Family Dynamics

A way unusual for me

signout — Mon, 02 Jul 2007 13:30:34 +0000

A way unusual for me

I have a secret crush on one of my patients, an 85-year old man who's recovering from a bad pneumonia. After a weeklong stay in the intensive care unit, he has recovered at a remarkable pace: the day after he was extubated, he was out of bed with a physical therapist, making his way slowly around the ward with a walker and a big smile.

What motivates him to work so hard at recovery, the nurses say, is his love for his wife. They have been married 60 years. She comes in to see him every day, wheeled around by their daughter. The whole time she is there, they say, he holds her hand as if it is the last time he will see her.

When I come to see him, he is invariably adorable. He asks some questions about his treatment, which consists mostly of diuresis and antibiotic therapy. He tells me he can't wait to go home. And then, he engages me in chat. We talk about his family, he tells me a joke, he remembers the city as it used to be. He is extremely polite, and so grateful it makes me uncomfortable. Every time I leave his room, I am smitten anew.

Yesterday, I asked him to tell me about his wife.

"She's like you," he said.

I demurred. What did he mean? That his wife was very tired, or badly in need of a haircut? Or was he reassurring me that when I'm in my eighties, my hand, too, will be held tightly by a nice man? My heart beat faster.

"Yes, she's like you. She wants me to go home."

Because I am so anxious for him to be back at home with his wife, I double-check his medications every morning, and I fret in a way unusual for me over the pace of his diuresis. It's not that I ignore my other patients, or that I offer him better or different therapies because I like him--but I do like him, and for that reason, I am especially afraid of what the hospital might do to him. The potential for mistakes, or just bad luck, seems more immediate and real than ever. Last night, I stared at the ceiling for half an hour before falling asleep, thinking about what could go wrong.

Does he get better care than my other patients? Probably not. Twenty-four hours a day, every day, the nurses on his unit do the kind of compulsive checking that I'm doing just today. I doubt I am changing his outcomes in any way.

It will be better when he leaves the hospital. Then, I can get back to caring for people at my baseline level of personal investment--with enough compassion to stay awake all night in the hospital doing what's right for them, but not so much that I can't sleep once I get home.

signout Mon, 07/02/2007 - 09:30

Need to be seen

signout — Sat, 24 Mar 2007 10:19:49 +0000

Need to be seen

The first phone call came about a month ago, on a day I wasn't in clinic. The phone nurse had left me a message: Rosie's mother wants to know why she keeps turning in circles."

I had never met the 10-year-old Rosie, but looking through her old records, I found that she has a non-specific kind of global developmental delay--something we used to call MRCP, for "mentally retarded/cerebral palsy." I also found that this wasn't the first time her mother had called with concerns about Rosie's circles--over the last five years, there had been at least as many calls with the same question, and Rosie's propensity to turn had been a major topic at all of her well-child checks from as far back as infancy.

I called the number in the chart, but it had been disconnected. I asked the office staff to see if they had an updated number, but there was none. Over the next two weeks, I got two more messages with the same question from the same non-functioning number.

Each time I heard the busy signal, I felt a small wave of relief--my game plan for the phone call had begun and ended with saying, "Tell me about Rosie's turning," and I didn't think I'd have satisfying answers for her mother. I also felt some concern, however: the persistence of the question combined with the difficulty establishing contact made me wonder about the safety and reliability of Rosie's living situation.

Three weeks after the first phone call, Rosie popped up on my clinic schedule. The visit reason listed in the computer next to the visit time was "Keeps turning." When I walked into the room, two identical, close-set pairs of blue eyes stared up at me, and containing them, two similarly dysmorphic faces. Rosie's was the smaller one with the pink cheeks. "I'm Rosie," she said, "and this is my mom, May." She then stood up, raised her hands to her shoulders, and turned herself in a circle.

It took me only a few minutes to realize that answering May's question was the least of my concerns: although Rosie had significant delays with stereotypic movements, her mother had deep cognitive deficits of her own that prevented her from understanding the depths of her daughter's limitations. Although she had only slightly more comprehension than Rosie, it was enough to allow her to express one of her major concerns: "I don't want her to grow up to be like me."

Over the course of the hourlong visit, I found that Rosie does not live with May; she is instead cared for by an aunt who lives across the street. Because May didn't have the capacity to participate in making a plan for Rosie's care, I called the aunt after the visit to make sure Rosie was seeing a behavioral specialist (she was) and that other aspects of her care were well-coordinated (they were).

Afterward, I discussed Rosie's case with an attending physician in my clinic, who asked, rhetorically, "What was the purpose of that? Did she really need to be seen?" I suppose the answer depends on who I was really treating.

This visit was for May. Although she certainly came to the office for reassurance, her presence allowed her to demonstrate something she would never have been able to demonstrate with a phone call: the genuine care and concern she has for her daughter, and the barriers that keep her from translating her love into good parenting. Those barriers, like Rosie's, will never go away. And, like Rosie, we will see them whenever they need to be seen.

signout Sat, 03/24/2007 - 06:19

Post-operative complications

signout — Sun, 13 Aug 2006 07:37:00 +0000

Post-operative complications

Since I came on the medicine service, my team has been taking care of a man who because of one of his unfortunate afflictions I will call Mr. Scrotum. Mr. Scrotum is a 70-something man who came to the hospital with an infected prosthetic knee joint. He had surgery to clean it out, then came to our service to get medically stabilized prior to beginning physical rehabilitation. Unfortunately, Mr. Scrotum had some post-operative complications, including some wacky mental status changes and a fairly reversible kind of kidney failure.

Mr. Scrotum's medical course, while not ideal, is a fairly common one. His family, however, is exceptional. Although Mr. Scrotum has full mental capacity, he defers to Mrs. and Daughter Scrotum for all of his medical decisions, and I imagine it has quite a lot to do with how unbelievably exceptional they are.

Mrs. Scrotum is the kind of person who, after she is served lemon butter instead of parsley butter with her lobster at the club, asks to speak with the manager; has the waiter fired; writes a series of angry letters; forms a community coalition; hires a lawyer; and still isn't satisfied after she wins, because it's the principle of the thing. Her daughter is the same way, only with younger, sharper teeth. It is really very unpleasant to be regarded daily by these people with such spectacular anger, distrust, and paranoia.

Understand, now, that I do not take the Scrotum family personally. To me, their collective affects speak of nothing so much as abject terror: They are so, so afraid of losing their beloved Mr. Scrotum. In a flailing attempt to gain control over something that threatens to take him from them, they scrutinize and question what they do not understand. Any barrier to their scrutiny is seen as an intentional, adversarial move-after all, it's far more satisfying to have someone to blame when bad things happen than to just chalk it up to bad luck.

If we don't take the time to help the Scrotums identify what they are feeling-fear and frustration-and to explain to them why we are doing everything we do, we run a great risk of making them feel that we are not on the same team as they are. It's that dynamic that results in lawsuits.

Ironically, the time that we could spend talking with the family once a day-which indeed is a pretty big demand on any doctor's schedule-we spend trying to cover our asses in case this situation does end in a lawsuit. We call consults, we call attendings, we have bitch sessions. If we could swallow our pride, answer questions for 15 minutes a day, and remember how little control this family feels they have, I think we could avoid a bad outcome, psychosociolegally speaking.

At least, until he dies. At that point, no explanation will alleviate their grief, and anyone who can possibly be blamed will be. I just pray it doesn't happen in our hospital.

signout Sun, 08/13/2006 - 03:37