There are several particularly stressful episodes from my experience on the wards that have cemented themselves in my memory and taken me rather a long time to come to terms with. One of these occured while I was a newly qualified doctor on the orthopaedic ward, and it caused me a whole bucketload of anxiety for a long time afterwards.
An elderly gentleman had been admitted with spinal fractures after a minor fall at home, on a background of multiple comorbidities and suspected underlying malignancy. In retrospect, with the luxury of greater experience and appreciation of the clinical picture as a whole, this man was exceedingly unwell, with a very poor functional status, and the priority was to provide excellent, compassionate care, to treat the readily reversible issues, and then to support to him and his family as he progressed through the natural process of dying. However as the newly qualified doctor on the ward trying to make it through the day, one tends to become somewhat blinkered with the rather glib aim of ‘don’t kill anyone‘. You might be able to tell where this was going.
While walking back onto the ward after taking a sample to the pathology lab and allowing myself to feel just a hint of pride at my efficient completion of the morning’s joblist, my heart collapsed into my heels as I heard the alarm bell ringing and saw a hive of activity surrounding this poor gentleman’s bed. I meekly peered round the curtain to see an entire crash team encircling a patient unrecognisable from the man who had sat there eating his breakfast this morning. Grey, mottled skin dripped pearls of panicked sweat, his sagging abdomen to-and-froing beneath his emaciated ribs and gasping, frothing mouth. I froze, deaf and dumbfounded, as the team bustled with notes and blood gases, scouting through clinic letters and looking for phone numbers. I watched as they unpicked the story in minutes, agreed rightly that further invasive treatment would not be in his best interests, and called his wife in to be with him while we kept him comfortable and allowed nature to take its course. She was understandably crushed by the abrupt loss of her lifelong companion, but clearly not surprised, and I watched with awe as she maintaned dignified composure by his bedside, gently stroking his ashen hand as the nurse administered palliative medications to make his breathing more comfortable.
Once I was able to talk I sheepishly approached the anaesthetist who was documenting in the patient’s notes.
“I’m so sorry, what did I miss?”
He gave me a friendly smile and slid a seat up, ushering me to sit down. “I don’t think you missed anything, I think based from his history this man has likely had a repeat acute cardiac event which isn’t survivable, and given how frail he is with a likely nasty cancer brewing the kindest thing is to keep him calm and settled”. I considered this for a while as he continued writing. I felt deeply ashamed that this had happened while I was off the ward, as if there was something that I would have spotted and been able to fix with all of my four months experience as a doctor, which had so far largely consisted of fixing printers and trying not to cry on the phone. The lump in my throat wouldn’t shift and I was fighting back tears as I blurted,
“But he seemed fine this morning, I just ran something down to the lab”
The anaesthetist smiled again, generously empathetic to my naive horror at a stituation he had clearly experienced innumerous times. “Try not to worry about it mate, these things can happen very suddenly, and there’s often nothing you could have done to prevent it.”
As you can imagine, I very much did worry about it, and even now years later I can still vividly picture that poor man’s gaping mouth and heaving breaths as he sat drowning in the vile pink foam that erupted from his broken lungs. But over time I came to accept that this may in fact just have been ‘one of those things’, and the whole experience taught me a very valuable lesson that has helped alleviate my anxiety since:
Sometimes things are beyond your control.
Sometimes, no matter what you do, how hard you work, or what precautions you take, bad stuff happens because the world is a big, messy, complex place and you as an individual simply cannot control everything. In fact it would be obscenely grandiose to even suggest that you could. The same applies to patients. Human bodies are exceedingly complex with their own unique genetic predispositions and environmental exposures that guarantee that they won’t follow the rules in your medical textbooks and will often trundle towards their own outcome, be that good or bad, regardless of what you do as a medical professional to try and help along the way. In fact half the time the body is probably healing despite our misguided attempts to help.
So what does this mean? It means you shouldn’t focus on someone’s outcome as a measure of your competence as a medical practitioner, because you don’t control their outcome, you can only influence it with your actions. Which leads me to the best bit of advice I have ever received and the motto I try to live by:
Use what you’ve got, do what you can, and start now.
As long as you have done your best with the resources available to you, and done it in at least a moderately timely fashion, then you’ve done a great job, regardless of the outcome.
The reason I chose to write this post today was because of a rather dramatic case I saw this afternoon, which gave me a real appreciation of how far I have come since that day on the orthopaedic ward.
A similarly elderly gentleman, with a similar constellation of medical comorbidities, presented to the emergency department vomiting blood with a steadily dropping blood pressure. He was swiftly brought to the resus bay, a major haemorrhage call was put out, and decent IV access was obtained to allow resuscitation with fluids and blood products. The emergency department team dug through his history to find he was recently diagnosed with an aorto-duodenal fistula and quickly contacted all the relevant people – gastroenterology, general surgery, intensive care, vascular surgery and anaesthetics – all of whom gave their input. Given his background, clinical picture, and rapidly dropping blood pressure despite volume replacement and adrenaline boluses, it was agreed he wasn’t fit for an anaesthetic, nor for endoscopy, and if we tried to transfer him to the vascular centre he would most likely die an undignified death in the back of an ambulance, causing avoidable distress for his family and the ambulance crew. As a team we calmly and promptly agreed that this man was bleeding faster than we could replace his blood and there was no available therapy that would fix the underlying issue, so the decision was made to keep him comfortable, and stop actively treating. He died with his family by his side, in no distress, and crucially avoided the futile CPR that would have likely occured had we not made the decision when we did.
We managed the case really well. The patient died, but that doesn’t detract from the fact that we did all the right things and made the right decisions, at the right time, with what we had available. His family were grateful because we gave him the best chance of survival we could without sacrificing his dignity or doing unnecessary harm, and as a result the team were rightly proud of how they managed the case.
If I’m completely honest, I think we often overestimate the impact we have as medics on our patients’ journey, and as a result, we increase our own anxiety and stress through an inflated sense of responsibility to ‘provide’ a good outcome.
Unlike a mechanic fixing a car, we are not fixing broken parts (unless you’re an orthopod), rather we are usually helping the patient’s body to repair itself. This means that the vast majority of the healing process is down to the patient, and is therefore out of our control.
There is one thing and one thing only that you can control:
“What will you do next?”