Empathy

Dodging shadows: the mysterious art of detachment

 

I watched a patient die before Christmas. He was surrounded by the full crash team, which nowadays is a fairly large group. As the attempt was abandoned, and another consultant ‘called it’, I withdrew into the background. There was nothing I could do to help. I walked away to prepare my departure for the week-long break (lucky me, most doctors don’t get that), and couldn’t help but think about him. His death. I wondered how it would affect me as I arrived home. The family were looking forward to seeing me, my return would mark the beginning of the ‘real’ holiday. I wanted to enter the house with a light spirit and smile. Yet, the image barely fading on my retina, and still vivid in my visual memory, was of a dead man.

How to separate the intensity of that memory from life outside the hospital? Detachment. That is the word, the process. An ability to cut the lines of emotion that stretch from the wards though the sliding doors, along the train track or the A-Road or the cycle lane, thin but tenacious like the silk spun by a giant spider of Middle Earth. Pull as hard as you like, they don’t snap. Yet, to avoid darkening our homes, they do need to be cut.

Detachment. This process has received a bad press recently. The surgeon who burned his initials onto a living liver was defended by Henry Marsh, who used ‘detachment’ as a justification. Detachment can impede our ability to sympathise and to emphathise. In this example, it permitted transformation of a patient in an object to be signed. Any detachment we achieve on leaving the hospital or the surgery, has to be reversed when we re-enter the building.

So perhaps it’s not detachment that is required. Perhaps it is management, of bad or upsetting memories. By this I mean the ability to live with them. Compartmentalisation. Reduction. Or temporary blindness. A method by which negative emotion can be pushed to the margins of our minds, while the lives of others who have no knowledge of the patients, and therefore cannot truly ‘care’ except in an abstract sense, proceed uninterrupted. Silence is one option. Yet this requires the healthcare worker to conceal his or her thoughts and behave normally. This means acting, and the dissonance between inner reflections and external actions could, in time, be harmful. I have no reliable answer. My own method, as readers of this blog will know, is to turn a thing over, look at it from several angles, and process it through words. That doesn’t work for everyone (there would be far too many blogs!).

My final answer is this: doctors and nurses will always bring the memory of death into the home. To leave it on the street is unrealistic. To bury it is harmful. To talk about it incessantly is unfair on those we live with. The only other option, perhaps, is to develop a special facility – to carry the emotional load with as much sadness and respect as death deserves, while simultaneously accepting that the lives lost do not intersect with those who are close to us. The sadness is of a different quality, with a translucence and impermanence that alters us but cannot rob us of normal social reflexes, or the ability to enjoy ourselves.

 

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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

Instant E

instant E

 

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?”

“Of course.”

“Any hepatitis infection, anything like that?”

“No.”

“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.”

“Wine? Cider?”

“Wine.”

“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.”

“OK.”

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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Glide

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A now traditional Christmas Carol-esque cautionary tale for busy doctors, which also owes something to another, less esteemed cultural influence…

oOo

Jim, a thirty-something medical registrar, stared out of an eighth floor window into the lifting darkness. With dawn came the prospect of home, and the end of his fourth night on call. He thought about going to the pub on his way back, but decided against it. Beer, at 9.30AM! What a mess.

A patient called out to him. Jim averted his gaze, the time-worn method of avoiding engagement with those who might distract him from more urgent tasks. But he was doing nothing, just staring at the city’s transition below, so he answered.

“Can I help you Sir?”

“Here, here.” growled the old man. Jim liked the look of him; there was humour in his eyes, a spark of cynicism.

“Yes?”

“Come here lad. I’ve got something to tell you.”

“Go ahead. I might get bleeped away though.”

“No, you won’t.” The tone was oddly prophetic. With a thin arm he directed Jim to make himself comfortable on the bed. Then he began…

I was a doctor you know? I was. I don’t tell people when I come into hospital… at 85 I know very little that would help, medically. But I know how people should be treated. I’ve been studying you… Jim, isn’t it. You’re at the top of your game aren’t you. Slick. I’ve seen you field questions, referrals, crises. You know a hell of a lot, and you think clearly. You’re fast too. I was fast. I could get round a huge ward of patients in a couple of hours, I could see twenty-five in a clinic. At your age. Then… I changed. I slowed down. I annoyed those in charge of the hospital, I caused a backlog, but I had to, you see. Want to hear why?”

“Yes.”

“I was doing a ward round. A man grabbed my hand, a bony hand it was – just as I grabbed your attention a moment ago. He pulled me down so that his mouth was at my ear, and he said – young man, you’re gliding, you’re gliding. Like you Jim. You glide. You’re fast and you’re smooth but you never touch down. What did he mean? He meant… I wasn’t connecting, wasn’t engaging. I wasn’t leaving anything behind. I was fast yes, I made the right decisions, mainly, but after I had left the patients they could barely recall the interaction. Do you remember seeing me yesterday Jim? Vaguely? You were in and out in a flash, focussed entirely on the medical facts. I was impressed, you made the right diagnosis and changed my treatment for the better, but I wanted to talk to you… about something else. I started, but you were already turning away. Teflon. Smooth. You didn’t realise I had something to say, because you were not open to the possibility of anything obstructing your serene progress through the ward. Leaving nothing behind…”

“How can you leave something behind with every patient? You’d be eaten away.”

“Nice image! Like piranhas eh? No, no. It’s exhausting, it has to be. If it’s not exhausting you’re not doing it right. It’s called empathy, and it costs, in the short term. And to do it you have slow to down, and touch the ground.”

Jim nodded, not exactly in agreement, but too stunned to object.

“Anyway, just a little bit of feedback! Off you go Jim. Get home.”

Jim stood up, ashen faced. He murmured his thanks and walked away. When he arrived at the nurses’ station he turned to look at the old man, the gnarled old physician with bright eyes. The bed was empty.

“Talking to yourself were you? Bit tired?” asked a nurse.

“Possibly. Possibly.”

And he walked home, slowly.

oOo

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