Empathy is good, but not too much

          Today my Professor was asking us how we can be so happy when our patients lie sick on the bed. Then he started talking about empathy, but some topic came across and it was left in midway. But recently I have also felt that change in me. The change in thought process, the change in behaviour, the change in the way decisions are made, the change which crept in slowly over the long years of medical education and training.

          I am talking about the empathy. Earlier during undergraduate days, I did not like to go and take cases of patients who are sick, because I shared their feeling and I had nothing to offer them other than kind and sweet words.

       But now when I see a patient, first thing I want to find is, how is going to get benefit from my treatment. If he or she is not going to benefit, direct them to where they can get better advice or if they have a non curable disease, explain them and make them prepare for it. I don't find sharing their feelings and expressing them a necessity.

      Marking a boundary for the empathy towards patient is so important. An extra emotional attachment to the patient often blinds the surgeon and makes him take decisions, consequences of which are not identified until it is late. For example he might take a decision to avoid a protective stoma over an anastomosis thinking of the morbidity of patient and ends up with a leaking anastomosis. Things, like delaying the insertion of a Ryle's tube in the hope that patient may recover from a post operative ileus, is very common in a surgical ward.

       The epitome example of what I described here is the triage system. There is no point in decision making based on human emotions in medical field. The one who is going to benefit, should not miss the treatment.  

Earth Quakes and after effects

         Earth quakes are national disasters and associated with lot of pain and suffering. It is not a good thing to happen. I have experienced a significant shake once, but not severe enough to cause any casualties.

       Our operation theatre is on the top floor of an eight story building. The time when I experienced the quake, we were in theatre. We had just completed a surgery and I was accompanying the patient to the recovery room. Then we felt the shake. It was a swinging movement, I felt like the tall building swinging to both sides, the theatre lights hanging from the roof moved away form focus, the small trollies with rollers moved a bit two and fro. A lightning of panic stroked and the people started running outside. The interesting thing was the expression of the surgeons and staff who were performing surgery in other theatre rooms. They were standing perplexed, waiting for the trembling to subside.

      This time during the disaster in Nepal, some trembling were felt in our hospital too. I was far away at my home, but my colleague told me about what happened here. It was our breast cancer clinic day. He was giving first dose chemotherapy for a patient when the building started to shake. The poor patient lying flat on bed saw the fan on roof swing here and there, felt the shaking movement of bed, thought  it was the effect of the chemo medicine!

       The panicked people started to make noise and rush outside. Our professor was persuading people to sit at their place and be calm. He said to the residents  'If we are going to die, let us die doing our job'. Fortunately no one was injured.

Weird dreams and some retro

               After a very hectic week came the day I was expecting for last 3 months, I am going to my home and I am writing this sitting at the waiting lounge in the airport. Need to mention in this last week, I dreamt twice of missing my flight home. At the first instance I was late and by the time I reached the gate of airport, the plane was locked and ready to fly. The second time was stranger. Hanging with my work colleague, I reached the airport late, only to know that the flight was cancelled because there was a fire in the plane. So ridiculous are these dreams.

               Left with nothing to do, other than staring at other people waiting with me for the flight, some childhood memories just passed through. How joining the medical field gave me some new light on some misinterpreted facts of past.

 

                There was a physical education teacher in our class when I was nine. She was a well-built lady with more than average height. The catching feature was her left arm was bulkier than the other. She used to take us to the ground and teach us warm up exercises and Physical training drills. I and my friends believed that her arm is bulkier due to the extra exercise she does with that arm.  I still remember those days when it used to rain outside, we had to sit inside the class room pondering at her big arm. May be memories are getting fader, or I am adding extra tones to it, but she used to look dull and may be depressed.

                A year or later she disappeared. I had already moved to Upper primary and we had another Physical education teacher, although her absence on PT ground used to strike me. Some more years later, the news waved through the school that she passed away. She was suffering from cancer. Now looking back, I guess she must have already been operated for breast cancer years back and was having lymphedema which we misinterpreted as a muscular arm.

"If you want to have a sound sleep at night......"

      "If you want to have a good sleep at night......" This is a very common idiom used by surgeons when they advice a colleague or teach juniors. Usually this is completed by something like "...you have to doubly ligate the vessel" or "....you have to over sew the staple line."

       So what is this that is going to impair the sleep at night? The fear. Surgeons' sleep is crippled by many things other than just fear of medico-legal issues. My Senior consultant often says that he could not sleep well before the day of a complicated surgery planning and thinking on how to tackle it most effectively. Since I haven't started doing any major surgery under my own responsibility I never had gone through such situation.

       When some big shots get admitted, sleep is deprived for all the persons on duty irrespective of hierarchy. Because big shots come big responsibility and every five minutes some one will call either to know about progress or some trivial things. Another stressful situation is when some relatives or people from our own regional area get admitted. We are influenced by so many things and we want to make them feel contend.


         But the one I have felt is when we operate a patient and his or recovery gets deviated from the normal course. This is the most difficult situation. It get worse when the recovery depends on time and the clinical findings are such a way that everything is inconclusive and you don't know whether to operate and over treat or watchfully wait. This is time where one wish there was a  person to advice. I have got my senior consultants now and I feel protected. But when they get similar problems, they get their equally experienced colleagues to involve and help them. This is the time when a surgeon ask for opinion from every one, including the juniors, residents on some input that could be useful. The time for some one to support. Sleepless nights become a common story then.

        I know that this is a risk associated with surgical field. A plastic surgeon may be worried of the flap viability,  A vascular surgeon may be worried of the leak, A thoracic surgeon may be worried of a broncho-pleural fistula, A gastro surgeon may be worried of a anastomotic leak. But as a part of training, the surgeons will acquire the acuity to ensure things that has to be done are done during surgery, so that they don't have a problem sleeping at night.
      

Knowledge do not come free

       "You have to earn bread with the sweat on your forehead"

 

 

              Recently our department conducted a one day work shop on thoracic surgery. It was a very useful program especially for residents. Since our unit was the main pillar of the program I was in charge of the audio visual co-ordination on stage. Well the nothing but collect the power point presentation from the presenters before hand and load it to the main computer ( that's my Angelina Lignocaine ..lol ) and maintain the continuity of program.

 

 

             So after the symposium residents were approaching me to copy the presentation. I have also done the same thing so many times, copying and saving stage presentations. But the when I think back, these thinks seldom become useful. Most of the time they get pushed back and back to some corner of the computer and never ever opened.

 

            Even if some of the presentations are opened and read they wont add much to the knowledge. It is actually the knowledge of the presenter that is imparted to the audience and the presentation as such does not give any advantage. Only time when a Power point presentation has helped me is when I prepare it. Then I know what the resources are and the idea conveyed in each slide.   

 

 

        So when I see this people roaming around collecting Power points, It comes to my mind

"Knowledge has to be earned with the sweat on forehead" There is no way to acquire knowledge other than the hard way and knowledge is converted to wisdom by experience.

 

        In this occasion I also remember how I started my presentations. The first one was in the anatomy hall, with hand drawn charts. By the second year we used to have Projectors and OHPs. And gradually came the era of computer presentations, bulky projectors and power points. After all I still feel the control you have when you present with a marker in the hand on a white board is the best one.

Habits

           I don't believe and I haven't met any person who loves to come to a hospital, whether as a patient or a staff. Even as a doctor, I am not attracted to hospital. Given a choice I would prefer to stay away from all those sufferings and be in a place where people come for peace and fun. It is true that there is always a heaviness in the heart while going to the hospital and feeling of lightness while coming back.

          There are two ways to reach the hospital building in our campus, one is straight ahead to the hospital building and the other passes between the library and auditorium. Somehow it has become a habit to go through the one straight to the hospital while going for duty and coming back through the other one. I thought it was just me, But no. Once the passage in front of the library was closed, and my senior colleague was looking slightly sad while going back. I asked why, then he said he also prefers to do the same.

       After all it might be just a display of predisposition for Common Wealth nation citizens to keep left on road.

The way straight to hospital complex

The way before library

Delhi has a weird winter!
 

 

Ego - The inevitable evil

           What I am going to share is something, everyone who has done a government job will understand. Not just a government job, any job for which you are paid without any feedback from the clients or any job which is not paid but done on compulsion. The ego, it is an inevitable part of human nature. It can be observed from the lowest level of hierarchy to the highest.

          Now a days I sit along with my consultant in the Out Patient examination room. I take history , examine the patient and discuss with him and take decisions. He is a very cool reasonable and experienced surgeon. More than just being a good doctor, he also have good observation skills and he has a great knowledge of human nature.

        One day a patient came to our room, he had a long standing perianal abscess, left untreated, it had become a painful collection. He needed a drainage of the collection. When we see patients who need minor surgical procedures on the same day, my consultant advices me to do it myself after the OP time. Other wise there are residents junior to me in the Minor OT to do these procedures.

       So I asked this patient to wait outside the room till the OP ends. It would take at least two hours for the OP to finish. But you know, patients are the most impatient. His wife came twice, to ask me how long they have to wait. I told them to wait till the OP ends. The third time she came, I was seeing the last few patients. Again I told her that they have to wait. Then she asked, whether I am going to one more hour? I didn't give a clear answer.( I was thinking, It is their problem to get drainage done, How they dare to ask me time?, Why cant she just see that OP patients are still waiting outside the room) I asked her to wait till I finish ( not in a soft voice). But after five minutes I was done with the patients and came out, but they were not there, I waited for another ten minutes. But they did not appear.

        After a moment I was feeling bad. This happens a lot of time. Why couldn't I speak a little more soft to that patient, why do I expect people to wait for me, without an explanation. Why do we take it granted that, as a doctor we can act bossy over the patient. It is not just the doctors, any employee in the hospital has this attitude except for very few. If the person sitting at the counter is playing 'candy crush' on phone, he will make the patient wait till that level is over. If the patient take an appointment for ten and reaches the counter at time, his card will take another half an hour to move and reach the doctors table.

        I don't think this is an easy thing to change this nature. To have control over ones ego and keep tight, not to loose the cool is a great character achievement. But this knowledge of human nature is essential. If you ask a office clerk 'can this be done', the first reply will be 'no'. But first 'no' is never the final answer. You have to probe again, why not, who does it, why you want to get it done etc. Then you will get a tip to how to start moving things for it. Now this is one thing I learnt being on both sides of the table.