September 25, 2011
I know it is done out of necessity, but sometimes it feels like it’s going on for ages.
Top 10 reasons why ward rounds take longer than they should :-
The patient that can’t stop talking. Some patients decided to indulge the team in their delightful homemade recipes when all we wanted to know is whether have they opened their bowels today. A simple yes/no question becomes this soapbox for the patient to explore their culinary roots out loud. Too time consuming to listen to, too impolite to tell the patient to ‘talk to the hand’
The consultant that can’t stop talking. I have an immense amount of respect for them. I truly value their desire to teach. But when they start going on about how their game of golf went over the weekend with a play-by-play commentary in the middle of ward rounds, I can’t help but mentally sigh. The most common scenario nowadays is they get so excited about the new iPad that they can’t help but do a live demonstration on its wonders. Then proceed to discuss the specs, and the apps. It’s not a bad conversation topic, except not the junior doctors are struggling to carry the files while waiting for the consultant to arrive at the decision whether to give the Frusemide or not.
The family members that can’t stop talking. I know they have a lot of questions, I understand that and we encourage the family to air their concerns anyway. Everything is alright and appropriate, until the day when you meet a bossy family member who decides to document everything you said and do in order to jump on you the moment something goes wrong. That still isn’t so bad, until you meet one whom keeps harassing you why the patient keeps burping and demanding a medication review on the spot.
The nurses who keeps pulling you away from your ward rounds. Often it is out of necessity, but on and off you get the trigger-happy nurse whom zooms in, tells you something trivial, and then expects you to do something about it right away. When you do maintained that you’ll see to it after your ward rounds, the nurse nodded and walks off to tell the patient’s family that the doctor will be there in ‘a few minutes’. Of course, failure to turn up in a few minutes would then result in you being swamped by enquiring family members in the middle of rounds.
The wandering/lost patient. Not in the room, not in the toilet, not in the corridors. The team then has to detour back on and off to check if the patient’s back. Some tend to return when it is close to 5pm, looking all fresh and bright as they had a ‘lovely spot of coffee in the sun’ while you’re looking like you could use a toilet break. Some are kidnapped by the physiotherapist.
The missing file/drug chart. Not at the nurses’ desk, not in the patient’s room, not in the medication room. This is not too much of a bother for a stable and well patient, unless there has been an event overnight and the patient is too sick to tell you what happened. The ward round then becomes a search party which sends the team in all directions. You will be surrounded by the files you don’t want, and never the one you need. When you do manage to locate the file, you find yourself having to wait in line while the social worker, speech pathologist, and the occupational therapist all have their turn.
There is never enough space to write your notes. The consultant is rattling off the management plan at the speed of light, including a couple of drug names which you’ve never heard in your entire life before – and then realise that you are at the last page of the progress notes with only three lines to spare. Either you squeeze your writing to the point which no one could read (including yourself), or you excuse yourself to run off to find more fresh pages to scribble on. Usually it is the latter.
Technology failure. That rare momentous occasion when the computer is lagging badly, or internal servers are down for maintenance. Your consultant wants to know the patient’s renal function before starting medication, your registrar wants to check the loading dose for the medication, and you want to know if the IT tech dude is asleep at his desk.
Coffee breaks. When a senior doctor says “I’m gonna get a cup of coffee”, no one protests. But I am pretty sure there are some of you out there whom would rather quickly get on and finish the ward rounds as soon as possible. The seniors would be sipping their favourite latte while the juniors smiling nervously to cover their anxieties over not having enough time later in the day to do the referrals.
The unsuspecting new admission. You walk into the room and see this new patient sitting up in bed, smiling back at you. You smiled back and say ‘How are you?’. In truth, no one has a clue who this patient is nor what are they here for. There are no admission notes, no previous history, and the only way to find out is to do a full admission yourself . One new admission takes as long as approximately 10 coffee breaks. If it is a patient that can’t stop talking, then it would probably take 10 coffee breaks plus lunch as well.
And now let’s do a poll :-
September 12, 2011
The skinny man reaches over his jug of water and points to the picture on the wall. “That’s my kids”, said he. We saw two kids, aged 7 and 9, standing around a birthday cake as he smiles at the camera. This was not too long ago; he was well built with a robust complexion.
“They are very cute”.
He smiled. Now a shadow of his former self. This is the same person as the one in the picture, yet now they are worlds apart. Fatigued and jaundiced as he lay frail on the bed. The cancer had already spread to his liver.
“I really want to go home. I know I only have a few months. There is nothing I want to do more than to go home to spend time with my kids”, he spoke in almost a whisper.
A soft sniffling can be heard coming from behind. I stood still, not wishing to turn around. Part of me not daring to ‘acknowledge’ the sorrow in the room – as his elderly mother shed tears over the harsh reality of his prognosis.
“We’ll get you as strong as we can quickly so you can go home soon”, reassured my consultant, “If things take a turn for the worse, you can come back to us for end of life care here”.
He nodded slowly and deeply, turning his gaze to the field beyond the window. As we headed out, I caught a glance of his parents behind me. The mother was wiping her eyes silently while his father wore a solemn expression over his aged face.
There is this inexplicable sinking feeling in me knowing that the next time I see him again, it won’t be for very much longer.
* * *
The young lady with long black hair looked up from her seat. A deep frown embedded over her forehead. Her eyes looked almost pleading.
“How long does he have left?” she asked, in heavy accented English.
I looked at my consultant whom shook her head. “We don’t really know for sure, but it might just be only a matter of days”.
The man is barely conscious. Every now and then he would mutter something in his sleep, and then heaviness would wash over him. We were told that he has been requesting for his son ever since he started deteriorating.
“My brother is still having issues with his visa. Hopefully it should be approved by today and he could fly out here to see our father…”, she trailed off, before hesitantly adding “…I hope he’ll be here in time”.
Soft chanting of monks filled the room. A small black player on loop can be seen placed by his pillow, no doubt containing incantations of religious scriptures. The atmosphere was heavy yet serene.
Wonder if the son will be here soon?
* * *
“Do you have any pain?”, we asked. Her eyes were half closed, eyelids occasionally fluttering. Was there a faintest hint of a nod?
We could hear her murmuring incomprehensibly between her laboured breaths. Her sister reached out and held her swollen arm; limbs severely edematous from the steroids. Pale, bed-bound, and completely devoid of hair, she looked much worse that day compared to a week ago.
I looked at the syringe driver which was humming by the bed. Continuous infusion of potent analgesics and sedatives were pumped through the subcutaneous butterfly cannula in her arm. Her pain had been unbearable, described as a burning sensation spreading across her chest. The cancer had spread beyond then.
Her family were gathered in the room. One of her daughters approached me with tears welling up in her eyes. “Is she able to hear us?”.
I looked at their mother in her semi-comatose state. Suddenly I became conscious of my own breathing given the stillness in the room as they were all waiting on me to speak.
“She has been in this unrousable state for some time, it is hard to recognise when she is truly asleep and when she is just merely closing her eyes at rest. We do not know when she is drifting in and out. I encourage all of you to keep talking to her as you do; I am certain there are times when she is listening, we are just not sure when. Keep talking, you never know.”, as I nodded to the family in assurance. They gave their thanks and I left the room.
Is she able to hear us? I don’t have the answer. But I know the answer that we needed.
* * *
The stories are reflections of a regular day in palliative care. It is moments like these when you deal with the very real face of mortality. Thoughts and insights often dwell on the vulnerability of the living being where disease and death spares no one. To the afflicted ones, time is extremely precious when there is little of it left.
The following are excerpts from a poem by William Knox :-
Oh, why should the spirit of mortal be proud?
Like a swift-fleeting meteor, a fast-flying cloud,
A flash of the lightning, a break of the wave,
He passes from life to his rest in the grave.
The leaves of the oak and the willow shall fade,
Be scattered around, and together be laid;
And the young and the old, the low and the high,
Shall molder to dust, and together shall lie.
The hand of the king that the sceptre hath borne,
The brow of the priest that the mitre hath worn,
The eye of the sage, and the heart of the brave,
Are hidden and lost in the depths of the grave.
The peasant, whose lot was to sow and to reap,
The herdsman, who climbed with his goats up the steep,
The beggar, who wandered in search of his bread,
Have faded away like the grass that we tread.
The saint, who enjoyed the communion of Heaven,
The sinner, who dared to remain unforgiven,
The wise and the foolish, the guilty and just,
Have quietly mingled their bones in the dust.
For we are the same that our fathers have been;
We see the same sights that our fathers have seen;
We drink the same stream, we feel the same sun,
And run the same course that our fathers have run.
Yea, hope and despondency, pleasure and pain,
Are mingled together in sunshine and rain;
And the smile and the tear, the song and the dirge,
Still follow each other, like surge upon surge.
’Tis the wink of an eye—’tis the draught of a breath—
From the blossom of health to the paleness of death,
From the gilded saloon to the bier and the shroud
Oh, why should the spirit of mortal be proud?
– From The Lonely Hearth, The Songs of Israel, Harp of Sion, and Other Poems –