Saturday, May 20, 2006

The first time

The problem of medical staff failing to treat patients respectfully is a very old one. Eventually, I think, many doctors and nurses just get used to seeing it. However, the first time you see it, it can make a big impression on you. I can still remember the first such incident that I observed. It has stayed with me for more than 20 years.

I was in the first weeks of my general surgery rotation at a small suburban hospital. The chief of surgery used to take the medical students around to see the patients. There was a middle aged woman who was suffering severe complications from alcoholism (bleeding varices). She was schedule for surgery and the chief told us that the surgery was very complicated, the chances of survival were small, and the odds were high that she would become encephalopathic in the aftermath of surgery and never regain consciousness. I had this in mind when the resident called me to observe him putting in a central line prior to surgery.

I pressed myself into a corner where I would be out of the way. The central line placement was difficult and the resident struggled over and over again. He was sweating and everyone in the room was tense. I could not see the patient's face from where I stood. It seemed that she was incredibly stoic as she was stuck repeatedly. Eventually, her voice emerged from beneath the drapes,

"I'm sorry, but I have to pee."

The nurse looked at the resident, and the resident shook his head no. He was already frustrated and he did not want to stop to let the patient use the bedpan. So the nurse told the patient,

"Just pee in the bed. I'll clean it up later."

I was shocked and evidentially the patient was, too. Was it really that much trouble to take a few minutes to let her pee into the bedpan? The patient said she would try to wait.

Again the resident was unsuccessful and again the patient asked for the bedpan. This time she was pleading.

"Please, I don't want to pee in the bed. I've never had an accident before. Please, please just let me use the bedpan."

By this time, no one was interested in the patient's distress. She wept as she eventually peed into the bed.

"I am so embarrassed," she kept saying over and over again.

It only took a bit longer and her central line was finally placed. She was wheeled off to the operating room, weeping. The surgery did not go well. She survived, but she never regained consciousness and died a few days later. Her last conscious thought had been embarrassment, because no one could be bothered to give her a bedpan. She was going to her death. Everyone in the room knew it, but no one cared enough to let her preserve her last tiny shred of dignity before she died.

8 Comments:

Blogger Flea said...

I'm sure you've fantasized about saying something to the resident. What would you say?

I was in a similar situation. The woman in question had had a stroke and it was very difficult to understand what she was saying. The resident (performing a spinal tap at the time) told her the same thing your resident said, but he did so fairly gently and reasonably. My thought at the time was that getting a bed pan under her with a needle in her back might not have been a good idea.

It's funny, not until reading your post did it occur to me that I should have said something.

The reason it's funny is that I, like you, am exquisitively sensitive to patient dignity, and was that way in med school too.

Maybe the power difference between me and the resident silenced me.

best,

Flea

11:19 AM  
Blogger Amy Tuteur, MD said...

Dear Flea,

I was just too cowed by everyone else at the time. It was pretty clear that they knew a lot and I knew nothing.

Now, of course, I would handle a situation like that very differently. I'd get the bedpan myself and appear at the bedside, saying sweetly, "Oh, I know that the rest of you were just too busy to get the bedpan even though you wanted to, so I got it for you and now the patient can use it."

4:08 PM  
Anonymous Anonymous said...

I live in Iowa. My mother is 70 y.o. & fortunately is in relatively good health. However, she has agreed to move to this benighted state so that if, Heaven forbid, something should happen, I can hopefully prevent the occurrence of such treatment. By the way, I can understand how the medical 'pecking order' can be an inhibition to speaking out.

12:40 PM  
Anonymous Anonymous said...

Have you given this blog up? It's a shame if you have; it's a needed topic.

2:28 PM  
Anonymous Anonymous said...

Hello,

I hope I don't have to be an MD to comment here. I've been searching the web for days for information regarding the benefits of having a family member/advocate present with a patient (post-op in this case) overnight. My sister was in a serious auto accident several days ago and is at a major central Massachusetts teaching hospital. She has had problems in the past with pain managment and is afraid to be left alone, but the staff (including the nursing supervisor) is adamant that I stay in the waiting room so she could "get more rest".

She had an absolutely horrible night. Her pain medications weren't given because she was sleeping and she awoke to severe breakthrough pain that couldn't be calmed. When she asked for more she was told it was what the doctor prescribed and she'd just have to suffer through it, that the second night after a sugery is always pain-filled. The staff didn't always answer her page and when they did, they shouted, "What?" into the intercom. They woke her repeatedly with the overhead flourescent to do basic vitals and even handled the rod and pin apparatus on her broken leg, (while still bleeding and aching) by the rods... using them as a handle to manipulate her leg! And the last straw was when the nurse finally did come in with medication (morphine), she asked him to inject it into the IV slowly and he snorted at her and told her it was her imagination that it hurt and proceeded to flush it in in one large gush. She shrieked loudly enough for me to hear her from the waiting room and was afraid then to complain because she felt at his mercy and like he had just "punished" her for being a difficult patient.

Last night I stayed in her room through happenstance, because the supervisor asked me to "stick around" to discuss an unrelated issue and she forgot about me until around 4am. My sister's care was VERY different with me there. The nurses were exceptionaly friendly when they entered her room. In fact my being there lightened their load a great deal because I was able to take care of the smaller practical issues like pillows, and ice, etc. When I would leave the room though and enter the hallway, a hush would fall over the ward and I could literally FEEL the bad vibes over my intrusion. It was almost as though the staff was used to being able to goof around all night and they resented having to behave professionally because they now had me as a "witness". She slept MUCH better because she was assured that she would get what she needed in the night.

I understand why hospitals don't want a room full of people past a certain hour, there are other patients to consider and the atmosphere can be more like a party. But I do NOT understand wanting to keep out a family member that is MORE than willing to bear some of the load of the patient's care and who will also offer the familiarity,comfort of home, and advocacy to their stay allowing them to relax.

How can I get them to ease up on this rule? Can I?

Thank so much... -Laurie

8:06 PM  
Blogger Amy Tuteur, MD said...

Laurie:

"How can I get them to ease up on this rule?

It is possible that there isn't a rule, but that the staff thinks it is more "convenient" for them to keep relatives away. That's because they know that relatives can advocate for a sick patient better than the patient can herself.

There are a number of things I would do if I were in your situation.

First, I would stay, regardless of what they say. If they have a problem they can call security and then they can try to explain to security why you shouldn't be allowed to sit by your sister's bedside.

Second, most major hospitals have a patient care representative. Contact the patient care representative to explain your situation. Ask if there really is a rule. Tell the patient care representative that you or another relative will be staying at night.

Third, if you do not get the appropriate agreement from the nurses or the patient care representative, call the office of the president or vice-president of the hospital to arrange a meeting. Let them try to explain to you face to face why your sister can't have someone with her.

Basically what I am advising is to do whatever you need to do for your sister and keep complaining until they give in. Sooner or later (hopefully sooner), they will decide that it is easier to let you stay than to deal with the hassle that you are creating. I know that this is a really difficult strategy, especially if you do not feel comfortable with confrontation, but your sister will be better off if you can be with her.

Good luck! Your sister is fortunate to have someone who cares enough to be there for her.

9:00 PM  
Anonymous Anonymous said...

Dr. Tuteur,

Thank you for your advice in this. Sadly, I'm here to ask for more. I wish I could say things went well, but they didn't. My sister is uninsured and it seems that that changes her status to "second class citizen". (She is a single mother and was able to find employment. But hadn't been working long enough to have health benefits yet and had been denied state benefits when she became employed.) She was released from the hospital too early, not just in my opinion, but in the opinion of the PT and the visiting nurse and the other MD's on staff. They all seemed shocked that she was going home so soon. They initially told her she'd need to go to a rehab facility, but sent her home instead when they learned she didn't have insurance.

She was assured she could reach an orthopedist at any time, (I was there when one of them told her so) but they didn't explain that only the one directly treating her could help with her pain management and that she would often be unavailable. (She was reinjured on Thursday when her fiance fell against her pins while trying to lift her.) The treating MD's staff treat her phone calls for help like the desperate cries of a drug-seeking junkie. They refused to talk with me as her advocate even when given her direct permission within the same phone call and I have been on the extension listening and the tone the staff uses is wholly unjustifiable. She's being bullied and is afraid to call because they make her feel so small.

The nurses come to take vitals and clean the pin sites but will not come when there is a crisis as in this case. They found they were 'too busy' to see her for her scheduled appointment yesterday and told her she should go to the ER. Beginning at 7pm on Friday she spent 5.5 hours there in excruciating pain while the staff explained that they couldn't treat her pain without evaluating her for it and that they couldn't do that "yet". They triaged her and had her x-rayed within the first hour and a half. Her leg was purplish red, it was so swollen the skin was shiny (significantly more swollen then when she was released after her surgery) and she was moaning and they felt more "evaluation" was necessary? She also had the written prescriptions from her treating orthopedist, but the doc had failed to fill in the dosage on one of the 3 (the percoset of course) so it couldn't be filled. Even with that in hand, the doctors would not help her.

She finally left the ER at 1:30 am with a 3 day prescription for percoset. The pharmacy was closed and it couldn't be filled. She reinjured her collarbone getting back in the house (putting her arms around us to "carry" her inside) and this morning the visiting nurse advised her to wean herself from the pain meds because the hopital would cut her off cold turkey soon. She also said she is of the opinion that they do this far too soon with most post-op patients. If the nurse had come when she was scheduled, she'd have been able to determine that an ER visit wasn't necessary. (no oozing at the pin-sites, ER didn't even bother with bloodwork) The trip to the ER exacerbated an already very painful situation.

My sister is disappearing into this injury. To say she is emotionally traumatized would be an understatement. She is absolutely terrified of the pain and we have found that the medical community at large here is completely unsympathetic and without any pro-active concern. Is there anything at all we can do? Is there any way to get her the help she needs when she needs it?

Sidebar- [I do understand that percoset is controlled and that it is addictive so I know why certain measures are in place. But, this is not a hidden back injury, etc., this is an obvious, swollen, inflamed, make-you-cringe-when-you-see-it injury. Shouldn't they be weighing the benefits against the risk?]

It isn't just pain management, it is the general tone of her overall care. Will it help to threaten legal action? Publicity? What can we do?

Thanks so much.. -Laurie

3:04 PM  
Blogger Amy Tuteur, MD said...

Laurie,

You can contact me privately at DrAmy5 at AOL dot com and we can discuss this in greater detail.

10:40 AM  

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