Frank Gabrin, DO, is a regular contributor to The Pulse. Check out a sneak peak of his upcoming article, “When It’s Our Turn,” detailing his harrowing experience on the other side of the patient-physician experience. See the print version when it comes out in the April issue of The Pulse.
I woke up alone on a stretcher feeling disoriented and drugged. I had horrible epigastric abdominal pain and felt like I was about to throw up. What was going on? I couldn’t remember anything. I had on two pairs of underwear, jeans, but no shirt. My shoes and socks were still on. I wasn’t in a hospital gown. My wallet and keys were in my pants pockets but I had no cell phone. I had an IV of NS hanging that had gone dry. The curtain in front of me was wide open and I saw all sorts of lab coat lengths and quickly realized that I must be in an Emergency Department at a teaching hospital.
What city was I in? Which hospital? How did I get here? I thought backwards. I remembered working a brutal 12 hour night shift in my ER and the drive home in the morning. I’d had horrible abdominal pain most of the shift and it was even worse by the time I’d gotten home. All I wanted to do when I got home was fall asleep so that I could escape the abdominal pain I was feeling.
A few years back, I developed chronic intermittent abdominal pain after an ERCP to remove a stone in my common bile duct. I was told by my gastroenterologist that I had developed chronic pancreatitis. He told me that I was going to have to learn to live with it. I figured the abdominal pain I was having that morning was just due to my chronic pancreatitis.
I remembered eating a few Rolaids and taking some Zantac and Nexium with a fizzing glass of Alka Seltzer. I watched a half hour of TV news, took some Benadryl and laid down in my bed. I couldn’t fall asleep. I got up and took an Ambien and laid back down. I still couldn’t sleep. My bellyache was really bad. I got up and took a big shot of vodka and laid back down. The last thing I remember was laying in my bed praying for sleep.
Now I am on a stretcher in an ER at a teaching hospital. I tried to reach for the call button that was coiled up and hanging on the wall behind me. As I moved, something was bugging me on my lower back. I reached back there to find a bandaid in the midline over the L4-L5 area. What? I had a spinal tap? I had no recollection of that at all.
Suddenly, I panicked. My mouth went dry. My heart was pounding and I became shaky. I had an urgent need for information. All those people running around in front of me I felt like I was invisible. I decided to stand up so that I could get to the call button. All I wanted was to talk to someone, anybody who knew anything about me.
As I stood up, my illusions of being invisible were shattered. A really young, burly male nurse bellowed from the nurses’ station, “Get back in bed before you fall down and hurt yourself!” I recognized the tone and I realized that he was talking to me as if I was a “drunk!” I told him that I was just trying to get my call button. He lurched in my direction in a very aggressive way and started running towards me. It became clear to me that he planned to “put me back in bed.”
Thank god I am an ED Doc, for I knew that if I did not get back on the stretcher at that very moment, security would be called and the next thing I would be telling you is that they put me in leather restraints. I sat down and got myself back into the stretcher.
After the nurse got to my bedside and slammed the side rail back into place, I got a good talking down to. He set limits and explained what the rules were. Then he put the call button in my hand wrapped my fingers around it and stormed away from my bedside just as quickly as he had arrived, obviously very proud of himself.
Everyone, and I do mean everyone, saw (and heard) what he did and what he said to me. During that interaction, I was not allowed to ask any questions. He clearly had no interest in helping me: His only goal was to publicly shame and humiliate me so that I would “behave.” So what was I supposed to do now? Press the call button? That would have just made things worse.
I was super shaky and adrenaline was running through every cell in my body. My mouth was so dry I wondered if I could even talk. I was even more panicked than I was before. I still did not know where I was, how I had gotten here, how long I had been here, what other tests besides the spinal tap they had done? Did they know that I was having really intense abdominal pain and nausea? With the call button in my hand, my fingers wrapped around it, I couldn’t bring myself to press the button. After that public display, I felt that there was little, if any hope, that anyone would see me as anything but that “unruly drunk guy.”
It took me a little while to get myself together, for my heart rate to slow and saliva to return to my mouth, and just a little longer to summon up the courage to press my call button. The flashing light above my bed went off and I could hear the ringing at the nurses’ station which was right in front of me. It seemed like forever before someone answered and asked if they could help me. I asked for my nurse to come to my room.
By this time, I had spotted a clock on the wall. It was 11:30, but was it AM or PM? Knowing that I’d had a spinal tap, I figured out that it must be PM. The last hour I remembered was 10:30 AM and I was in my own bed. Thirteen hours were lost. As my nurse walked up to my bedside, before I had a chance to speak, she began to tell me that I was already admitted and that she was just waiting for my bed to be ready so she could call report.
I said hello and thanked her for that information and told her I had some questions. She said, “Oh? OK.” I said, “Before I ask my questions, I want you to know that I am an ED physician, I don’t usually drink and I am not an alcoholic.” I explained to her that the last thing I remembered was being in my bed trying to fall asleep at about 10:30 this morning. A little while ago I’d woken up on this stretcher and found a bandaid over my spine and realized that someone had already done a spinal tap and I had no recollection of the procedure. I told her that I didn’t even know where I was, how I’d gotten here and/or what was happening to me. I asked her if she could please fill in the blanks for me.
She said, “Oh, I’m sorry, but I can’t answer those questions. All they told me in report was that everything is done, the orders are written and all I had to do was call report when the bed was ready. I have not had time yet to look at your chart. Let me go and read your chart. I will come back and try to help you.” About an hour later she returned. She told me that I’d arrived by ambulance, that I was being worked up for confusion, that I had a 21,000 white blood cell count with bands and a left shift and that my CT and my LP were both negative.
I asked if “they” knew that I have a history of chronic pancreatitis and that I was having horrible epigastric pain and nausea. She said nobody mentioned that. I asked if I could talk to the ED attending. She went to ask, and about twenty minutes later she returned and said that the attending currently on duty hadn’t seen me, and that the attending who’d seen me earlier, had already gone home. Since I’d already been admitted, I’d have to speak with one of the doctors on my “team.” I asked her to ask the doctor on my team to come speak to me. Later she returned to let me know that doctor was tied up with an emergency on the floors and would speak to me once I was settled in my room. My inpatient bed was not ready and there was no telling when it would be.
I said, “Well then, can you get me a paper scrub top and take out this IV?” She asked me why and I said, “Well I am not going to allow myself to be admitted to the hospital under these circumstances, especially if no one is willing to talk with me or tell me what is going on.” She said, “Let me page your doctor again and let them know how you feel.” She returned fairly quickly and told me they were still tied up and couldn’t come talk to me right now.
I told her that it was clear to me that I’d been labeled as a “drunk,” and that no one here, except her, felt that I deserved even the time of day. I told her that I have never been treated with such disrespect and prejudice. She went to get the paper scrub top. She apologized to me as she took out my IV, and asked me again to stay. I said thanks, but no thanks. I walked outside, got into a cab and went home.
Over the next four days my abdominal pain and nausea only got worse. I drove myself to my ED at a community hospital. I was febrile, jaundiced, hypotensive and tachycardic. Labs showed that I was in full blown multi system organ failure and sepsis. CT and MRCP showed a large stone in my common bile duct causing complete obstruction along with a pancreatic phlegmon. They were unable to remove the stone at my community hospital so I had to go back to the tertiary care center where I was treated so badly. I elected to go there as an outpatient.
After an office visit with a high powered gastroenterologist I had the ERCP with ultrasonic guidance done as a same day procedure. They were able to remove the stone and place a metal stent in my common bile duct. Later that evening, after the anesthesia wore off, the pain I began to experience was really bad. I waited almost a week, as the pain got worse, before I realized that I had no choice except to go back to that same awful ER because my pain was completely unbearable. My pain was so bad I could hardly breathe.
When I arrived in triage, it was clear that I was obviously in distress. They actually rushed me back to a room. I waited almost a week to go back there because I knew that as soon as they read my “old” chart, they again would not take me seriously and the label of “drunk” would again be applied.
Actually it did not even take that long, as soon as I said the word pancreatitis, everything changed. When I asked the ED Attending for some pain medicine I was matter of factly denied and was told that I would have to wait for all the test results to come back first. She was kind enough to start an IV and give me some Zofran for nausea.
The ED doc who refused to give me pain medicine must have been embarrassed when the work up was complete because she sent the GI Fellow to tell me that the workup in the ED showed that I had developed post procedure necrotizing pancreatitis. It looked like I had already lost about 13% of my pancreas based on the CT scan. I looked at the GI fellow and said can I please have some pain medicine now?
I was admitted and taken back to the GI lab to have a PEG-J tube placed to facilitate complete gut rest, I remained in the hospital for almost a month. That fateful night in the ED, when I was treated as if I were just a “drunk,” was about five months ago. I have not been able to work since that night. I have lost 40 pounds. I am malnourished and run down, currently battling a bad case of shingles. I still have the PEG-J and I do six tube feedings a day. I have not been allowed to have even fluids by mouth yet. The visiting nurse comes twice a week. I hope and pray that when I see GI this coming week, they will give me permission to start clear liquids.
This illness has been devastating and catastrophic for me. It will be a couple more months before I will be strong enough to go back to work in the ED. Had I not been treated with such a lack of human dignity and respect, would I have signed out AMA?
We all took an oath to do no harm. I don’t remember what happened in those 13 hours that I lost, but once I was awake and coherent, no doctor would even take the time to come to talk with me. I will never know how much harm may have happened to me as a result of my decision to leave AMA. Things might turned out exactly the same, but I should not have to wonder about a different outcome.
Had I stayed, maybe I would not have developed multi system organ failure and sepsis as a result of a large stone in my common bile duct. What if I could have had the ERCP before I got so sick? Would I have developed post procedure necrotizing pancreatitis? That first night, would I have stayed if a physician, any physician, had come to hear my concerns? Probably.
We all know that since they started looking, burnout is on the rise among all ED physicians. Were the ED physicians involved in my care suffering from burnout? If you believe the statistics, they probably were. One of the symptoms of our burnout is that we label people or groups of people in a derogatory manner. Our perceptions of people become dehumanized.
It is so easy for us to objectify our patients and treat them as caricatures of their dis-ease. This gives us the ability to depersonalize them so that we no longer see them as people, we give ourselves permission, to care less. I hope that no one reading this ever has to be on the other side of the stethoscope of a doctor, nurse or even a medic who has become so desensitized and burned out that they have lost their concern or respect for the very patient they have a duty to care for.
My intention in writing all of this is to say, we can do better. I know first hand that this sort of thing happens in ED’s all across this country each and every day. I know because I could have given the same speech the male nurse gave to me demanding that I stay in bed. I have treated alcoholics this way. I have seen other ED docs tell ED nurses that they will not go to speak with a patient who has questions they would like answered before they go to their inpatient bed. “They are not my patient any more. They are admitted and they will have to talk with their doctor on the floor.”
I believe that we all became physicians because we wanted to care. I also believe that caring for others should be one of the most rewarding jobs on the planet. Care is an intangible thing and care, like love, is a transaction that occurs between two people. Care can’t happen at our computer stations. Care asks us to stand up and walk to our patient’s bedside. Make a connection with them and begin to understand their fear or their pain.
Just connecting with them will naturally move us into a state of affective empathy, where we begin to feel their discomfort. If we allow our natural curiosity to carry us to the state of cognitive empathy where we ask what it would be like to be in their shoes we will automatically be transported to the state of compassion, where we honestly want to do something to make things better for both of us.
This is where the transaction of care happens. It is at the bedside where real healing begins. The cure for our own dis-ease of burnout lies within our own participation in the transaction of care. When we miss the opportunity to care, to make a difference and change things for our patients and ourselves, we miss the opportunity to feel good about who we are and what we do. As a result of our omission of care, our own burnout gets a little worse. If we continue to practice this way we will never get what we really wanted in the first place, which was the opportunity to care. Our own dis-ease called burn out will surely worsen, both collectively and personally. Please, go care, make a difference and change (y)our world.
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