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.
From here on it is my editorial comment as requested by the
editor
“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.
Note
This appeared in the Indian Journal of Cancer and it's editor, Dr Sanjay Pai has permitted it's posting here
