Bharadwaj V. Chada reflects on the human side of patient suffering
“We’d made a promise”, she began carefully after much deliberation, “that if either one of us took ill, we wouldn’t come into the hospital to visit”.
Her words were heavy and loaded with emotion, belying her every instinct to come and see her husband, their earlier agreement straitjacketing her natural impulses. The hospital’s official stance was straightforward: relatives and carers were permitted to visit their loved ones during the terminal stages of their illness, at the discretion of the nurse-in-charge. The policy was largely a welcome one; the permission to visit offered a rare moment of humanism amidst the glib world of restrictions, guidelines and protocols to which we had become so accustomed. Yet at the same time it rang hollow, a safe distance away from the families forced to make these decisions. Balancing the risks to their own health with a desire to see their beloved for the final time; reconciling the impacts of quarantining on work, childcare, and shopping for groceries; juggling the guilt that would linger in their heart with the common sensibilities that presided over their head. As doctors, sincere and conscientious though we were, the best we could offer were platitudes: “we’ll continue to keep you updated”, “the option to visit remains open”, knowing in our hearts the outlook was dire. We were at the behest of hospital guidelines, powerless to make the decision on their behalf.
The new year begins much like a macabre Groundhog Day, the Pfizer and Oxford vaccines the only silver lining in a cloud otherwise leaden with record numbers of cases, overstretched hospitals, and a beleaguered workforce. There lingers in the air a sense of resignation and fatigue, a pervasive aura that is invisible but no less stifling. Fatigue from the intractable easing and tightening of restrictions; fatigue from social isolation and disruptions to routine; fatigue from the daily reports of case numbers and death rates, each reduced to a statistic.
As healthcare professionals, indefatigable in spirit if fatigued in mind and body, we were grappling with an emergent and dynamic body of evidence, best-practice medicine one day discarded as nonsense the next. The more academically minded and inquisitive would regurgitate the latest scientific trials, confidently presenting to their colleagues what they considered to be the panacea to this mystery illness. The more circumspect would wait for treatments to be operationalised into trust guidelines, a case of policy governing practice.
It became simpler – preferable, even – to view the illness as the sum of its management: home if 48hrs apyrexial; dexamethasone if requiring supplementary oxygen; ward-based care for the elderly and infirm; palliation if desaturating despite high-flow oxygen. This was hardly surprising. Remaining emotionally dispassionate offers a necessary defence against the trials and tribulations of working as doctor, now more so than ever. Yet much as the death count condenses each of those patients into a single percentage point, so too does protocolising their illness overlook their story, their values and convictions, their memories.
I recall an incident earlier this year of a gentleman, Mr. S, in his early sixties who had presented to us with decompensated heart failure secondary to restenosis of his aortic valve replacement. We had offloaded him satisfactorily and referred him to the cardiothoracic team for consideration of redo surgery. They had agreed he was a suitable candidate for the procedure, preferring to perform the surgery as an inpatient given the uncertainty surrounding elective and semi-elective lists. We worked-up the patient with the requisite tests including a coronary angiography and CT coronary artery calcium score, and he was awaiting a pre-procedural transoesophageal echocardiography (TOE). There had been a considerable delay in performing the TOE, more urgent cases pushing Mr. S down the list.
Mr. S nonetheless remained steadfast in his patience and amicability, quick to befriend his companions in the bay, and making the ward altogether more convivial than one would imagine an otherwise dreary heart failure unit to be. On the day of the TOE, I had been informed during the morning handover by the nurse looking after Mr. S that his younger brother had passed away unexpectedly the previous day. During the ward round, a customarily brief affair, Mr. S – whom I’d by now developed a good rapport with – was visibly downtrodden, and I made a mental note to return after the TOE to speak with him.
Later that afternoon, as I busied myself with a pile of discharge letters, the nurse overseeing Mr. S’s care walked with intent into the doctors’ office, bringing it to my attention that he had returned from his procedure a short while earlier and had now deteriorated markedly. I quickly attended to him, observing him to be distressed and short of breath, tachycardic, hypotensive, and febrile. Coarse crackles could be heard, too fluid overloaded to even need a stethoscope. I immediately sought the assistance of my colleague, and no sooner had the antibiotic been drawn up, Mr. S went into cardiac arrest. The crash team arrived with typical urgency, as my senior medical and ITU colleagues took over, their composure and professionalism under the circumstances a source of awe, were it not for the gravity of the situation. Unfortunately however, despite thirteen cycles of CPR and our best efforts, Mr. S never regained consciousness.
His wife had been informed by the ward staff that he had deteriorated, although she was not yet aware that he had passed away. She arrived a short while later, and we took her into the quiet room, a solemn assembly comprising myself, the nurse, and a medical colleague. It was my first – and to date, only – experience of having to break the worst of news, and it’s true that no amount of communication skills training, role play, or OSCE practice can prepare you for that moment. My voice rang hollow and meaningless, as I grappled between maintaining a respectful silence and offering vacuous words of scant consolation. I observed as she oscillated between agonising grief, disbelief, and an inspiring resolve to pick up the pieces and move forward.
A congregation of my senior colleagues assembled outside the quiet room within earshot of us, offering their thoughts as to what may have caused this rapid and unexpected decline; the TOE operator wondering if it was a post-procedural complication, whilst his colleague made reference to a case of acute pulmonary oedema with concurrent sepsis he had seen some years earlier.
I was not surprised that this case piqued their professional curiosities; on an academic level, I too was intrigued by the sudden deterioration. Yet that day, as I watched the impact of my words play out and shared a part in her grief, I realised the far-reaching effects of practicing as a doctor, extending well beyond prescribing medications, performing procedures, and verifying deaths.
Interventional cardiologists and orthopods are more than the sum of their angioplasties and hemiarthroplasties, a fact not lost on the millions of appreciative patients passing through this NHS every year. At this junior stage in my career, it would be remiss of me to be virtue signalling to my colleagues, and it goes without saying that desire to better the lives of our patients is the lifeblood that courses through the veins of our clinical practice. Yet now more than ever, as our health system finds itself at an indeterminate and unprecedented juncture, and families increasingly reliant on healthcare professionals as the emissaries of information, we would be well served to remember the patients and stories behind the hospital numbers.
Bharadwaj is an Academic Foundation Year Two doctor currently working in the East Midlands.