Reflections from the edge

I sit in the emergency department, beside the bed where my father-in-law lies, listening to the bustle around us. We are sheltered somewhat by a thin curtain, but the smells, sounds and energy are undeniably familiar to me. Through the edge of the curtain I see a stretcher being pushed along by two EMTs. The cargo is a pale, elderly, white-haired man. His eyes lock with mine in the millisecond before he passes out of visual range. What is transmitted in this instant is a deep and terrible fear.

My father-in-law stirs, and I ask him how his pain is now. “Not so bad,” he responds, “but I sure need to pee badly.”

I head off to find a urinal to help give him some relief as we await the results of his hip x-rays. There is no question in my mind that his hip is fractured and will require surgical fixation. He's had a freak accident, an unfortunate fall over a bag placed too closely behind him at our local airport.

As I approach the nursing station to request the urinal I overhear a conversation in progress about the elderly man I have just seen being wheeled in. “We have an 86-year-old man with diffuse abdominal pain and signs of shock. BP 90/60, O₂ sats 68 but recovering to 85 on O₂.” The dishevelled resident looks exhausted as he utters something about a possible leaking aortic aneurysm, placing a second IV line with saline wide open, getting an emergency ultrasound and calling surgery stat.

Not a word of this is directed at or intended for the elderly man. He is quickly wheeled away into another room, the doors shutting behind him like the mouth of a hungry monster closing on a tasty morsel. I reproach myself for being judgemental; obviously, this is a dire emergency. And I turn my attention back to my father-in-law. We wait for several hours more, until the emergency department staff confirms that his hip has been fractured. He is admitted for surgery, and I drive home.

But my mind keeps returning to the look in that old man's eye. There was intelligence and character in his face, and yet there had been no acknowledgement of his humanity. The needs of his body were dealt with, but the turmoil of his spirit was completely ignored. A few reassuring words, a hand on his arm, eye-to-eye contact, an assurance that everyone would do their best to help him — this would have done much. It would have required only a few seconds. Couldn't anyone have seen that? Then it occurs to me why these thoughts are so disturbing. It is because I have been guilty of similar conduct myself.

The stress and sheer volume of urgent demands override sensitivity and compassion. The daily immersion in sickness and disease provokes our subconsious fears of similar ends. As a natural defence we separate our spiritual core from what is going on around us. The hardened shell we leave exposed is functional, but devoid of the ability to interact in a truly empathic or compassionate manner.

When I try to to think of moments when I have made some positive, lasting impact on my patients, I feel a sense of failure. There have been few, if any, heroic, life-saving moments. But I have grown to realize that it was the small acts of kindness, concern and empathy that my patients seemed to appreciate and respond to most. The times that I made a difficult diagnosis (or missed one) have left little lasting impression or effect. What matters was that I had cared and tried my best. The most positive effects arose from those times when I have been able to reach inside and truly give something of myself. The ability to place oneself within the patient's frame of reference seems to be the key to forging a strong relationship. Conversely, the most lasting negative effects I have observed in my patients seem to relate to slights and acts of unkindness that they have experienced while in someone's care. The surgeon who fixes the broken hip but is distant and unable to respond in a caring manner is perceived negatively. Patients who are made to feel that their complaints are frivolous feel hostile toward their physicians. Simple and self-evident as these things may seem, I was never taught them by my profession. It is my patients who have taught me, time and again.

We are entering a phase of unprecedented technologic advancement in which our ability to manage and treat disease will expand exponentially. I fear that our ability to treat disease will extend far beyond our ability to treat the patient as a whole. Patients, sensing this, are turning to alternative medicine in increasing numbers. As physicians, we can make a profoundly positive impact on our patients' lives. We see them at their most vulnerable, at the most painful of times. This opens a gateway to the spirit so that we can interact in a deeply meaningful way. Even if this takes more time and effort on our part, could the rewards outweigh the cost?