Tuesday, February 24, 2004

Doctor Doctor

I was an intern when House of God came out. We didn't need a novel to tell us that being an intern sucked, and that ridiculous overwork sometimes desensitized us, but it was liberating to see that we were not alone in using black humor to get us through the night. Some of the book's phrases have fallen into a disreputable niche of the medical vernacular. An unfortunate one is GOMER, meaning a frail, elderly, often severely demented nursing home patient with multiple diseases all in various states of impending or actual decompensation. It's an acronym, and stands for "Get Out of My Emergency Room." It encapsulates the sense of frustration and futility that comes from having, time after time, to treat a patient whose quality of life can maybe be brought from miserable to terrible by treating yet another bout of CHF or aspiration pneumonia, only to have it recur a few days after discharge.

I got to thinking about "Get Out of My ER" this week after reading Spanky's Place, an ER nurse's blog. The writer is a nurse practitioner now, doing urgent care, but he obviously has worked in ERs for years. If Sam Shem offered us a tempered and deconstructed glimpse of the underbelly of health care providers' negative feelings in House of God, Spanky whips out the under-underbelly and proudly parades it with an almost contextless glee.

I'm trying to come up with the opposite of "Get Out of My ER" -- something like Humans Avoid That E R -- which works, but imperfectly. Because, in fact, it's only certain humans that need to avoid Nurse Spanky: female, obese, non-English speaking people of color on welfare.

It's possible -- even likely since he's apparantly still employed -- that Nurse Spanky maintains an impartial, non-abusive and professional demeanor at work. Nonetheless, the depth and breadth of his verbal animus is breathtaking. His comments bristle with sizist, sexist, racist, classist, and xenophobic phrases. Here are a few excerpts.

Is there some reason bipolar passive-aggressive corpulent women find the need to gravitate to the ER on Sunday nights? Are they so lonely they would rather come to the ER and get stabbed with sharp objects rather than stay home alone and run up their electric bill with their “back massager?"

You got that fat by yourself, why should I hurt my back and jeopardize my entire income and lifestyle because of your inability to control your appetite. One of the nurses I work with has a permanent back injury caused by an insensitive lard-assed pile of goo. This fat, lazy, shit encrusted pustule wanted to sit up in bed...

This particular (ambulance) call was for an enormous black mama, 500 plus pounds. Who had fallen between the bed and the wall, and was wedged so tightly they couldn’t budge her. Keep in mind this was at the back of a large projects building in a unit with no elevator.

Anyone who works EMS or ER knows when they hear a certain address, it’s going to be a bad call, and the ER is going to be overrun with toothless, tattooed, worthless consumers of oxygen.

The next three snippets are from his ER manifesto. The phrase "we hate you" recurs throughout his piece like a refrain.

1. Don't go, it's not really an emergency, and we hate you. No really, you think you have an emergency but it's really not. And seriously, we hate you. Just stay the home, or at the restaurant, movie, massage parlor, your lovers house, or even with your significant other, just anywhere but the ER. Have I told you we hate you yet?

2.         What is the most frequent reason for dragging Jose, Keneesha, Bryttynii, Boneki, Kristyan, Christiaan, Twannekaa, FeMolly, Miiho, and Sterling to the ER? Earaches. Now follow along closely ya hear. EARACHES ARE NOT EMERGENCIES, EARACHES ARE NOT EMERGENCIES!!! ...

14.       And for you fat middle aged psyche women with the psyche look (We know who you are). The best way for you to remain unimpressive to me, is to tell me you have fibromyalgia, mitral valve prolapse, and hypoglycemia. Ok, so one out of three diseases is real, the other are pure bullshit. Fuck-off, die, and get the out of my ER.

What is the value of putting extreme stuff like this "out there" ? Is it to somehow validate feeling this way ? Writing like this is way beyond satire. It is invective, screed.

As a woman who has had her share of body image and eating issues, I read his ugly, cruel, way over-the-top description of catheterizing an obese female patient with chagrin. It is the antithesis of the Buddhist concept of "right speech." It is harmful, hateful, aggressive speech. In House of God, empathic care actually triumphs. In the House of Spanky, it's not that clear.

But what's in the job description of health care provider IS crystal clear: compassion. And not selective compassion. I'm not just being cute or sentimental. Dale describes compassion better than I ever could as a cultivatable skill. A practice. It takes a simple maneuver, a little act of the imagination. A tiny leap out of the self. Imagine being very poor. Imagine, if you're white, being black. Imagine being obese and, on top of that, having to climb countless flights of stairs to your apartment in the projects. Imagine the humilation of falling and being unable to get up. Imagine being ill and smelling bad and seeing disgust on people's faces. Imagine being an obese woman needing to get a urinary catheter in the ER. Imagine being a poor single mother with kids. Imagine being a single mother whose child is screaming and tugging at its ear at two AM. Imagine trying to get care from providers who don't speak your language and who resnet you for not speaking theirs. Imagine being without health insurance or on welfare. Imagine having a a body that hurts everywhere all the time and disabling fatigue and a diagnosis that your health care provider believes, vociferously and scornfully, is not "real." Imagine (this one's for me) having severe, acute low back pain and no doctor and having to go to a walk-in clinic to see an unfamiliar provider and convince them you're not just scamming for drugs. Imagine, then, being the person hooked on oxys or vikes or percs, sick, having to scam for drugs. That can't be a picnic.

Take it beyond the clinic. We were just warming up, doing the Hanon exercises. Imagine being the father who killed his children and buried them along a forgotten highway then killed himself in his jail cell. Imagine that. You can take this exercise as far as you like.

I think the practice of compassion enables right speech.

I used to have what I'd jokingly call Dr X's two rules. Not unSpanky-like. The first rule was "no family in the exam room." It wasn't a rigid rule, but it was there. Dr X herself, being the loner that she is, would never think of bringing her mother or husband into the exam room with her for, say, a visit to the doctor for a cough or cold. Or ear wax.

I came to realize what an completely awful "rule" this was; that a patient's need for moral support superceded my own need not to have a relative chiming in from the exam room corner or otherwise scrutinizing my care of their loved one. Or my own prejudice that people should undergo a medical encounter stoically and alone like I do. So I abolished rule number one. Ashamed that I'd ever suggested it.

Rule number two -- no crying -- was never really enforceable. Or meant to be enforced. It simply was my way of expressing, with some black humor, my own discomfort with people's tears. I tell myself, self, if a patient can't cry at the doctor's, where can they cry ? It's true. Of course they can cry. My discomfort remains. I'm working on it. It's a problem. My problem. The imperative is not to make it the patient's problem.

This week, speaking of crying, I found myself in tears while reading the New England Journal's CPC. Every week the NEJM prints a "clinical pathological conference" in which someone presents the details of a difficult medical case, and an expert discusses the case and the differential diagnosis. It's an institution. They are often fascinating, and instructive, but this one was unexpectedly moving.

It wasn't so much the usual "come up with the diagnosis" exercise, for the diagnosis was clear: it was a woman with terrible burns. The presenter described the ER care and then the subsequent lengthy ICU care of a case of critical lung and dermal injury from fire. There were pictures of the acute burns, which went so deeply they charred her skull, and also of the areas when they'd healed; they included a picture of her, smiling frankly at the camera, wearing a beautiful wig. One eyebrow is pulled upward by scar tissue, but it's subtle. And, at the end of the conference, she comes out and addresses the doctors herself. She'd been in the Rhode Island night club fire, whose one year anniversary was this week, in which 100 people died and many sustained horrible, mutilating injury.

What moved me, I think, was how she, and patients, all of them, are our teachers. And how gracious and lovely this is. "Doctor" comes from the Latin root docere meaning to teach. But our patients are teachers, too. Not just during our training. Every encounter is instructive. Especially the ones that push our buttons. Listen to the patient. Listen to ourselves. Listen ! Audite ! The first word of St. Benedict's Rule.

Yes, I know that there's little spare time for the luxury of investigating interpersonal dynamics in an understaffed, busy ER. And, yes, I know that ERs are there for saving patients like the critical burn victim I described above, not for delivering routine, primary care. And, furthermore, I know that nursing is physically taxing and often dangerous -- I do some occ med for our hospital and see many nurses with back and neck injuries. Usually not from caring for particularly large patients, either.

Maybe Nurse Spanky is simply venting, and he's really a fine, empathic fellow. Maybe he keeps his distress inside: keeps it as his problem, and doesn't make it his patients'. But I could not let the curious venom in his ER vignettes go unanswered.

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