Hold A Hand

Our ER case manager and I recently walked out of the family room after having to tell an only-child that his 85 y.o. mother was critically ill. She was so ill, in fact, that she had required emergent intubation for her respiratory distress and was now being sedated and paralyzed. This allowed the ventilator to do all of her breathing, conserving this woman's body of some much needed energy. The patient's worsening circumstances had transpired over the past three hours at her nursing home prior to being transferred to us and, unfortunately, her son had been en route when his mother decompensated in our ER, circling the drain before our very eyes. Thus, he never got a chance to visit with her before her intubation.

As we left the family room to go back to the patient's room and continue medical management, the case manager and I walked in silence, affected by the situation at hand. I had tried to hold off this patient's intubation for a few minutes, hoping that her son might soon arrive to exchange a few words with his mother, but it didn't happen. Because the patient's living will had requested that she be a "full code" (my understanding was that she lived a fulfilling, independent life), all efforts would be employed in attempt to save her life and help her through this medical crisis. We had intubated her successfully and aggressively began her medical management.

Suddenly, the case manager stopped smack-dab in the middle of the hallway and spoke to me. "You are amazing in that room, do you know that?" I looked her in the eyes, trying to see if she had picked an inopportune moment to hassle me, to tease me the way that us ER co-workers sometimes do to lighten such heavy, burdensome moments.

She was being serious. "After introducing yourself and shaking this son's hand, you sat down on the couch beside him, touched his shoulder, introduced the rest of us, and asked him how he was doing before slowly, in words he could understand, explaining everything that had been done so far to save his mother's life."

"Yeah," I said, "so?"

She continued. "Did you not feel the tension in that room? And somehow, after you were done delivering the worst of the news, the room felt hopeful, at peace. You could see the son's face slowly accept the news you were giving him. You eased his worries by instilling that we were doing everything we can to help his mother, without falsely elevating his hopes."She paused here, taking in a deep breath. " You showed him that you cared."

"Doesn't everybody do this, though?" I said, knowing the answer before I finished asking.

The case manager laughed in a regretful, wistful kind of way. "Are you kidding? You would be appalled at some of the ways I've seen bad news delivered in that room. No introductions. No sitting down. Blurting out the bad news without any preparation to the family. Leaving without addressing any of the family's questions. Jim, you need to teach more doctors how to act and speak more appropriately in that room."

By now, we had started walking again and were standing outside of the patient's room. The son was going to be escorted back in just a few minutes.

Not one to gloat over getting a compliment, I walked back into the room and continued helping my senior resident with this patient's care. It was, once again, a thing of beauty to watch our team methodically go about each of their responsibilities and, as a result, we were soon rewarded with this patient's condition stabilizing. She was still very sick, but at least the son could now spend some time at her bedside. Which turned out to be a blessing as, in the end, this patient passed on that same evening.

Later on that night, at home, after tucking in my kids and a glass of wine in hand, I was giving much thought to our case manager's words. Just a few weeks prior, during a night shift, a nurse supervisor who had accompanied me in the family room spoke similar words to me when we were done. "The way you approach patients and their families is remarkable," she had said. I may have blushed, but her words were greatly appreciated and I viewed them as the ultimate compliment.

Why isn't everybody at their best, especially in that room? I thought to myself, though, becoming a little annoyed. When did medicine become so shifted to view patient's and their families as "its" and not as human beings, as "hes" and "shes"? When did we abandon learning patient's names and their life story? Of taking a little more time in their treatment room? When did compassion and kindness sneak out the window and rush, rush, rush sneak in. When did the the quantity of patients one treats replace the quality of care given to each individual patient, defining, in some peoples' eyes, a better physician?

Sadly, most of us in medicine know that answer. With the increasing struggles of our profession, from insurance cutbacks to legal threats, from hospital cuts of personnel to the shifting thought that patients' rights outstrip our own, medicine isn't the field it once was when I signed up for a career twenty years ago. Especially in the ER, it is now common for us to be 4-6 hours behind every day, patients now relying on us not only for emergent care but for treatment of their chronic illnesses as well as maintenance medications. Can you see the frustrations? This quantity has potential to impede on our quality, to cut into the time we spend with each patient and their family.

I recently gave an hour lecture to our residency physicians regarding kindness and compassion. I started it with a tragic video of 9/11, scenes playing out to Sarah McLachlan's "Arms Of An Angel." We then watched a synopsis of the Columbine tragedy before I started talking. There was nary a dry eye. "See this devastation, this grief, involved in such atrocious acts?" I asked the residents. "What makes this grief and loss any different from that which you will encounter in a patient's treatment room or our ER family room?" A dropping pin could be heard in the room. Grief is grief, I reiterated. Loss is loss. Death is death. Respect is necessary. Kindness and compassion are a must. Addressing such concerns, I assured the residents, is one of the most important jobs they will ever face. Put the time in and learn how to view this responsibility as a privilege and not a burden.

This lecture was never finished. Before my time was up, only half of the slides had been presented. Instead, we had spent a great deal of time talking about personal techniques on how to interact with patients and their families and how to deliver devastating news. My residents shared personal stories of their best and worst experiences. It was clearly evident that some of them were quite comfortable in their roles, while others struggled with this part of their jobs. This hour lecture on kindness and compassion had gone from the category of "light and fluffy" to receiving the respect it deserved. From the feedback of the residents, they were appreciative and definitely more cognizant of their roles in treating patients and their families.

As karma sometimes dictates, a few nights later, while reading Cutting For Stone, a brilliant fiction novel by a brilliant writer, Abraham Verghese (he who also happens to be a brilliant man of medicine), I happened upon a collection of words on page 519 that left me with goosebumps. In the novel, Dr. Thomas Stone, a leading liver transplant specialist, reads a letter from a mother of a trauma victim that he had treated. It follows:

Dr. Stone--

My son's terrible death is not something I will ever get over, but perhaps in time it will be less painful. But I cannot get over one image, a last image that could have been different. Before I was asked to leave the room in a very rough manner, I must tell you that I saw my son was terrified and there was no one who addressed his fear. The only person who tried was a nurse. She held my son's hand and said, "Don't worry, it will be all right." Everyone else ignored him. Sure, the doctors were busy with his body. It would have been merciful if he had been unconscious. They had important things to do. They cared only about his chest and belly. Not about the little boy who was in fear. Yes, he was a man, but at such a vulnerable moment, he was reduced to a little boy. I saw no sign of the slightest bit of human kindness. My son and I were irritants. Your team would have preferred for me to be gone and for him to be quiet. Eventually they got their wish. Dr. Stone, as head of surgery, perhaps as a parent yourself, do you not feel some obligation to have your staff comfort the patient? Would the patient not be better off with less anxiety, less fright? My son's last conscious memory will be of people ignoring him. My last memory of him will be of my little boy, watching in terror as his mother is escorted out of the room. It is the graven image I will carry to my own deathbed. The fact that people were attentive to his body does not compensate for their ignoring his being.

Brilliant. Simply and utterly brilliant. Thank you, Dr. Verghese.

We need to bring back kindness and compassion. We need to fix the medical field as it now exists so we can begin, again, to pay attention to that which is most import--the patient and their families. With kindness and compassion at the forefront.

Enough said.

As always, big thanks for reading. If you have had any experiences, either as a patient or as a family member sitting in that family room, that may enlighten us readers and make us better at what we do, please share...