Waking Up

An elderly man startles awake after a man in a white coat touches his shoulder.  He looks around and sees three other white-coated people standing around his bed.

“Sir? Good afternoon, sir. How are you?” says the man who touched the patient’s shoulder.

“Oh, I’m fine.”  He’s perfectly calm.

“I know this is a silly question,” continues the man, “but do you know where you are right now?”

“Of course, of course. I’m at home.”

The slightest pause. “Sir, you’re in the hospital.” The man in the white coat names the hospital.

“Oh yes, the hospital,”the patient agrees. It’s as though being at home were just a slip of the tongue and not the mind.

“Do you know why you’re in the hospital?” the standing man presses.

“I’m here… I’m here because you’re giving me circulation to my leg.”

“Actually, you just had an amputation of your leg.”

The patient’s expression freezes, but like many people with dementia, he covers whatever internal processes he has.

“Your leg was just amputated.”

This is not the first time the patient has woken up after his surgery.  According to the nurses, he had been tearful all day trying to cope with the loss of his leg.

“Can you repeat that after me?  Your leg is amputated.”

The patient repeats it, in a tone that I’ve used to talk about the weather.

“Okay?  Your leg is gone.”

And just for good measure he lifts up the blanket and shows the patient the nothing that is there:

“Your leg is gone.”

The doctor turns and leaves.  The other people in the white coats who are not in the patient’s home not giving circulation to his leg follow his lead.  The whole encounter takes no more than 120 seconds.

The third year medical student in the white coat looks back at the man’s frozen expression. With this glance, she has already fallen out of step with the team.

A social worker enters as we leave, pulling the curtain around the patient’s bed.

A curtain around a man who doesn’t wake up from nightmares but into them.

Someone please tell me.

Someone please tell me how to make a box in my mind and put patients into it and seal it and make the patients stay in there until I say they can come out and–actually, on second thought–maybe I’ll just never let them out.

Because I am having nightmares too. But at least I am waking up in my home with both my legs still there.

Someone please tell me how to steel myself against this profession I have chosen.

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20 Responses to Waking Up

  1. Old Geezer says:

    May I humbly suggest that you have chosen a vocation that requires you to be deeply involved, compassionate, caring, loving and empathetic; and then to also leave all those feelings in the room when you pass through the door. Yes, you must care about your patient, but you cannot carry your patients’ burdens with you as you go from room to room or from professional to private life because it will soon overwhelm you, leaving you unable to benefit anyone. I was a firefighter/EMT. I saw things you cannot imagine on the street. You have seen and will see things I cannot imagine in your area of practice. In either arena, it is absolutely necessary to let go of the one patient in order to be entirely ready to help the next one as well as to be serene in your own self. That comes with time.

  2. Shara Yurkiewicz says:

    Thanks. I know there’s a balance between being bettered by empathy and being weakened by it. Everything is still brand-new right now, so I’m okay erring on the overly affected side. I realize it’s not sustainable in the long run, though, and I imagine like everything else, the burdens are something you eventually get used to.

  3. Old Geezer says:

    And, Shara, please don’t get me wrong. I have been retired for 17 years and still vividly remember doing a secondary survey on a two-year old girl, pulling broken glass out of her diaper as I looked into a fixed, unresponsive stare while her drunken father (who had just driven them over a 30 foot embankment) wandered around uninjured. Empathy and sympathy do have their place as well as well placed anger.

  4. MedStudent says:

    Don’t steel yourself — you’re being rightly aware of what you think is a problem and blocking it out isn’t the answer. Do what you started to do — breaking ranks — and go a step further not in calling out your superiors but in doing the right thing for the patient. 3rd year is the best time to be an advocate for the patient.

  5. A Patient says:

    Wow. I stumbled upon this through a news aggregation app (Zite) and it really moved me. And I read Old Geezer’s reply and that moved me too.
    I woke up into a into my own nightmare and while I know each morning what has happened, I still deal with that nit are every day. All I know is that I am very glad that there are people like you out there who stopped me from dying, have given me a quality of life and cared for me.
    I knew in hospital that as they moved from bed to bed that they forgot about me when they moved to the next patient, but while they were with me, my health and myself were their primary focus. And they didn’t really forget about me, they would remember little things and visit and that would make my day.
    There will always be patients that you will be able to do little for and who will test your resolve, but there are also a lot like myself who are eternally grateful to you for the wonderful work you do and the lives you save and make better. And it is not just us, but our families and friends who appreciate your care ofntheirnloved ones.
    Thank you.

  6. Aaron Smith says:

    Doctor-to-be,

    Don’t compartmentalize them, don’t distance yourself, don’t cut yourself off. We need doctors who care, who feel, who emphasize.
    You are not the cause of illness, of accidents, of time, of bad luck, of happenstance.
    You are the one who chose to help the ones who are the victims. You cure, when you’re able. You take away pain, when you can. You help, when the universe turns around and bites us on the ass.
    It’s trite, I know. But maybe its the best statement of how to deal with your humanity, slightly altered to include secularity.
    “Let me develop the grace to accept the things I cannot change;
    Let me develop the courage to change the things I can;
    Let me develop the wisdom to know the difference;”
    and, I might add,
    “Let me never lose the compassion to care.”

    Its people, like you, who gave me the last 20 years with my wife.
    We need you, and more like you.

  7. Sarah says:

    I think it’s supposed to hurt. I had a patient who did something stupid in her car and her two children were killed. I was her doctor and I had to tell my physically unharmed patient that her children were dead. That was several years ago and I still think about her often, and part of me is changed forever for seeing that happen to another mother and for being an unhelpful actor in the worst day of her life. But some things that would have really hurt me during my third year of medical school don’t hurt much anymore.

    There isn’t a neat and satisfying answer, and I don’t think there is supposed to be. Every man and woman becoming a physician has to decide for themselves what gets to be painful to us because it keeps us human, and what doesn’t get to be painful because it would take away more of our ability to function than it is worth. We all do the best we can to strike the balance.

  8. God. I’ll never forget. My roommate was an EMT in Oakland. This tall, rangy, cool black dude. Killer racquetball player. He used to do doubles. One morning he came home. Me, all rested. Him, weird.

    “You know what just happened?”

    No, Carlton, what happened?

    “Dude jumps from the 8th floor. Lands on a car roof. That guy just WALKED AWAY, man! He just WALKED AWAY right in front of my eyes!!”

    There were many unexpected drinks that morning.

    I’m so glad I go to bed in my bed and wake up in my bed and am me and don’t have to see bad things. Because if I saw bad things, I wouldn’t be me any more.

    I’m glad I’m not a doctor or an EMT. So I don’t have to see bad things.

  9. cybercitizen says:

    There is a long tradition of medical students being abused by bullying medical training staff during their interships and residencies. Maybe these educators take on a drill sergeant role in their own minds to try to “harden” the new recruits and it also rubs off on the patients.

    As Dan Rather would say, “courage.”

  10. Cristina says:

    Wow. I’m sorry, I don’t have any advice to give in the realm of medicine, but I thought your text was so beautiful and so moving that I had to leave you a comment.

  11. Omar Baig says:

    Dear Shara,

    The team at Premed Network has recently come across your blog.

    I’m the President of Premed Network, a nationwide network of premed students.

    http://www.PremedNetwork.com

    The vision of Premed Network is to create a platform for the next generation of physicians.

    We are reaching out to select medical student bloggers to share their posts in our community.

    I look forward to hearing from you.

    Sincerely,

    Omar Baig
    President, Premed Network
    16180 Alum Rock Avenue
    San Jose, CA 95127
    (408) 802-5267

  12. Cleo says:

    Wow – this one is powerful. You bring tears to my eyes – for him and for you.

  13. Robert Gould says:

    On the one hand, they say if you meet up with someone who has fallen in a hole, you can either jump in the hole with them…..or throw them a rope. If throwing them a rope doesn’t seem to work, then what? I don’t think tears and nightmares are an abnormal reactions to medicine. In a way, after 30 years, I still feel I suffer from PTSD after my 3 months of internship in LA County Hospital ER. How can you get woken up at 3 am, rush down to the ER to see some bloody mess with visual gore, auditory gore, olfactory gore and emotional gore without having it affect you? Then, somehow, you patch it together and move on. Later, you have to tell someone that they have lung CA with mets to the brain. How can anyone do that? On the one hand we doctors have the privilege to “touch” people deeply. We are in a position to really make a difference. On the other hand, it hurts us. Like the sin-eaters of old, maybe.
    I have a family member in Special Forces of United States Army. He related to me a story of a gun fight. People were killed. It was crazy. The one image that persisted in his mind for too many months was the 6 year-old girl who had 3rd degree burns who was dumped in my family member’s lap for “treatment”. There was no doctor for 8 hours. That girl was the same age as his daughter. She was in trouble and needed more help than he could give. That was the birth of a whole new PTSD experience.
    After 3o years, I still cry, sometimes with a patient, sometimes alone after seeing a violent medical situation. If you don’t, who are you? You move on. Perhaps, the best we can do is to keep pushing it out of our face so you can do it again.

  14. Stefanos Rotas says:

    Of course this is not a way to confront patients. I try to stick to the basics: why you have amputated this man’s leg – to relieve unmanageable pain or to save his life from an infection and what is the way forward, cratches or artificial leg, which should be introduced before the operation. Reason is the support for my hurt (but not amputated) feelings. And still there are things I know I cannot confront and I have chosen only to be able to provide early diagnosis and emergency treatment for them.

    A Doctor

  15. BT Mom says:

    I agree with what others have written above. I was a counselor and when I was doing my training at a rape and sexual abuse center, my teacher suggested that when I worked with clients I pretended to put on a bubble that would keep the painful memories and experiences out. In therapy, if you try to take on other people’s pain it can prevent the healing process. Therefore my imaginary bubble was used to help survivors regain control of their life.

    I wish I could say that this approach worked all of the time. I went on to work as a child protection social worker. Even my imaginary bubble could not stop the nightmares because that line of work forced me to confront evil on a daily basis.

    Now I am a patient that has been diagnosed with terminal brain cancer. From the compassion you write, I can honestly say that you are the type of doctor I seek out. As a patient, I want to know that what you are telling me is difficult, but that you will tell me anyway because you know I deserve honesty. As a patient, I want to hear the truth but with it I want some compassion. Before I got cancer myself I co-led a patient support group for the Leukemia and Lymphoma Society. I cannot tell you the number of stories I heard where a ED doctor would just tell a patient he/she had cancer and then leave. I know telling a patient these types of things is hard, but as a patient it is harder to hear when there is no compassion attached to it.

    I honestly believe that remembering what it might be like to be in the patient’s shoes and to keep this in mind when you are telling them things, is what will make you an amazing physician. As for the nightmares, I hope you find a good way to deal with them so you can move on and focus on the positive aspects of your job. In my case, I have 3 brain tumors that apparently aren’t going away but here I am writing to you and fighting.

    Thank you for caring and entering into a profession that needs you, that needs doctors who will ask these questions! Best of luck!

  16. Kathy Torpie says:

    Shara – Please don’t lock me away in a box out of sight. I could be your your father or mother. I might even be you one day. My leg is gone forever, as is my short term memory. You don’t have to take my pain or loss on as your own. Just don’t close your eyes to me! Don’t take compassionate care and human dignity away from me too!

  17. From Both Sides says:

    The way the “white coated man” talked to this patient is so wrong and so sad.

  18. From Both Sides says:

    Dignity and compassion first in all things….a brief moment to hold a hand, a brief moment to let someone know that while things are bleak, you will do everything you can to keep them comfortable….that can mean the world.

    One should never let their feelings overwhelm them to the point where they cannot act or think rationally in the best interest of the person they are treating… sometimes you need to take a moment, take a breath….but sometimes, when someone sees that you too are holding back tears….or that one has slipped down your cheek…It’s ok…they know you are human, they know you care.

    Medical treatment often CAUSES pain…people endure the pain or side effects of a drug a doctor administers because it equals hope of mitigating a current or potential greater pain (i.e., if I don’t get this done, things could get really bad). They are scared, they make the appointment because there is something about their body they can no longer control–and what is more sacred than our ability to manage our very selves?

    When a person is ‘difficult’ (I hate that term) perhaps it is because they feel a greater loss of control….in the form of feeling misunderstood, of feeling that someone does not comprehend what a given treatment or condition will ‘do’ to their life outside of the medical office. A sore knee in a doctor’s office is one thing. When it’s time to climb the stairs into ones house or get off a toilet, it’s a whole different thing. Life continues beyond the hospital walls and one must not forget that……

  19. Pingback: An Introduction: Sharing Stories with Strangers | This May Hurt a Bit, Scientific American Blog Network

  20. Julie says:

    Here’s the lesson that I would encourage you to take away from this encounter. Don’t forget it. Please continue to let it touch you deeply.
    Go find the social worker and learn how compassion approaches such a problem.
    Figure out what didn’t feel right about that situation. Was it the patient who needed to go in a box? Or was it the approach that your “teacher” was offering that needs to be questioned?
    Promise yourself to never be standing around a bed with another bunch of overtired strangers and being that person who says, “Can you repeat that after me? Your leg is amputated.”
    This is the kind of thing that you must realize that you are learning from your trainers – how to NOT be like them.
    There is a balance between recognizing and feeling someone’s hurt and not letting it overtake you. Professional training programs of all kinds tend to call it empathy. After all these years, I call it compassion.