Battered and bruised versus confused

I've narrowly avoided being hit over the head with a walking stick.

I've also (literally) had my wrists slapped, been called a 'stupid cow', and had to wrestle for control for a telephone handset.  I've had to persuade patients that self-discharging themselves at 2am is not a wise move, and had to disappoint patients claiming to await their (long deceased) parents that they probably won't be visiting today.  I remember well one particular incident where a nurse nearly got punched in the face by an elderly patient.  My friend and colleague who was the doctor looking after them was distraught about eventually having to give the patient some mild sedation so that neither the patient or anyone else came to further harm.

This is a side of the ageing population people don't see, or perhaps even hide away.  Delirium. Dementia.  Call it what you will.  Sometimes patients are confused, and as a result can become agitated, distressed or even violent.

Having just finished another week of night shifts, I am all too familiar with this scenario, and yet I am still scared by it.  It can be a daunting prospect to be called to resolve these issues, and it's usually once the nursing staff have done everything in their powers to calm things down.  I always teach my medical students to remember that the person brandishing a water jug as a weapon is still a human being.  They have a life, family, friends, a career and hobbies.  And they would probably be horrified to see how they were behaving if only they could know.

When it comes to my patients, I always try to understand or see reason in what they are saying (or shouting).  Their rage almost always comes from a logical place - even if it does not seem logical to us.  I'd be pretty darn confused if I woke up in a strange place with strange people.  I try everything from explaining where we are and what's going on, to encouraging patients to talk about their wife/dinner/previous job.  Usually this diffuses any tensions, but not always.  I have only twice had to resort to using medication, and it is always with a heavy heart and a feeling of failure.

My German grandmother is 93 this year, and although my other grandparents are no longer alive I have been lucky to know most of them as an adult.  Granny Deutschland has had a life every bit as exciting as I could imagine, growing up in what is now Poland, living through the second world war, emigrating for a short time to South Africa and travelling the world with my grandad in their retirement years.  I see her in every older patient I see, and remember her life and adventures.  I imagine every one of my patients would tell me their stories if they could.

I'm off to Germany next week after yet another set of nights to replenish my stock of Granny Deutschland tales with my sister and niece.  Hopefully I will successfully dodge any further walking sticks or similar in the mean time.

In fact I am baking banana bread (with some creative ingredient substitution) and reading entries for a writing competition today, tucked up in my little cottage. Rock. And. Roll.  

(Not) Breaking Bad News

There are a few magic words in hospital that are likely to get a doctor to your side in reasonable haste, but not all of them require any intervention.  A few examples of these include 'I've just had a fall', 'I've got chest pain' and 'I've got a weak arm'.

Now, not every fall is really a fall, not every bit of chest pain is a heart attack and not every clumsy arm is a stroke.  All warrant medical review.  But having assessed the patient, I'm still learning the nuance of when to intervene, and when to have the confidence in your clinical acumen to leave it alone. Half the trick of being a doctor is as much deciding when not to do something as when to do something.

But there are some things that you cannot leave alone, and must be investigated.  Often we're investigating because of the small chance it's something serious, like a cancer.  And it occurred to me and a few of my doctor chums at lunchtime that sometimes we are absolutely lousy at verbalising this.

All of us could recall the first big bit of 'bad news' we had broken.  I think it is quite a defining moment for a junior doctor.  I still remember mine.  I had the whole family sat around me, keen to know some scan results.  I did everything they had taught me at medical school; found out what they already knew, what they were expecting, what their concerns were.  Often, by this point, people have a notion of what might be going on.  Not this time.  Gulp.  There was no getting around it.  I just had to say it.

'I'm sorry but I've got some bad news'.

Of course they were upset.  But I explained what we knew, what we were doing next, when we could next discuss things.  They thanked me.  They smiled.  Relief.

Because breaking bad news is something you can only do once, so you'd better do it well.  And yet, my little lunch group and I felt uncomfortable about the fact that we've started to skirt around the issue when we're still at the 'query' stage.  They teach you that you should check how much people want to know - but if patients don't even know that a serious diagnosis is on the list, how can you really check?  There are certain clinical presentations that now ring alarm-bells in my mind, and as a result I will request certain tests to rule serious things out.  I worry that sometimes I anticipate some kind of telepathy on the part of the patient about this.  The other day I got so worried that I was simply expecting the patient to be on the same page as me that I actively put down what I was doing, sat down again and went through their ideas, concerns and expectations.  Cheesy, but true.  It was a huge reality check - had I simply used medical mumbo-jumbo?  Had I managed to strike the right balance between being clear about what we were checking for and not instilling unnecessary panic?

Somehow there is something incredibly scary for you, the doctor, about saying out loud that you're doing a test because it could be something serious.  I know that sounds incredibly selfish.  But really it's all about communication.  And not hiding behind cryptic words or alternative phrases is part of that, as well as not sending someone into an unnecessary panic.

I actually do love my job though.  There are few things more satisfying than getting a few smiles out of a patient or three despite the misery of being stuck in hospital.  It literally makes my world every time.  But this is a package deal.  (Not) breaking bad news is not an option.