A glass of water.
Cancer management is developing at a rapid pace. Since it requires a multidisciplinary approach, in most large cities dedicated cancer care institutes have come up that provide holistic care to cancer patients. Most cancer patients directly approach these centres for specialized care. Plastic surgeons play an important role in reconstruction following excision of malignancies but owing to the reason stated above, it is rare for a freelance plastic surgeon not working at a cancer institute to encounter such patients. And rarer so to get something to write about such an encounter!
This is a (real) story of my rendezvous with Mr. SN.
My first meeting with Mr. SN can’t be described as a pleasant one, not even in the wildest of imaginations!
Before I begin my narrative, I wish to briefly outline the facility that lead to my brush with Mr. SN. The general surgeons at our hospital have an attached dressing room while all the surgical super-specialities share a common dressing room. I being a plastic surgeon, dealing with trauma, burns and reconstructions, occupy this other dressing room (henceforth called as dressing room no 2 or DR2) for maximum duration of time on any given day. Almost all my patients need dressings and going by the teachings of my MCh professors, I never (I repeat never ever!!) hand them over to anyone else. I have hence, been declared the uncrowned queen of this DR2 by the staff who time and again joke that the DR2 should be officially declared as the Plastic Surgery headquarters for all practical purposes. Being the one who has kind of usurped the DR2 ever since I joined there, I have always enjoyed the privilege to finish my dressings first.
All was going as per the routine, until one fine day when my queendom stood challenged! And the one who challenged was none other than Mr. SN! He had been shifted into the dressing room by the staff on instructions of the spine surgeon and for one whole hour he occupied the DR2 as the surgeon hadn’t yet finished his OPD consultations and wasn’t able to come to the room to dress him. The patient could not be moved in and out of the room again and again as he was paraplegic and recently operated. Hence, the staff gave me a sorry look and asked me to wait until the spine surgeon came and finished the dressing. Left with no option, I returned back to my OPD room and finished evaluating my remaining patients. By the time I came back to the dressing room, another hour had passed by. However, to my dismay the spine surgeon hadn’t yet arrived and my patients had started breathing down my neck complaining that they had been waiting for nearly two hours for dressing. Although I could empathize with SN’s condition, somewhere inside I was fuming (in all probability due to the challenge posed to my territory). Added to this, nagging by my patients and their attendants raised my temper further. With great difficulty I swallowed my anger and decided to wait, until a call from the OT sister broke the last straw of my patience. I had posted a case at 2pm but some emergency case had come which they wanted to post at 2pm and since the OT was free before that they wanted me to start my case at 1pm and finish it before 2pm or else to operate only after 7pm. A quick glance at my watch and I realized that it was already 12:30pm and all my patients requiring dressings were still waiting for DR2 to be vacated. With all my patience tested, I marched towards the staff nurse seething with anger and expressed great displeasure at their lack of co-ordination with the doctor. I suggested that next time they should take any patient inside only when the concerned doctor had come to DR2 and not in advance and block the room causing inconvenience to other patients for hours at stretch. She responded saying that she was just a staff nurse and couldn’t say no to orders from any doctors. Mr. SN and his attendants were all ears to this conversation and by the look on their face they weren’t exactly pleased by my suggestions to the staff nurse. To my relief as soon as my conversation with her ended, the spine surgeon had arrived. He finished dressing, SN was shifted out, I hurriedly finished my dressings and headed to the OT. This was my first meeting with SN!
I had learnt from the staff nurse that SN would come for dressings on alternate days and I made it a point to finish my dressings before he came so that I never encounter him but little did I know that fate had different plans! I kept bumping into him or his attendants almost every other day for next couple of weeks, somewhere in the waiting area or near the dressing room. Needless to say, the look on their faces suggested that there was a kind of cold war going on at my supposedly unconcerned and unkind suggestions to sister at SN’s first visit. Over a couple of weeks after my first brush with him, I learnt that SN had been operated for some spinal tumor. A month into my first encounter with Mr. SN, I had almost forgotten the incident when the spine surgeon called me one evening asking me if I could see one of his patients who had developed wound dehiscence following a surgery. I asked him to send the patient the next day to my consultation room. To my surprise the patient was none other than SN! He and his attendants were aghast to see me. With great reluctance they let me see Mr. SN’s wound. He was having marginal necrosis with total dehiscence of surgical site and frank CSF leak. He looked much weaker and exhausted than when I had seen him for the first time. He coughed badly and was diagnosed as having severe bronchopneumonia and uncontrolled diabetes besides the wound problems. On going through his medical history, I came to know that he was 83 years old diabetic, operated for a spinal tumor at the level of 9th thoracic spine a month ago. He and his family at the time of diagnosis itself had made the decision that they would let the spine surgeon remove the tumor in the hope that patient’s paraplegia improved but in case it turned out to be a malignant tumor they would not want any adjuvant therapy. Histopathology and immunohistochemistry had revealed it to be a low grade B cell lymphoma but the patient only wanted palliative treatment. It was decided that the patient would be admitted under the spine surgeon for observation of CSF leak besides being treated for bronchopneumonia and I would look after his wound and daily dressings. After discussion with the patient it was planned that once Mr. SN’s pneumonia improved, the CSF leak would be repaired and flap cover would be done for his exposed spine so that the quality of his remaining life would not be compromised.
Nervousness was palpable on both sides! From their looks and attitude, it appeared that the patient party wasn’t very comfortable with me managing their patient. On the other hand, even I wasn’t exactly keen to manage a patient whose family did not trust me or my intentions. After a long deliberation and convincing by the spine surgeon, the patient agreed to be treated by me. For the first 2 days, I would visit the patient daily, do his dressing, write my notes and come back. I wanted to talk to the patient but he was too breathless to talk. Attempts to talk to the attendants were also not paying off as they were reticent for initial 2 days.
On my third visit, the patient’s general condition had improved a bit. As soon as I wished him good afternoon and he opened his mouth to respond, I noted his dry tongue. A quick glance at his urobag showed dark coloured urine. The next question was a spontaneous, “Are you thirsty? Would you like to have some water?” Back came the response in affirmation by nod of his head. The attendants had been asked to wait outside till I finished my dressing and the sister had gone to arrange for dressing trolley. So I spontaneously picked up the glass kept on the table besides his bed and poured water from a bottle kept there. SN eagerly snatched the glass from me like a child and in a matter of seconds drank the entire glass and asked for one more. I happily obliged. I was all smiles inside somewhere patting myself, at having diagnosed his dehydration when he broke the silence and said that “How did you know that I wanted water? You will become a very good doctor one day. You can read through a patient’s mind. I was thirsty for quite sometime now and wanted to drink water but doctors and sisters have been coming for rounds back to back and then they had started me on nebulization so I couldn’t drink water.” I finished my dressing and went to write my notes, after which I left the hospital. This was my first conversation with SN! And it left me happier as that awkward silence was broken.
On my fourth visit, he had improved a bit further clinically and to my surprise opened up to me about his family, life and profession. His family also shared with me the challenges they had been facing since he was diagnosed with tumor. They told me how his life came crashing one fine day when he suddenly developed paraplegia. According to his family, he was an extremely self-reliant person whole life and the news of tumor had broken him completely inside. On my next visit, he had a childlike excitement in his eyes and told me that his childhood friend along with his wife were coming to see him from Chennai. He excitedly shared what all he had asked his wife to cook for his childhood friend and how he had been asking his son to call her every now and then to know if everything that his friend liked was on the menu. Over next four days, I had gained the trust of the patient and his family and they would share important events of the previous day with me. They had become comfortable with me and I had renewed enthusiasm to treat the patient who showed trust in me. After all, finally they and I were on the same page that they would let me try my best to heal his wound. Rest they wanted to leave to God.
Suddenly, SN became critical the next day and needed ventilatory support but he and his family had decided against the same when he was fully oriented and had signed a note in advance at the time of his admission. To my disappointment, by the time I reached the ward they had already left with him against the advice of his primary doctor and I couldn’t meet SN that day. As I was leaving, the staff nurse handed me a note they had left for me. I opened it with trembling hands. It said, “Thank you doctor for all your efforts but he wants to spend his last days at home. Hence we are taking him.”
I do not know how long he would survive but "the glass of water” that broke the ice between him and me is going to stay in my memory for quite some time. On reflection, I realize how a small spontaneous act as small as offering a glass of water changed my equation with the patient. A patient party that had been almost been at war with me (sans the visible weapons of destruction!) had suddenly started respecting and trusting me and my treatment. I realized that there may be times when we may not have exact solution that can cure patients but small acts of kindness that show that we care for them can ease their pain a bit and help them spend their last days well. This is especially true in patients with cancers. Even with all advancements and pathbreaking researches we will many a times encounter situations where we cannot scientifically help such patients much. As I walked to the DR2 with a heavy heart, Leo Buscaglia’s quote echoed in my mind ,”Too often we underestimate the power of a touch, a smile, a kind word, a listening ear, an honest compliment, or the smallest act of caring, all of which have the potential to turn a life around.” This incident brought to my mind the famous quote by William Osler that I couldn’t comprehend when I read it for the first time as a MBBS second year student,
As I reflect, I also wonder at what would have been my response had I drank a “glass of water” my own self when I was fuming on the very first day of my encounter with SN. Could it have extinguished my anger resulting in a calmer approach to the staff, no cold war from patient party and lesser stress to myself? Well… that only a “glass of water” would be able to answer, when I drink it next time I’m displeased with a situation beyond my control!
Till that happens, I leave all the readers to reflect on the Hippocratic advice of, This quote perfectly sums up what we as crusaders of cancer need to remind ourselves at all times.
“You will become a good doctor someday”
“Cure sometimes, treat often and comfort always!”
“A good physician treats the disease; a great physician treats the patient who has disease”
These are three quotes I have taken from the real-life experience narrated by Dr….
Most of us become good doctors as we progress in our profession if we have the right attitude. The very sick Mr. SN realized that Dr…is after all not such a bad doctor when he was given that much needed glass of water. He did not say, you are a great doctor but said, “you will become one someday”.
Many of us when we enter medical school harbor high ideals of service, compassion, helping the sick and needy and other similar ideals. During the many years of grueling training, these take a back seat and are replaced by the ambition to become some body, earn reputation and money, and climb the social and professional ladder. Patients and their ailments become steps in this direction. In the bargain, many of us ignore health, sleep, exercise, family, friends and other interests. Real happiness becomes a casualty and quality of life suffers in this pursuit.
Focusing on the management of disease becomes more important than handling the human being with the illness. This is particularly so when one climbs the ladder of specialization. When one is stressed with work, especially the work as described by the doctor who is a plastic surgeon working in a cancer hospital, where he or she must be seeing very many seriously ill patients, one is in danger of becoming inured to suffering.
One major complaint, many patients have is that we are not concerned about them. One hears patients stating, “he did not even place the stethoscope on my chest” or “he did not even ask me why I am there” or “he just looked at my reports and wrote out a prescription”. Often, we take our patients for granted and do not think that their concerns are of great importance, as we already know what is wrong and what to do. But patients have many worries and concerns and want to share these with us. It is our duty to listen to them even if these don’t always make sense to us.
We sometimes forget that in their own field of endeavour, they are more accomplished and they are here at the receiving end, not out of choice but because there is no other go. When we seek help from other professionals, say an engineer or an accountant, don’t we expect courteous interaction? We, more than in any other profession, need to be better at human relationships, because we are dealing with the suffering.
If one removes the relationship between us and our patients, we become mechanical robots - often very efficient ones - as many of us must have become... This is the death knell of our profession. Relationship, whether transient or prolonged, is the foundation of satisfaction for both doctors and patients. As aptly described by the author, the act of giving a glass of water triggered the development of this relationship and made the author progress towards becoming a “good” doctor.
This relationship is not just with the patient but also with his/her family, relatives, and other well-wishers. It is not merely medical, it is also social and psychological. Can one have a relationship with out getting affected? The answer is no. Involving oneself with the social and psychological aspects of a patient’s illness can be distressing. However, one needs to participate and be a part of patients’ worries, concerns, and not infrequently, their joys.
We, more than in any other profession, have this unique opportunity to become better human beings if we learn to treat patients as persons and not a collection of organs. There is also a possibility of being healed ourselves.
This appeared in the Indian Journal of Cancer and it's editor, Dr Sanjay Pai has permitted it's posting here
This appeared in the Indian Journal of Cancer and it's editor, Dr Sanjay Pai has permitted it's posting here