Graeme Rocker is a professor at Dalhousie University in Halifax
Editor’s note: Part I of this series appeared as a Humanities in CMAJ.
I woke from the anesthetic with the worst dry mouth ever and the agonizing sensation of a massive overfilled bladder being ripped apart from the inside. I let loose some very repetitive Anglo-Saxon expletives not generally expected of a health care professional. When asked to rate the degree of agony on the usual scale of 0 to 10, I spluttered 15! Finally, a hydromorphone bolus kicked in, and I then settled into a few hours of patient-controlled analgesia. At some point that first night I felt the most sublime sense of calm, as if my place in the universe was just as it should be and that all would be well for all time. I can only presume it was an opioid haze. It still felt as if a mule had kicked me in the pelvis, but for a while it just it didn’t matter. That remarkable feeling never came again, but I was awed by the powers that these drugs have when used in the right amount, time and place.
There were three special relationships in all of this. Two had already occurred (with my surgeon and anesthetist). One was to come. My own appreciation for the value of relationships has shifted as I have moved to lead a program of care that and continues in a . Caring clinical relationships can make a difficult experience bearable; their absence compounds any problems that arise.
The surgeon walked me along the operating room corridor, caring to the last, making me laugh even though I felt I was on my way to my execution. His post-op visit and willingness to be called anytime was hugely important to me. The anesthetist was not long home from Afghanistan and, to his eternal credit, expressed sorrow for what I was facing. He imbued our brief encounter with such a sense of competence, confidence and expertise that I willingly surrendered myself into his care. The third relationship involved a quite excellent urology resident who unblocked my catheter the first time it clogged.
All three seemed to understand that vulnerability transcends jobs, titles and intellect, and responded accordingly. In contrast, complete strangers wandered into my room at night unannounced, flashlight in hand, walked around silently and left, presumably having satisfied themselves either that I was alive or that there were no intruders. Someone officious swabbed my nose and my bruised groin, presumably looking for some exotic multiresistant pestilence with no more explanation than “everyone gets this.” Worst of all, a colleague of my wife’s somehow ended up at my bedside ahead of my wife. This unwelcome intrusion and others through a first night so fractured by the repetitive grinding sounds of the IV pump all conspired to make sleep impossible. If sleep aids healing, we have to rethink standard post-op protocols and redesign silent IV pumps with silence in mind. By the morning, I was totally ragged — emotionally and physically.
Patients have call buttons. I was no different, except when I pressed the button, hoping for some acetaminophen once the pump had gone, nothing happened. I waited a bit, then pressed again. My son traced the wires. The plug had come adrift enough so that no message was being transmitted or received. It doesn’t take much imagination to wonder what might have happened if I had been a more elderly man with similar difficulty shifting phlegm from major airways with limited respiratory reserve, alone and with a malfunctioning call button: potential for a medical disaster. Life and death situations don’t always present as obvious crises; some arise from the most mundane errors of omission, as the airline industry knows only too well.
Hospital stays often entail many service-type interactions. One involved the person who delivered breakfast but didn’t move the bedside table so that I could actually reach it. At this point, any stretching movement was a serious challenge, so this small act of caring would have been welcome. Another young woman had barely introduced herself before asking some absurd questions about my diet, food fads and whether I had experienced any unintentional weight loss in the previous two weeks. Her timing was dreadful. It would have been so much more valuable if she had provided some indications of what foods might speed bowel recovery and what to avoid. Instead, all she did was complete her check-list from her vantage point at the end of the bed. Standard care at a tertiary "care" centre meant well-meaning urology residents would blast in at 0630, wake me, fire some quick questions — always starting with “Any nausea or vomiting?” — then have a cursory look at my swollen belly before disappearing. I don’t remember any of their names, and I don’t recall any of them addressing me by mine, or in any way recognizing me as a colleague. To such transient visitors, I was more than likely “the prostate in room number 37,” or more specifically, a staple line, a source of vitals, but never, it seemed, anything more than that. In a similar vein, I’m sure I was asked at least 20 times and had the answer recorded on numerous checklists that I was on no medications and had no known allergies. How ironic then that despite all these repeated checks, I arrived home to discover no prescriptions for pain relief within the discharge kit. Who knows where or in whose hands the hydromorphone prescription ended up. I had lesser analgesics at home, but what if I had not, or if I lived miles from any pharmacy and had no family doctor willing or able to prescribe the necessary medications?
Home at last, but not for long
Not long after getting home after the standard two post-op nights, bladder spasms led to floods of urine on the floor at home emanating from around — not through — the catheter. I called the ward and was advised, reasonably, by the nurse who had looked after me well in the morning, that if there was no improvement after drinking a fair bit, I was to return. There was no improvement, so I showed up on the floor a while later and encountered a second nurse who told me that I was in the wrong place; I wasn’t an inpatient and I should have gone to the emergency department at a different hospital half a mile away. Moreover, it should have been a simple matter of flushing out the catheter, but I’d had no instruction prior to discharge on how to do this, and I had received no necessary equipment. My wife was equal parts horrified and mystified: “Flush out with what and how?” At that point, I was parked in a small waiting room for family members wondering how it would look if I urinated all over the floor. How quickly we sacrifice patient in favour of expediency when we don’t want to be bothered, particularly towards the end of a shift. It was especially galling to feel that I was an inconvenience.
From the moment the excellent on-call resident looked in (relationship #3), the situation improved immeasurably. His manner was reassuring and professional. I felt like he cared about me rather than about process and protocol. He had to be a bit more aggressive than I would ever dare given new suture lines connecting my urethra to my bladder, but eventually clots moved and flow returned. I was content to remain overnight before being discharged again the next morning.
Health care really worked a few hours later when, after being discharged for the second time, the catheter blocked again. I called my surgeon. “Any problems?” he asked. “Same thing,” I said. “Come straight in to the urology clinic,” he said. Friendly nurses ushered me in, gently escorted me to a procedure room, all paper work taken care of and then a clinic cystoscopy to identify and flush out remaining clots. Never comfortable, but all done with such professionalism and grace that it warmed the heart while solving the problem. No futzing around, no ridiculous side journeys to an over-stretched emergency department — just the right intervention, at the right time, by the right people. After that second complication (or “hiccough” as my surgeon preferred to call it with a grin as he told me that I had wrecked his readmission stats), I was a bit paranoid. As it happened, this proved to be the major turning point and the start of a recovery that has since moved on more smoothly.
Author’s note: I acknowledge that my experience as a physician may not be typical, but this is an accurate account of events from my perspective. Part III will end with a series of suggestions that I hope will provoke discussion and wider debate about the true meaning of care.