Julia’s phone rang – she answered. Another patient whom she hoped to enter into a research study had arrived downstairs for the final consent meeting. Julia had another important commitment, a one off, in half an hour. The morning was getting tight. She entered the cubicle and explained the situation. Certain death vs a 50% risk, if we can get an anaesthetist… so what do you think? Will you agree to surgery? The patient looked away, unsure, confused. Julia glanced at her watch – just a tiny tilt of the head.

“OK… Mrs Taylor… it’s a hard decision, we’ll leave it a little longer for you to think about it… perhaps wait for your family to arrive, discuss it with them.”

Julia left. Her team followed her, not sure what the next step was. Julia looked at her registrar,

“Can you come back in an hour and try to reach a conclusion, I’ve got to get going.” Then she walked away, her registrar by her side, and added,

“To be honest Diane, I don’t fancy her chances either way. Fifty percent may be optimistic. But the choice is… definitely die, or probably die. It’s a pretty hopeless situation.” As she said this a young man in everyday clothes passed them. He paused, then moved on.

Julia saw her research patient and attended her meeting. Then she walked back up to Mrs Taylor’s ward. There she found her registrar, SHO and a ward matron in with the patient, who was crying, and her son – the man who had walked passed her – bowed over the side of the bed holding his mother’s hands. Julia backed off and asked another nurse what was happening. The nurse replied,

“After your ward round we heard lots of crying… apparently one of the family overheard someone saying it was all hopeless… we had to get your team up to calm everything down, they’ve been here for an hour.”

Julia stood by the nurses’ station and looked into the bay. The clean-up operation was in full swing.

***

three covers

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