Posts tagged narrative medicine

The Struggle

For weeks, a patient had been ambivalent, struggling with the decision between full medical care or comfort care only. It was only a matter of time between the disease would make that choice for her.

Everything we could do to prolong her life had been done. There was no process left to reverse. The disease was reaching its ultimate conclusion. With great reluctance, the patient agreed to comfort care.

It pained me to see her struggle because I knew how much it chewed her up inside, to leave behind her family and friends, to be confronted with the threshold of death. It was obvious she loved dearly and was dearly beloved.

I saw her briefly again today after finishing my rounds, passing through our hospice. After seeing her struggle for so many weeks with this decision, I was relieved to find her smiling, having finally found peace in these last hours, surrounded by friends and family. As they gathered to look at old photo albums and share stories under the warm winter glow, her eyes flickered with joy as she laughed with her grandchildren.

For a moment, our eyes met as she caught a glimpse of me by the nursing station. Quietly, we acknowledged each other.

When I was waiting for test results I tried to make up a description in my mind of the consequences of a bad outcome; for myself and then for my wife and my children. For myself it maybe is not too bad - straight to the grave - which is where we all go; even if we think it is too early whenever it comes to that. It is awful, it is difficult to get used to that thought - if you ever are able to…it would be worst for my wife…she is the one who has to take the blow.

When I heard of going to the cancer clinic, I began shivering all over my body. As soon as I opened the door here I felt the smell of the house of death. I can still feel this smell. The word cancer is loaded with fear, I think, and I know some persons who have died of cancer. A tumor is a tumor; uncontrolled cell division, something growing and attacking inner organs.

I react severely to the cytotoxic drugs. I feel so sick, and although I get other drugs to subdue the vomiting, the sick feeling is there, rocking my body all the way. I feel as if I am being run over by a steamroller - my whole body is reacting.

I remember when I woke up from the operation the surgeon told me they had found “islands of outgrowths” in the peritoneum, which was negative news. Something strange happened to me; all anaesthetics and all drugs disappeared from my body, my brain become crystal- clear and I thought: “How can I tell this to my wife?

An excerpt from Expressive Metaphors in Cancer Narratives by Carola Skott, PhD RN.

The Bleed

"Unhook me from these machines. I am going home now and not a moment later."

More than an hour before, I stood by the bedside and watched as the team worked furiously to resuscitate him. Esophageal varices, a cluster of severely dilated and pressurized veins, had been slowly brewing within him over his many years of alcoholism. With the tension of its walls reaching the breaking point, the time bomb had exploded in a torrential gush of blood.

More time than we could handle.
The other day, something very unusual happened: we had more free time on our hands than available work. The day was already off to an atypical start when the patient list fit onto a single page as opposed to the usual two. While rounding, it soon became clear that many of them would be discharged, leaving little in terms of in-house management.
"Perfect!" said my preceptor. “We will go to the hospice then and review our patients there." And so we went, having finished early. A typical morning seldom included the hospice round because of time constraints. This day we were lucky. 
We arrived on site to find: only one patient issue. Total time of management: ten minutes. Yet again, we were stuck. My preceptor scratched his head as he sifted through his planner. There was nothing to do for another two hours.
In a career where there never seems to be enough time, we suddenly found ourselves with more time than we could handle.
"Well this is awkward," he commented almost disappointingly. “Shall we go for coffee then?"
And so we sat in a Starbucks and caught up on life, the universe, and everything. There was an otherworldly feel to the morning, an uncomfortable ease as we tried to relax into our seats. Threaded through the eye of the medical storm, we tried to enjoy a moment of downtime but could not, knowing there was more work to be done, more work waiting for us, helpless to the time that separated us from it.
Sitting there, I wondered if we were truly lucky to have had time to sit and talk. I wondered if medicine suddenly found itself with more moments like this, would it drive doctors mad? 
How wonderfully odd creatures we are to thrive on the fast track life of our work.

More time than we could handle.

The other day, something very unusual happened: we had more free time on our hands than available work. The day was already off to an atypical start when the patient list fit onto a single page as opposed to the usual two. While rounding, it soon became clear that many of them would be discharged, leaving little in terms of in-house management.

"Perfect!" said my preceptor. “We will go to the hospice then and review our patients there." And so we went, having finished early. A typical morning seldom included the hospice round because of time constraints. This day we were lucky. 

We arrived on site to find: only one patient issue. Total time of management: ten minutes. Yet again, we were stuck. My preceptor scratched his head as he sifted through his planner. There was nothing to do for another two hours.

In a career where there never seems to be enough time, we suddenly found ourselves with more time than we could handle.

"Well this is awkward," he commented almost disappointingly. “Shall we go for coffee then?"

And so we sat in a Starbucks and caught up on life, the universe, and everything. There was an otherworldly feel to the morning, an uncomfortable ease as we tried to relax into our seats. Threaded through the eye of the medical storm, we tried to enjoy a moment of downtime but could not, knowing there was more work to be done, more work waiting for us, helpless to the time that separated us from it.

Sitting there, I wondered if we were truly lucky to have had time to sit and talk. I wondered if medicine suddenly found itself with more moments like this, would it drive doctors mad? 

How wonderfully odd creatures we are to thrive on the fast track life of our work.

Words Never Spoken

A man struggled with severe depression and suicidal ideations for many years. No amount of counselling, medication, and therapy could lift him from the bleak depths of his own personal hell.

He had been involved in the loss of a life. On a dark and rainy night in the summer of yesteryear in a far and remote place, a car barrelled through a stop sign into his own. He was hurt, but she was gravely wounded. Without phone reception and without a soul in sight, he carried this stranger with him on that lonely road hoping to find help, to find anyone. In that darkness, the stranger died.

Racked with guilt and a sense of helplessness, he spiralled into depression with a burden of having not saved this person from their fate. Every night, the nightmares came; every night, he failed to save her. It was agony. 

One day, the doctor tried something new. “I want to you take control of your dreams. Think of new endings to that moment. Let your thoughts carry themselves into your dreams. Change what happens.” The man was puzzled. “Perhaps imagine yourself to be Superman. Fly her to the nearest hospital. Maybe dream up an ambulance.” The man was hesitant to try, but decided with everything else they already did, what was the harm in trying? 

"You do not recognize me, do you?" A stranger said to the doctor one day at a coffee shop. He looked up perplexed but suddenly recognized the man he had seen those many months before. It surprised him. The man was smiling, well kept, and spirited. The difference was night and day.

"What happened?" 

"It worked, doctor. Your dream therapy worked for me. Thank you."

"Did you save her in your dreams? Was that what it took?"

"No. I was never able to save her. But one day some months later in my dream, carrying her as I always did down that lonely road, I heard words she never spoke, but words that helped to give me closure."

"What did she say to you?"

"Thank you for not letting me die alone."

Breast Cancer Survivors Find the Michelangelo of Nipple Tattoos

In the waiting room of Little Vinnie’s Tattoos, bikers and punks sit side by side with church-going grandmas and soccer moms. Customers fly in from as far as Saudi Arabia, Spain, and Brazil, to an unassuming strip mall just outside of Baltimore complete with tanning salon, liquor store, and adult DVDs. Anxiously, they enter Vinnie Myers’ shop, the final destination for many breast cancer survivors attempting to recover what mastectomies have stolen away.

For all of medicine’s advances, the best option for areola reconstruction is tattooing, and in the field of cosmetic tattooing, Vinnie’s trompe-l’oeil “areola portraits,” as he calls them, are widely regarded as the best that money can buy.

Read more…

Why Physicians Need to Write

I would argue that one cannot be a good doctor without being able to communicate one’s thoughts, knowledge, opinions, and analyses in writing.

I write for many reasons. One of them is to reflect on my day, to debrief on the moments that my colleagues and seniors impart on me. Another reason I continue to write is to keep the passion of medicine alive.

It is no secret that most of us lose our ability to empathize in third year, a year where we are exposed to the real world of medicine for the first time. We are young and impressionable and bad habits can quickly form if one is not careful. Our passion for medicine, as it turns out, is a fragile and easily corruptible entity; I try not to lose sight of that.

I write for these two reasons and many more personal ones as well. Why do you write?

First Breath

The patient was going to have a C-section.

"Let’s go see the patients together," said the nurse. I followed, coming to the realization that it was a two-patient case; for now, we could only speak to one.

I had spent very little time in surgery beforehand. Initially, the trouble was not about knowing how to scrub - this was further down the list. Rather, the initially worry was finding my way to what I needed to do. I scurried down halls, asked directions, and walked through the same halls again.

This morning, barely past seven, I worried about keeping pace. The nursing station was gathering a crowd as nurses and doctors checked in with the morning schedule. We walked into the holding area and found an obvious match: the only patient there with a round belly, anxious but excited.

Personal Best by Atul Gawande

Dr. Atul Gawande, a endocrine surgeon, reflects on the art of coaching in this piece for the New Yorker. An excerpt:

I watched Rafael Nadal play a tournament match on the Tennis Channel. The camera flashed to his coach, and the obvious struck me as interesting: even Rafael Nadal has a coach. Nearly every élite tennis player in the world does. Professional athletes use coaches to make sure they are as good as they can be.

But doctors don’t. I’d paid to have a kid just out of college look at my serve. So why did I find it inconceivable to pay someone to come into my operating room and coach me on my surgical technique?

Within medical school, there is a very distinctive transition: we begin first in the lecture theatre and end our training in the clinical ward. Our learning switches from lecturers giving us information to coaches critiquing and assessing our performance. It is through that engagement whereupon we offer up ourselves and our work to their judgment that we learn from our mistakes, our shortcomings, and improve upon them. It is also perhaps the time often quote by my seniors as being both the most arduous but also the most rewarding years of their education.

Admittedly, part of that stems from the excitement of finally practicing medicine in a real setting. We often itch to dive into the thick of it, after years of accumulating the foundational knowledge to practice. But yet another part is perhaps the growth we know we will find ourselves in. My seniors always reflect on how much they have learned and how fast they have improved. “You’re better almost every day,” I remember one clerk said. It is an amazing time to be a student. It is an amazing time of coaching.

Though I have yet to advance that far, I look forward to the next few years of learning, and the experiences that will shape and define my growth, but the question of course remains: how do I keep up with continual learning? How do I continue to improve myself as I move through my careers? Every doctor I know spends some time reading on the latest clinical guidelines, familiarizing themselves with the latest studies, and understanding new breakthroughs in medicine. But can we do more?

Night by Tony Judt

In a deeply personal and vivid account, Tony Judt describes what it is like to live with Amyotrophic Lateral Sclerosis or Lou Gehrig’s disease, a degenerative condition of the brain and spinal cord nerve cells that control voluntary muscle movement. He delves into the toll of living with the condition and the things we take for granted during our health. As he summarizes, “there is no saving grace in being confined to an iron suit, cold and unforgiving.”