- Email: [email protected]
Getting the story
Spotlight
Essay Getting the story
Winner of The Lancet Respiratory Medicine Essay competition Barbara Jones is an assistant professor of Pulmonary & Critical Care Medicine at the University of Utah and Veterans Affairs Health System in Salt Lake City, UT, USA. Her research focus is practice variation, medical decision-making, and informatics for pneumonia.
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The minute I walked into the room I got the feeling that it would be hard for us to see eye to eye. The patient, a 70 year-old woman with “no medical problems” (rather, no medical care), lay in the intensive care unit bed, drifting in and out of consciousness. I could rouse her, and she knew the date. But soon after my hand was gone from her chest, she drifted quickly back to sleep. I would have to take a history from her husband, who shifted in his chair by her side, wringing his mesh cap in his hands. In the first instant of his look, I registered several emotions. Worry. Fear. A bit of disdain. And maybe some anger. Like most physicians, I hadn’t walked into the room blindly. I had discussed the case with the emergency room physician: presenting with a head laceration, but confused, with a fever and an oxygen saturation of 60%. I had reviewed her diagnostic studies: chest imaging with multifocal infiltrates, electrocardiogram with atrial fibrillation, elevated creatinine and liver enzymes, and lactic acidosis. I had entered with one story already. “She’s been like this for about 8 days,” her husband said. He described her decline, starting with a cough, then weakness, then somnolence, culminating in a series of falls, the last of which resulted in a scalp laceration. This story took several minutes to elucidate. In addition to that information, he also described at exasperating length some problems with his truck, the fact that there was also construction happening on their street, her past difficulty with bunions, and their son’s inability to find a new job after being laid off at the plant. He was a “poor historian”, as they say, weaving in and out of topics relevant to my history-taking. The urge to interrupt him was almost irresistible. But as I listened, I felt his look lighten. Less anger, less disdain. Still fear and worry. I let him tell the story at his own pace and rhythm. “By Wednesday, I was wondering if she had had a stroke”, he said. It was Sunday. “I looked it up on the internet. Seemed about right.” I noticed my own look and quickly directed it to the floor. Anger. Disdain. Why hadn’t they
sought care earlier? What kind of person would watch while his spouse deteriorated in front of his eyes? “…So how long are you going to keep her here?” Without answering, I completed a physical exam. Crackles and rhonchi. Bilateral oedema. No focal neurological abnormalities, but lethargic and oriented to date only. We sent off a blood gas. While awaiting the result, I did as I always do: I told him my story. I explained, in probably exasperating detail, the results of all of the tests and my interpretation of them. I explained the concepts of pneumonia, sepsis, respiratory failure, and acute kidney injury. I expressed concern for her ability to breathe on her own. I expressed concern for her heart. I then described the treatments and diagnostic studies that were underway and those I recommended. Antibiotics. Rate control. Echocardiogram. Intubation, perhaps. “So she is quite sick”, I said. “We are doing everything we can. I always ask everyone who is in the intensive care unit though, if this level of care is consistent with what they would want. What do you think she would say?” Several seconds went by. His look softened. He broke into tears. “She would have killed me for bringing her here.” He described their life together. She had always been fiercely independent, and she hated doctors. They had filed for bankruptcy after his heart attack. Her father had suffered a prolonged death in an ICU. He had just brought her to the urgent care clinic for stitches. “And now look where we are.” Through the rest of the night, we developed a treatment approach that honoured her values. She was given the care instructions do not resuscitate/do not intubate. She was supported with BiPAP, and her mental status improved. She responded well to therapy, and a few days later she was discharged home. By listening to each other, we had come together to write a mutual story that represented both the clinical and the human experience.
Barbara Jones [email protected]
www.thelancet.com/respiratory Vol 3 December 2015
Essay Getting the story
Winner of The Lancet Respiratory Medicine Essay competition Barbara Jones is an assistant professor of Pulmonary & Critical Care Medicine at the University of Utah and Veterans Affairs Health System in Salt Lake City, UT, USA. Her research focus is practice variation, medical decision-making, and informatics for pneumonia.
932
The minute I walked into the room I got the feeling that it would be hard for us to see eye to eye. The patient, a 70 year-old woman with “no medical problems” (rather, no medical care), lay in the intensive care unit bed, drifting in and out of consciousness. I could rouse her, and she knew the date. But soon after my hand was gone from her chest, she drifted quickly back to sleep. I would have to take a history from her husband, who shifted in his chair by her side, wringing his mesh cap in his hands. In the first instant of his look, I registered several emotions. Worry. Fear. A bit of disdain. And maybe some anger. Like most physicians, I hadn’t walked into the room blindly. I had discussed the case with the emergency room physician: presenting with a head laceration, but confused, with a fever and an oxygen saturation of 60%. I had reviewed her diagnostic studies: chest imaging with multifocal infiltrates, electrocardiogram with atrial fibrillation, elevated creatinine and liver enzymes, and lactic acidosis. I had entered with one story already. “She’s been like this for about 8 days,” her husband said. He described her decline, starting with a cough, then weakness, then somnolence, culminating in a series of falls, the last of which resulted in a scalp laceration. This story took several minutes to elucidate. In addition to that information, he also described at exasperating length some problems with his truck, the fact that there was also construction happening on their street, her past difficulty with bunions, and their son’s inability to find a new job after being laid off at the plant. He was a “poor historian”, as they say, weaving in and out of topics relevant to my history-taking. The urge to interrupt him was almost irresistible. But as I listened, I felt his look lighten. Less anger, less disdain. Still fear and worry. I let him tell the story at his own pace and rhythm. “By Wednesday, I was wondering if she had had a stroke”, he said. It was Sunday. “I looked it up on the internet. Seemed about right.” I noticed my own look and quickly directed it to the floor. Anger. Disdain. Why hadn’t they
sought care earlier? What kind of person would watch while his spouse deteriorated in front of his eyes? “…So how long are you going to keep her here?” Without answering, I completed a physical exam. Crackles and rhonchi. Bilateral oedema. No focal neurological abnormalities, but lethargic and oriented to date only. We sent off a blood gas. While awaiting the result, I did as I always do: I told him my story. I explained, in probably exasperating detail, the results of all of the tests and my interpretation of them. I explained the concepts of pneumonia, sepsis, respiratory failure, and acute kidney injury. I expressed concern for her ability to breathe on her own. I expressed concern for her heart. I then described the treatments and diagnostic studies that were underway and those I recommended. Antibiotics. Rate control. Echocardiogram. Intubation, perhaps. “So she is quite sick”, I said. “We are doing everything we can. I always ask everyone who is in the intensive care unit though, if this level of care is consistent with what they would want. What do you think she would say?” Several seconds went by. His look softened. He broke into tears. “She would have killed me for bringing her here.” He described their life together. She had always been fiercely independent, and she hated doctors. They had filed for bankruptcy after his heart attack. Her father had suffered a prolonged death in an ICU. He had just brought her to the urgent care clinic for stitches. “And now look where we are.” Through the rest of the night, we developed a treatment approach that honoured her values. She was given the care instructions do not resuscitate/do not intubate. She was supported with BiPAP, and her mental status improved. She responded well to therapy, and a few days later she was discharged home. By listening to each other, we had come together to write a mutual story that represented both the clinical and the human experience.
Barbara Jones [email protected]
www.thelancet.com/respiratory Vol 3 December 2015