Tuesday, September 6, 2011

Barriers in Communication

The evening had slipped hurriedly into the night. The street lamps outside had brightened their glow, their brown amber halos splashed onto the ground. like liquid gold  From where we stood in the hallway of the fifth floor of the hospital, business as usual was in progress in the external world. On the street across from the hospital, cars were buzzing by in their hurry to deliver their occupants, where they had been intentioned. And were I in one of the cars below, I would have thought the same business as usual was going on inside this giant well-lit hospital building. But no, I would be wrong.

My colleagues and I were standing in that hallway after encountering what could only be described as a “train wreck.” The patient was a elderly man who had a ruptured diverticulum in his bowel and he had progressed rapidly into a “shock-like” state. The bacteria from his bowels were teeming into his abdomen (peritoneal cavity) and through ruptured capillaries, filing directly into the blood stream. His life was staggering over the precipice looking down into a dark abyss called “septic shock,” - the event horizon from where half of those afflicted never come back to breathe another breath. The hallway was quiet, save for our muted conversation and the infrequent hum of the compressed and conditioned air as it crawled its way through the ducts in an a-periodic frequency to shake the decorative window-blinds from their reverie.

Surgeon: “You should have seen his interior, purulent and messy. Every tiny capillary was oozing. I found the source tic, though! And in feeling through his bowel we found an incidental colon tumor. It was the size of a golf ball. The frozen path suggests a carcinoid. That is the least of this chap’s problems unfortunately.”

Infectious Disease: “Well, I think he is going to need Broad Spectrum stuff and we will throw in some fourth generation for good measure till the C and S are back.”

Hematologist: “The poor guy is in DIC. Got to figure on treating that. Hope we can stop it or you might have to go back in there to evacuate blood, which as you know can further propagate the DIC in a vicious cycle.”

Surgeon: I don’t want to even think of going back in. It’s a nightmare in there right now and Heaven knows what it will be later. Especially with that Disseminated Intravascular Coagulation of yours that is going on.”

Nephrologist: “I got him on Bicarbonate and added some Calcium. I’ll watch the acid-base data in three hours and make changes. His Creat is 4. Might need Kayexalate for his K and maybe a temp dialysis too.”

Surgeon: “No PD. His peritoneum is teeming!”

Hematologist: “Fix that acid-base stuff and the DIC might calm down. Those damn endotoxins in the abdomen are wreaking havoc. I checked the parameters; both PT and PTT are high and the platelets are dropping as the FDPs rise from all the clotting that is ongoing. So I’ve got him on Fresh frozen and ordered platelet infusions for now.” Then addressing the surgeon, “Did you run your hand over his liver. Feel any mets?”

Surgeon: “I did, the liver was slightly nodular, but when and if he stabilizes, we will have to scan him.”

Pulmonologist: “I am worried about his third-spacing. I will need the central line to monitor his pressures. Did you put one in?” And with only a pause in his breath he stated, “We also need a heart guy involved. His ticker appears time-limited.”

Surgeon: “Yup. Anticipated and done!”

Pulomonologist: “We’ve got to get an endocrinologist to monitor his diabetes. He is very fragile based on the history from his family. He has Type II.”

Surgeon: “Get someone of your choice. Ok guys! stay posted. I’ve got another one to follow in the OR. See you later. And thanks for your help!”

We all disbanded a few minutes later. But as we did so, I noticed a young 20s something guy lurking. I had noticed him fiddle with the vending machine before and now again noticed him staring at it. His eyes were fixed but his mind, one could see, was wandering. He raised his eyebrow and a sigh escaped from between his tight lips. He couldn’t fool me. There was a sense of desperation in it. A warm wisp of moisture, just barely enough to cover the glass panel of the vending machine escaped, as he tossed a look that seem to suggest a conundrum between choices E4, a peanut M&M packet or F6, a Snickers chocolate bar. Neither, however could or would satiate the desperation behind his saddened eyes.

“Can I help you?” I asked.
“No, no, just looking.”
“Oh! ok. Sorry.”
“Oh! Maybe you can.”
“What were you doctors all talking about?”
“That is privileged.”
“No, I mean you speak in some language that is so difficult to comprehend.”
“We were discussing medical issues about a patient.”
“Yes, I know, but when I was in the room with my grandmother and the doctor came in to tell us about what was going on with her. He used these highfalutin words that none of us in the room understood.” He paused a moment and then finished with a deeper sigh, “He might have been speaking in Latin.”
“I am sorry to hear that.” I offered, but the words were hollow, even to me. “Maybe I can help?” I said, not knowing what I was getting into. He tried to explain his grandmother’s malady and I listened and tried to help as best, I could, but my hands were tied by the ethical and legal constraints of speaking with another physician’s patient’s family member. The best I could do was not good enough.

We parted company shortly thereafter, both parties dismayed, unsatisfied and filled with an emptiness that spoke volumes about the dilemma. This young man’s anguish was about a monologue instead of a dialog. Maybe, and I am quite certain of that, maybe the doctor had discussed it in a medical terminology unable to unburden it in layman’s version. He might have used “medical lingo” to describe the disease, its manifestation and the treatment that he or she was envisioning and fully expecting a complete understanding by the recipient. As patients sometime are wont to nod to hide their ignorance, the conversational gulf expands. The flow of those descriptive words however might not seemed to have bridged the gulf. The recipient’s slate remained blank and yet managed to get stained from a frustration and miscommunication. The power of the words for them might have been reduced to a barrage of indecipherable syllables and consonants. Even though words had been uttered with the greatest of  energetic emphasis, they failed to crossover, comfort and explain.

Physicians are constantly involved, coping with the burden of disease, thinking, speaking as specifically and accurately to one another about the management and they will sometimes continue that expressive dialogue with the patients and their family. Yet in the emotive, expressive, urgency of the disease and the nuances of proposed therapy the "expressive" reveals itself over the more controlled, conventional watered-down version of the explanation, meant for the patient. As physicians we tend to hold everyone to the same degree of understanding and that can be form the barrier in communication with patients and families. It is akin to a biologist speaking with an astrophysicist or an artist speaking to a Physicist about Quantum Mechanics (Something that he -the physicist, probably doesn’t understand either and then has to explain in metaphors), where the facts get bundled in the complexity of the detail. Sit down with the patients and their families, face to face and mete out the difficulties one by one.

Patience is a virtue for all things underneath this wide canopy of blue. A polite conversationalist never interrupts. So it behooves a physician to listen, direct a conversation to pertinent issues and never hide ignorance behind medical dictionaries. Somewhere in the vast literature of spilled ink is a statement that extols the virtues of honesty. That is good for both, patient and the healer. Recent graduates and others with some years under their belt should NOT emulate TV actors in House MD as models for communication. It is good drama but bad bedside manners.

To all things complex such as a consolidation of multiple diseases, a measure of simplicity and a dose of commonness is needed in discussing the ramifications of the malady with the patients and their family. Look them in the eye and behold the lack of understanding and then explain, until the glint and glimmer of “Aha!” is achieved. Understanding involves bringing the patients and their families into the circle of awareness. With that awareness comes the recognition of the complexity and the efforts that are being undertaken on the patient’s behalf to conquer the disease and save his or her life. Communicate with exquisite thoroughness and with mastery of each spoken word! The listeners are hanging on every nuance and word uttered by their physician. Make your words worthy of their attention. There is a difference between a robotic reciting of medical science and a human discussion, the same as there is a difference between a guideline-algorithm and excellence of care.

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