Tuesday, November 11, 2014

Dr. Orthochick: Respect

On Friday I was walking from Point A to a rather remote Point B and I ran into one of the peds ICU docs so we walked together. (side note: I have no idea how I know the peds ICU docs because I try to stay out of that place, but for whatever reason, I've always been the type of person who knows everyone. This happened to me in med school too)

Me: Hey, is everything OK? You seem sort of...bummed.
PICU Doc: I pronounced a kiddo this morning.
Me: Oh wow. I'm sorry.
PICU Doc: His father is probably going to go to jail.

I'll spare you the details, but it was probably one of the most sickening child abuse cases I've ever heard. (And if you're in ortho, you see child abuse. And domestic violence. And elder abuse. I don't talk about it much, but I see a fair amount of it.) Not to get too graphic, but the six month old baby had multiple skull fractures and had been shaken so hard that the gray matter of the brain couldn't be differentiated from the white matter of the brain. And that was just the injuries he had to his head.*** I wound up talking down the PICU doc for a while which was a little strange since I don't really know him, but he kind of seemed like he wanted to talk.

I've also been to some really sad places lately. The other day I was doing something in the ER and one of the general trauma docs (Dr. MarineBerg) asked if I could help him for a little while because he didn't have a resident and a Tier 1 trauma was coming in. So I followed him into Trauma Room B, gowned and gloved up...and the medics brought in a dead 13 year old. Gunshot wound to the chest. Dr. MarineBerg pronounced, I left the room.

The reason I bring all this up is because I was involved in a (different) upsetting case the other week where a 20 year old guy tried to kill himself by jumping out of a building. He broke his neck, his back, both legs, both feet, one arm, and lacerated his liver and his lung. One of his ankle fractures was open so we had to go to the OR to wash it out and do what's known as "damage control orthopaedics." (DCO for short) He was hemodynamically stable, intubated, and appropriately packaged by about 22:00 so we headed up to the OR then.

I really try to not get holier than thou, but I was disgusted by the behavior of most of the OR staff. The anesthesiologist said repeatedly he wished the kid had succeeded in killing himself so we wouldn't have to operate on him now, the circulating nurse said it pissed him off that our tax dollars would likely go toward the guy's medical bills, the scrub nurse said we should just finish the job and kill him in the OR, and my attending said he couldn't understand why we were bothering to save him since he was a suicide.

I'm sorry, I'm better than that. I was raised better than to make comments about how people should kill themselves and I"m not even going to make a comment about finishing the job as a joke. That's disgusting. I know it's late at night, but that's the sacrifice you make when you go into medicine. Sometimes problems don't happen between 9 and 5. Yes, it's inconvenient, but here's someone who really, really, really needs help. Let's do this. No, it's not what i was planning on doing with my Saturday night, but it's my job and I will do it to the best of my abilities. So I wanted to tell everyone to please refrain from making comments like that, but I didn't want to come off as holier than thou. So I didn't, but I wish I had.

I am very sensitive and I worry that since this stuff upsets me to the level it does, maybe I'm not cut out for trauma. But if the peds intensive care doc can still get upset when kids die and be a damn good doctor, then it's OK for me to get upset when people get hurt.

And quite frankly, I wouldn't want it any other way.

***If it is any consolation to anyone, all of his organs were harvested. Heart, lungs, kidneys, intestines, pancreas...everything. I think there were three transplant teams working at the time.


  1. One of the things that drove me to go into psych was the fact that many of the patients I saw on other services were there due to untreated/understated psych issues. The access to psych here is atrocious and the way that I saw these patients being treated by other providers was often horrifying. It should be upsetting that a 20 year old had so little hope that he felt like suicide was his best option and it's really awful that he's going to be handicapped for life now. I'm glad at least one person in the room had some empathy.

  2. Yes, the organ donations helped.

  3. Great post. Working in Emergency, it's amazing how often psych patients are viewed as and described as "a waste of our time". Presumably this attitude is driven by people's own ignorance and fear of mental health issues. You'd think doctors would know better.

  4. Would those doctors/nurses have felt differently if they were working on a patient who had been *pushed* out of a building and sustained those same injuries? This guy needed you EVEN MORE.
    Don't lose your sensitivity and compassion. Personally, I think they are essential qualities for a good doctor to have.

  5. I've experienced such negative views from colleagues as well and it really upsets me. I never know what to do either. The last thing I want to do at work is get in an argument or a debate. But I always feel guilty for not saying anything.

  6. Your patients are very lucky to have you and I hope you will retain your empathy throughout your career.

    I can't throw full shade on the other docs & the scrub nurse as I think it's probably hard for them to wrap their heads around someone throwing everything away when they doggedly fight every day to save people from unexpected, horrific trauma. They probably have a high degree of "compassion fatigue" working in a (inner city?) trauma center where they see a lot of terrible things. And it truly is a shame that this guy's care will cost hundreds of thousands of dollars *and* leave him handicapped for life because of an intangible, if powerful, thing like hopelessness.

    While none of this justifies the comments, maybe it helps to explain them. I doubt that every person who made ill comments is 100% a**hole.

  7. Thank you, Dr. Orthochick, for this post. I wish there were more forums for discussing these things. And I really appreciate your particular voice, so I hope you keep using it. I am a med student and really concerned about how to best prepare myself for the vicarious trauma of this job, without losing my humanity. And I am also concerned about picking a specialty that won't burn me out. This exercise is more than theoretical, due to my prior job as a crime reporter. At the time I was really young, with no training specific to the stresses of the job, and had no experience having a gun pointed at me (that happened), seeing five kids in a Geo metro wrapped around a traffic light (that happened), seeing the remains of a suicide by train (ditto). When that last thing happened, my editor asked if I wanted to day off. That offer just pissed me off. I was like - 'that was nothing - where were you when all those other things happened!' … But of course I realize now I had never talked about any of that. (Or the death threat I received). I was trying to prove myself in a tough profession. And somehow my image of what that meant was stoicism. I know now going into this new profession that I was not equipped for those types of stressors. I still am not. And medical school certainly isn't preparing me formally, at least. There are the basic things we can do. Have a support system. Listen to yourself. But structurally we have no methods of obtaining a "mental health day." There is no pause button on clinical duties. There is no safety net for health care providers. We know we need to exercise and rest and spend time with the people we care about. We just don't always have that time. It is dangerous and irresponsible system and we, of all people, should know better. How can we take care of people who really need it when we can't take care of ourselves? (I agree - the behavior of your colleagues that you recount is just awful. I don't want to excuse it entirely because I believe there is more to it than this. But I also hear that these are people who have had aspects of their humanity stripped away - so they are behaving inhumanely. That's a pretty reasonable outcome for a pretty unreasonable set of expectations.) … This was a long post - but lastly - I am concerned about the abuse by patients in medicine. There is no great way I know of (yet) to handle this. This particular article seemed like half the story. Any thoughts on the other half, what to do about these situations: http://www.slate.com/articles/health_and_science/medical_examiner/2014/11/sub_human_pos_doctors_acronym_for_the_worst_patients_is_shpos.html

    1. That article took kind of a weird turn. The author showed some pretty good insight here:
      "While being berated, I was aware of my heart pounding, and of the effort it took not to retaliate verbally and physically for this assault. I maintained my self-control, but at a cost. For days I ruminated over the event. I imagined that my struggle to contain my own anger had damaged my cardiovascular health. I felt humiliated in front of my colleagues and unmasked as a weak person not competent to manage difficult patients."
      Then she went on to completely blame the patient.
      My advice to you is to remember that no matter how frightening or abusive a patient is, you (the med student, resident, attending) are actually the one with all of the power in that situation. If someone threatens you physically, all you have to do is step out of the room and call security. If someone threatens or makes comments to you sexually, then again, go. Refuse to continue seeing that patient. If someone makes you feel stupid or look bad, remind them that they are being treated just like every patient in the hospital, and they are getting standard medical care for their illness based on the most up to date treatment guidelines. Just don't play that game where you are just a girl, and the patient is a (intimidating, threatening) man. This isn't just some encounter on the street. You are the medical student/doctor, and he is the patient. Even if it feels like play-acting, you have to remain in that role.
      Also, always stay between the door and the patient, and leave the door open if you feel uncomfortable.

  8. I am so very sorry. First because you have humanity and that's hard to have in medicine. Second because how others were acting. We patients know they judge us, and its why we lose trust in medicine. Instead of letting things go, it interferes in care. That's what other docs have said. Time and again Ive seen if a doc likes you, you get good care, or you are connected. All it does is destroy trust and faith in docs.

  9. Unfortunately,I'm not surprised by the lack of compassion. It's the greatest epidemic
    that has and continues to face our nation. Perhaps when people stop thinking about
    their own hurt,and start focusing on other people's pain, things will change.
    However, based on what I've read on this blog and others, I highly doubt it.

  10. I thought I was pretty jaded, but that must turned my stomach. People say those things OUT LOUD in a professional setting? And YOU are the one worried about the reaction your words would get? I really really hope I never get to that state.