Friday, September 19, 2014

Personal Responsibility And Chaos

She was sick.  Not sick like a high fever, body aches and a runny nose.  Sick like she had spent the last half a decade in nursing homes as most of her internal organs failed.  There was oxygen, and dialysis, and a colostomy.  She propelled herself vigorously through the crowded halls in the custodial wing of the nursing home, her wheel chair a natural extension of her body thoroughly unhampered by bilateral leg amputations.  

She was sick, but she was thriving.  Every hospitalization, every set back, met with a perseverance and a stoicism of body that was nothing less than magical.  The fairy dust unfortunately spread no further than the entrance to her semiprivate room.  The rest of my patients didn't always pull through so well.

So when the biopsy came back cancer, there was little hesitation when she decided on having the surgery.  There were risks, I reminded her.  The chance of sudden death on the operating table was nothing to scoff at.  But I had no reason not to clear her.  The cardiologist agreed.  After much haggling and arranging, a surgery date was set.  A date that fell smack in the middle of my only planned vacation for the whole year.  Seven measly days off.

The surgeon was busy and couldn't rearrange his schedule.  I visited her early morning before leaving town.  She opened her eyes sleepily.  You are going to take care of me in the hospital, right?  She of course new that was impossible, but asked to be certain.  I assured her that the hospitalist group was excellent and would be attentive.

I left town.

Seven days later I returned to find her transferred to a distant hospital.  A few phone calls later my fears were confirmed.  She had a cardiac arrest a day after surgery.  She died.

It is hard to explain to the laymen what personal responsibility means to a physician.  Every death, every poor outcome is studied painstakingly.  A single question pervades this endless search, what could I have done differently?  It's not some sadistic game we play to torture ourselves.  It's more of a ritual.  A safeguard.  The study of medicine is significantly complex, and the foibles of human ability are delicate.  In a world where perfection is unattainable and the stakes are absolute, the only path to sanity is an overwhelming obsession with detail.  We swear to never make the same mistake twice.

For the most part this works.  I never forget to check the EKG of the demented delirious patient in the ER because of the acute myocardial infarction I missed in medical school.

Now, everyone would agree that even doctors have a right to a few days off now and then.  But it's often difficult to turn the demon off.  This obsession with taking responsibility for my patient's well being defies logic.  And I cling to it.  Every day, every moment, with every ounce of strength and might that I can muster.

Because without it, I fear, I will be more likely to become an agent of harm.   And this profession that has flowered in the bosom of my identity, will devolve into complete chaos.


Anonymous said...

you are right -- it is an obsession, but where would our patients be without our commitment and sense of responsibility? There is inherent chaos in coverage by providers who don't know the detail, don't know the history, don't know the character of the patient as we do.

But we are only human, and our families need us, our bodies need rest, our minds in turmoil at the load we carry.

Keep writing and telling us, your colleagues, what is so familiar to us. This is what keeps us awake at night, and gets us up in the morning. Emily from Barnstorming

Anonymous said...

I'm glad some still have this. I had a doc who's ego is such that he doesn't care whether or not he makes a mistake because he is NOT the one who has to pay for it.

No skin in the game. No one has ever threatened this guy with lawyers or the like but they send them after them or dump their care (they're a subspecialist with no other groups you can go to in the area) if you breathe one word of discontent.

Anonymous said...

My condolences on the loss of your patient friend.
Thank you for making time to consult with a trusted colleague before clearing her for surgery.
Thank you for making sure your patient understood both the risks and benefits of her surgery.
Thank you for allowing your patient to make an informed decision.
Thank you for honoring her wishes.
To me, it sounds like your hearty, odds-beating, double-amputee, ostomy- bagged, dialyzed, optimistic, nursing-home energizer-bunny- patient-friend with cancer died because she finally ran out of reserve.
You ask, what could you have done differently?

Sue Rumack said...

Dear Doctor, and you are that special human being who chooses to doctor the rest of us, I have come to believe that each of us is born on a specific day for a specific reason and whether or not our work here is done, we are also destined to exit this life on a specific day. To this end, there are those who help us to arrange our schedules to be at the appointed place at the appointed time. Sometimes it feels like you are the responsible part for what is destined BUT you are not. You are simply one of many players in the script. There was nothing you could have done differently for this or any other patient. They have their schedule to keep and so do you. Keep doing what you do with the enormous sense of responsibility that you carry on your shoulders.