The Eye Of The Storm

Why is the third part to the previous posts titled so? We all know that the eye is the calmest part of a hurricane. However to get to the eye, or to get out, you have to pass through the ‘eye wall’ which happens to be the most dangerous part of the storm.

You see, even though they are caught in the storm, to the decision makers, we are the people where they find reason, assurance and even peace, maybe. The only problem being, the figurative ‘eye wall’ of confusion, mistrust, helplessness and grief needs to be crossed.

Now imagine that finally, after all that waiting outside the door, the relatives have been called inside and the formal meeting with the doctor has happened, and the condition, plan and updates have been explained to them, in a language that they understand. But have we ever thought about the extent to which they were listening or how much they understood? Sure, we always ask them whether they have any questions, but were they even listening to us or were they distracted by the ICU settings and also trying to catch a glimpse of their loved one?

I don’t know if it ever crossed your minds, but only recently did I realize the psychological trauma that relatives have when they see someone in ICU. To us, the IV access, arterial lines, ET tube, monitors and the other equipments are just extensions to the patient’s body. But imagine the horror of a non medical person on seeing it all. The beeping, the alarms, and the numbers on the monitors definitely doesn’t make any sense to them while being horror inducing nevertheless.

Breaking bad news often includes explaining to the relatives the option of withdrawing supports. When the option is suggested to the relatives, it’s because it’s the only logical option left to us , because usually the alternative will be complete dependency on life support, till the tired body finally gives up. Or even worse, the rest of the life that’s spent in a vegetative state, assuming that he/she tides over the other problems. But, imagine the state the poor relative is in when you tell him to make the call. We can never blame him if he feels we have just asked him to commit murder. Even if he completely understands why we have suggested the option, it’s still an unthinkable option. As doctors we never commit to anything with 100 percent certainty. Even when we suggest withdrawal, our numbers are something like 0.1 or even 1 percent chance of recovery. Now this number makes sense to us because we understand the condition with it’s prognosis and anticipated complications, but for a lay person , even the smallest chance of recovery is still a chance that’s worth taking if that means the patient is going to make it. I mean, a drowning person will even clutch a straw to stay alive.

More than the proverbial straw, there are multiple reasons that prompt people to not withdraw life support, even after explaining everything in detail. Sometimes it’s the doubt that makes him question whether he has done enough to give his loved one a chance at survival. Sometimes it’s just the longing to have them around for as long as possible.

As a country, we are not very comfortable with the idea of death. The possibility of a catastrophic event happening and what next is never talked about. I can’t even imagine us doctors talking about a living will and what is to be done next in the event we are the ones who are on life support. Hence the confusion about whether or not the patient would have wanted the plug to be pulled is almost universal (not that patient autonomy vs relatives wish is big in our country either, but that’s for a different day ).

So the moment withdrawal of supports is mentioned, it’s almost like throwing them at the ‘eye wall’ all over again. We have just added to the confusion by suggesting an unthinkable action. Even we struggle with the concept of vegetative state, minimally conscious state and brain death at times. It’s a difficult concept to wrap even our trained heads around. For a non medical person, its definitely not going to make sense – because our concept of life, culturally, is that of a beating heart, not so much about the brain. So in their eyes, the heart is beating, he is taking breaths, hence the patient is alive, right? It doesn’t matter if they are on maximum inotropes or they are breathing only because of the ventilator. As long as it’s happening , they are alive.

I agree that sitting down with the relatives and explaining to them till they understand fully is not a feasible option, especially if it’s an arrest or something requiring urgent decisions. Even otherwise, spending so much time with the relatives is not possible as we are all severely pressed for time. Also, all this while, we have not even addressed the emotional trauma inflicted on the relatives- I’m sure that a significant number of them slip into clinical/subclinical depression, or have something like PTSD after they leave the hospital. I guess the number would be directly related to how sudden the event was, considering they have had less time to adjust to the situation.

This brings me to the suggestion of giving equal importance to the relatives’ mental health, especially in situations involving critical care. Most of the times, you have angry / defensive/ difficult relatives because they didn’t have any time to process. Most of them only need some time. Contrary to popular belief, the relatives don’t want our empathy/ sympathy. They just want clarity, they are willing to hear the truth as it is , as long as they have some time. Unfortunately that is exactly what we don’t have. Someone wise told me during my difficult time that breaking bad news is like building a house. You have to lay a foundation first, then once that’s strong, build the walls, and put the roof once the walls are ready. I’m now of the belief that having a counselor available at all times in critical care will change a lot of the difficulties we face in breaking bad news. I’m saying this because I was mostly doing the role of a counselor the time I was at home. The clarity in which the doctor explained the prognosis and further options was definitely the calm at the center of the storm. However what protected the relatives from being blown away was the reassurance that they were doing the right thing, which did not come because I reassured them. The reassurance came automatically because I played the role of a counselor.

While I don’t know how much of the way I break bad news is going to change after the whole experience, I know that I will never be upset at a relative for not trusting me or being angry at me because now I know where it’s all coming from.

Every patient, every relative is different, every experience is different, however the pain, the confusion and all the other emotions they feel are similar I guess. And through it all, even with their mistrust, even with their anger, even with pain, they are looking up to us to be the source of clarity and sound judgement, the calm at the center of the storm.

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THE CHAIN REACTION – PART 2

In my previous post, I had forgotten to mention a particularly unlucky person among the bunch of relatives outside the ICU door. She / He is the one whose phone keeps ringing the most, the one who has to coordinate things at home while being at the hospital, and of course, the one with whom we doctors always meet to give our updates. It’s that member of the family who is the closest relative of the patient, who has to take all the decisions on the behalf of the patient. It can be a parent, a spouse, a child, or even a sibling.

Now if the closest relative is someone who was already carrying out the responsibilities of being the head of the house, and calling the shots at home, before whatever the unfortunate event brought them to the ICU had occurred, they are a little better off than the rest.  For the others, decision making suddenly becomes a new skill that they are expected to learn immediately, and be excellent at it because whatever they decide is what is done, which for the really unfortunate ones, include decisions regarding life and death. All of us as Doctors may have, at some point, become frustrated because the relatives couldn’t make up their minds. You may ask, why should it be so difficult for someone to make a decision, why doesn’t it come naturally to anyone who is old enough to be the one calling the shots?

Allow me to draw a parallel here. Try remembering the first code you ever ran, all by yourself, when the nearest senior was at least 10 minutes away. Did the steps of BLS and ACLS come easily and fluently to you? Were you able to remember all the causes of a cardiac arrest and investigate and treat in that acute situation? Now was it because you did not know the steps, the algorithm or the theory behind it? Was it because you hadn’t practiced it during the simulations as the team leader? Was it because you hadn’t seen enough resuscitation in real life that was led by someone senior? Of course not.

The confidence and expertise to run a code smoothly comes only with experience. When you are running a code, you know that each one of your decisions can make a difference of life vs death in the patient.

Now just imagine the poor soul who has been thrust into the position of a team leader when he/she hasn’t done it ever before without someone helping them out. I’m assuming that every single one of them will panic.

As doctors, we are all desensitized to pretty much everything that is thrown at us. We approach everything with a cool calculating mind that is only concerned with plans, assessment, reassessment and change of plans accordingly. That is not a bad thing at all because it is not feasible to get sidetracked, mostly because of the skewed doctor to patient ratio. We only have a limited number of hours in each day to do all of that for all the patients assigned to us. To help us in our calculation, we are assisted by our understanding of the textbooks, wisdom from seniors, our own experiences and latest updates regarding patient care.

However the poor soul who is currently responsible in making decisions regarding patient care has no such back up. He suddenly has to call the shots, there is panic because he understands to some extent that each of the decisions made can mean life or death, and he doesn’t even have the understanding of critical care to aid him in his decisions. On top of all of that, he/she has to console the rest of the family, is answerable to everyone else, all the while somehow handling his grief also. At this point, let us not forget the highly prevalent beliefs regarding ICU among the general public, the most malignant and widespread of it all being- “Doctors want the patient to be put on a ventilator just to get money, the patient is not going to recover”

I have always wondered what the relative must be thinking when we ask them their decision regarding intubation, resuscitation and the rest of critical care treatment and procedures. I mean, what will the poor guy be understanding when we say “we will have to put a tube to help him breathe, shall we put it?”. On what basis of understanding or knowledge regarding the procedure is he saying ok for intubation? I’m sure that ‘yes’ is coming partly from the fear of making a wrong decision, and also to avoid the guilt and the ‘what if I made a wrong choice’ thoughts later in life.

What I never realized prior to the incident in my life is that, whenever we meet the relatives, what we are meeting along with them is fear, confusion, panic, grief, defensiveness, mistrust, frustration at the lack of knowledge, and  helplessness. And I don’t think we can ever realize the magnitude of it all till we ourselves go through such a situation in our lives. No amount of classes, or breaking bad news to a patient can help us with that understanding. However, to achieve that understanding, we have to be in the patient’s shoes, which, unfortunately is bound to happen only as the result of a catastrophic event.

 

(To be continued)

The Chain Reaction

As medical students, breaking bad news is a skill that we were taught as part of the curriculum. This is further fine-tuned once we start working, initially observing our seniors, and later being bearers of the bad news ourselves. We are always told to be clear about the prognosis, to give them time to understand and ask questions, while being empathetic.

However, what I never knew, and what no one ever taught me, is that we start a chain reaction by breaking the bad news. That is, till I was at the receiving end a few days ago. I guess this is more applicable when the bad news comes out of the blue as opposed to something that the family was expecting for a while. Probably in the latter situation, what makes the difference is that the ‘acuteness’ factor is missing.

I’m going to mention only the relevant observations from my experience. My family was suddenly struck by a tragedy, and it involved me experiencing what it means to be on the other side of the ICU doors. On day One, the first thing that caught my attention was the sheer number of times our phones were ringing. “Do we even know these many people” is what I very nearly wondered aloud. Relatives who I didn’t even know existed were calling to find out what was happening.

Mind you, this was all before we had seen the treating doctor, at that point we didn’t even know what the condition was or what the prognosis was properly. So with whatever little we knew, we had to satisfy all the people who were calling, which clearly wasn’t enough because questions and comments and subtle accusations ranged from ‘how can you not know’ to ‘are you sure you have taken them to the correct hospital’ to ‘if that is the condition, then so and so is the ideal treatment’ and the universal ‘be careful, they might want to keep him there just to get money’. Do not forget, all of this is coming from people who have absolutely no medical background ever. That meant that even before we had a chance to speak with the doctor, on top of dealing with the tragedy, we also had to deal with a bunch of people who have managed to get us second guessing.

Now I was at an advantage compared to the average patient relative because I knew that before someone from the ICU is going to speak to us, they are going to give handover, do rounds and make plans both within the ICU and with the treating unit. And this can sometimes become lengthy if you have many patients who are sick or need a reassessment or change in plans. However, to the non medical relative waiting outside who doesn’t have a clue about any of these things, any small delay before visiting hours starts can be incredibly frustrating, that is definitely getting compounded by all the above mentioned relatives and friends people pitching in with suggestions.

So even before they have met the doctor for a formal update (because casualty would have been just a whirlwind to anyone), the relatives are definitely not in the best state of mind to talk to anyone. In addition to the lack of knowledge and understanding of the situation, another major contributing factor to all the frustration and confusion is definitely the helplessness that comes with the whole situation. I mean, from their perspective, suddenly they are unable to do anything to help, when probably they were the ones doing everything for the patient prior to being sick. For lack of better phrasing, the sudden loss of control over a situation is definitely frustrating I guess. Hospital is a place that is not foreign to me, with me practically living inside one for the past one year, and I was going crazy because I was not able to do anything to help. So I can only imagine what someone, for whom the entire set up is almost like a different planet altogether, would have been feeling.

(part 2 will follow soon)

Challenge #2 : Hygge

Saturday was the best day of the week during college,and it became better as you became older.
In first year, it was never fully your own. You would come back and nap for a while, but sometime in the evening, some senior- (insert) house captain/ hostel secretary/ committee in charge/ would come to call you for some work or the other. For most part of second year, you became the senior who was calling the junior for something or the other.

Cue the latter half of second year, when you were more or less in charge of your time – that’s when you started to appreciate the sheer beauty that was Saturday afternoon. Suddenly you didn’t have to worry about being called for work/ or being the one calling the juniors for work. You would come back from college, already lulled into semi sleep because even the classes weren’t very intensive, everyone wanted to just get back. You came back to your room, and just went to sleep. Now this was the only time a nap served it’s purpose of being refreshing. Maybe it was just me, but any other time I took a nap, I woke up even more tired. Anyway you woke up sometime around 5 ,all refreshed and happy. Everyone had their own Saturday routine. From what I understand, the nap was fairly common to all.

At this point, let me explain the heading- ‘Hygge’. Pronounced “hoo-ga,” this Danish concept cannot be translated to one single word, but encompasses a feeling of cozy contentment and well-being through enjoying the simple things in life.

Saturday was my hygge day. After I woke up from my nap, I went to canteen for my coffee, for that fix of filter coffee that was always ‘double strong, half sugar’. Almost always, I went on my own, and I liked it that way. I would be plugged in, listening to my special Saturday playlist, and drinking that coffee, while just lazily browsing through Pinterest. That’s when the more responsible one of us started to gently, and later quite vigorously, ask us to brainstorm what to have for dinner. Ironically , it was rare that any of us wanted to go to a restaurant on Saturday evening. We preferred to order in and chill. But the ordering was always the tiring part. I hated choosing what to have for dinner. But after so much soul searching ( I’m talking as if we had that many options to choose from- mind you, these are the pre- swiggy days), dinner is ordered.

While waiting for the food, the three of us would gather in one of our rooms. It was usually the tall bossy one’s (I’m sorry 😂) room- it was the neatest and the one with fairy lights. In retrospect, as everyone eventually realises, it was not about the food or room, it was the company that made this special. Some random movie, more often than not something ridiculous, was chosen, so that we could keep commenting on the ridiculousness while having dinner. It was impressive how the one who always slept off during movies stayed awake during Saturday evening. Post dinner, some more random talking , followed by dispersing to own rooms to talk to the family, and we all went to bed early on Saturday.

Saturday evenings were therapy. Sometimes I feel like it was almost like an addiction, because the evenings in which the ritual couldn’t be followed made me so restless and discontent. I never realized how much this meant till I became an intern. Suddenly ,you rarely had control over your time. No matter how much you try adjusting to being at the bottom of the food chain again, its not the same , because now you know how it feels to have control over your time, and you miss it sorely.

I miss those Saturday evenings. I really do. I can only hope that some alternative for it comes up soon, because once you are used to being ‘hygge’, it doesn’t feel natural to be without it.

PS: For those who are curious about hygge, I recommend reading this tiny but excellent book called- The little book of Hygge: the Danish way to live well , by Meik Wiking

Challenge #1

Things that make me really happy

The saying that it’s the small things that matter holds especially true if you are a doctor. Forget a fancy dinner, I’ll be more than thrilled if I had the time to stuff something down while running to work. Now a lot of things ( most , actually) that’s listed below is a direct reflection of the last 365 days as an intern, so , maybe I should add- as an intern, to the title.

Disclaimer: I have not put anything along the lines of a patient getting better, cos that deserves a post of it’s own
Anyways, here goes nothing:

1. Waking up and realising that it’s a Sunday AND Im not on call

2. When the mess akka and the Fnh Anna remembers how I like my coffee without me having to remind them

3. Collapsing on the floor of the room cos I was too tired to change out of hospital clothes ,and didn’t want to contaminate the bed, and then hear your roommate collapsing next to you, and then just keep talking till both of us fell asleep

4. Sunday morning breakfasts with the gang

5. Being ward on call on an OPD day

6. When I get the marrow and the biopsy bit at one go in a patient for whom I was expecting trouble, the weird satisfaction of seeing the straw colored liquid rush into the syringe during a pleural or ascitic tap

7. The beauty that is a neatly arranged and well stocked ward stationary cupboard

8. On call nights when your favorite nurses were on night duty

9. When the patient and their by- standers called me Doctor and not sister, without me having to correct them (believe me I can count those occasions on my fingers ).

10. Seeing a nice gumbal on Asha steps on my way back, and joining that instead of going to sleep

11. The SWIGGY MAN! Seriously , those men in Orange have made many , many on call days and bad dinner days in mess a hundred times better.

That’s all folks- for now..

The blogging challenge

A little bit of background info here – I love to write. I really do. However, the occasions in which ideas decide to visit are too far apart. Which is why I started a blog in second year of college, wrote diligently for about a month , and then forgot all about it till January 2019. That’s when I had a new idea, and then remembered the blog I made 3 years ago.

So in order to not let this current blog die, I have decided to take up a blogging challenge. It’s gonna be my noradrenaline infusion equivalent to keep this blog alive.

Also, considering that my stock of ideas is just woefully inadequate, I have shamelessly searched on Pinterest for ’30 days writing challenge’ prompts. However my twist on those will be to adapt it to the hospital environment. So stay tuned

Disclaimer: Daily writing may not be ( most probably not) possible, so please don’t judge 🙈

The Good bye

The good bye wasn’t hard
A hug, a smile, and a keep in touch
But each were preoccupied
The fear of the unknown for some.
What-ifs’ at it’s loudest for some.
The safety of staying back for the rest (along with slight envy at the others who were about to fly on their own).
Good bye wasn’t hard.
What was hard was the subtle reminders.
The lack of a familiar face at meals.
The lack of a familiar face to roll eyes at something ridiculous at work.
Seeing the new bunch taking your place in mess, the iconic steps,
Coffee shops, and the general hang out areas.
Saying- ‘dude, check this out’ , and suddenly being hit by the realisation that the ‘dude’ isn’t there.
The chances of saying ‘wassup man, how’s it going’ being less than finding an attender for an errand.
It’s subtle, but it’s there
What was home suddenly seems less so.
Maybe it’s a hyperbole, but it’s almost like the proverbial cutting of the umblical cord. The ones left behind are suddenly struggling to cope, the goodbye made harder cos we were only prepared to stay back. We weren’t prepared for the rest leaving.