14 November 2007

15 NOV The Bandaid

15 NOV The Bandaid
It is 0330, and I’m writing this in my hooch. I probably should sleep soon as I’m on call in a few hours. It is nice to be able to write from my cozy cave. I’m wrapped in the woodland camouflage blanket that M. knit for me. The computers in the Wounded Warrior Lounge are very slow and sometimes lose their connection. What I write tonight I’ll bring to the hospital on my thumb drive and post to the blog from there.

When I was thirteen, and decided to become a doctor, I wanted to be a pediatrician. I am the oldest of five children and helped take care of my brothers and sister. I often babysat for neighbors and friends. I enjoyed caring for children. I thought that it would be a lot of fun taking care of children as a pediatrician. Well it turns out that caring for a sick child is a lot different that caring for a well child. It is not as much fun. It is extremely difficult to watch a child who is ill and suffering and answer to worries of mothers and fathers. I have found that it is a lot easier taking care of an anesthetized child, which partly explains why I can make it a lot easier as a pediatric surgeon than a pediatrician. The things I do when I correct birth defects or surgical emergencies might seem violent or chaotic. But in the sterile calm of the operating room, isolated in the blue square of surgical towels, the careful cutting and controlled bleeding of a child isn’t as frightening to me as an awake child in pain.

Still, medical care requires unpleasantness, and I find that I am often responsible for putting a child through misery on the path to getting well. I remember being a medical student assigned to the pediatric surgery service. During the day I would assist Dr. J. Alex Haller as he performed amazing precise operations to transform a child’s deformed chest into a healthy round shape. The children would drift off to sleep at the beginning of the operation as they inhaled anesthetic gas perfumed with the scent of bubble gum or cherry. When the operation was over, they would emerge from the anesthetic slowly and be given strong narcotic pain medication. During the night, I would take call with the residents and attend to the needs of the children staying on the pediatric surgery ward. The call would come; a child had lost their intravenous catheter, and needed another. The resident on duty would send me to take care of it. By the time they called us, the nurses had already tried and failed. It always seemed absurd to me that I was being asked to try after a much more experienced nurse had been unable to complete the task. What I did have on my side was desperation. I wanted to become a pediatric surgeon more than anything in the world, and it seemed to me that I had to master this first task if I was to have any hope of making it. Sure I could go back and wake up the intern if I failed, but at the moment seemed to me that I was the last chance this child had to get a dearly needed intravenous catheter.

I can easily call up the pitiful scene in my mind right now. Intravenous catheters were placed in a little room on the patient ward called the procedure room. One difference that sets good hospitals for children apart is the presence of child life specialists. These professionals tend to the special psychological and emotional needs of children of ages enduring an illness. One principle of child life is that the child’s room should be reserved as a place of sanctuary where they will not be hurt and can rest safely. By the time I arrived on the ward, the child had already been moved to procedure room. I would open the door and would see the child, perhaps recovering from an appendectomy, or maybe dying from some cancer. They would have red-rimmed eyes and trails of tears down their cheeks from the previous attempts to insert a needle into a vein. The child’s mother or father would be there, comforting their child. They always looked so tired and would wear a worried expression. They would turn and look to me, a medical student, with eyes carrying a mixture of hope that I could help and suspicion that I could not.

I would introduce myself and explain that I was about to try again to insert an IV that would work for their child. I would tell parents that they were welcome to stay and watch whatever I did to their child, but if it was too difficult to endure, they could step outside for a moment. The nurse would help position the child and hold his or her arm down for me to work on. As soon as the child realized that another needle was coming they would begin crying again. Some would plead for me to stop; others would scream and yell at their parents that they hated them. Either way, most parents would begin to cry. I would try to drown out this pain. I took note of the previous needle holes and bruises, calculating which vein would be easiest to hit. I would speak softly and soothingly, methodically explaining what I was doing so that there were no surprises. I hoped and wished that my needle would find its target on the first try and a deep red show of blood would appear at the hub of the needle. Often it didn’t. Missing a vein would mean fresh cries from the child when I told the parent that I was very sorry but I needed to try again. Thinking about it brings a lump to my throat even now. But I had desperation on my side. I knew that without that IV, we could not get that child well. No matter how much they cried or fought, it was unacceptable to give up and not give them the treatment they needed.

It felt horrible the first few times. After the IV was in I would retreat to the stairwell, shaking, wondering if I could do this for a living. It got easier to start and easier to move on to the next task, but I still ache when I have to cause pain to an awake child. I never lie and say that it won’t hurt. The child would never trust me or another doctor again if I did. I tell the child and the parent how well they did when I finish. It is no fun for a child in the hospital. I’m not a nice guy. I do mean painful things to children. But as long as that is what they need to get well, I’ll keep doing them.

So yesterday morning, Laparoscopic surgeon S. asked me if I would perform a fluoroscopic examination on a child. The test would involve putting an uncomfortable tube into the child and he rightly assumed that I would be able to get the child through it. The boy was shot in the belly a month ago. He had recovered enough to go home, but was losing weight and had little appetite. We needed to know if his stomach was blocked from internal scars. I set up the x-ray machine and sat the child on the table. With the help of translator M., I told the boy, who was 9, and his mother that if he was able to drink the liquid that shows up on the x-ray, I wouldn’t have to put the tube in. He looked at me suspiciously, took one sip of the contrast material, then grimaced and spat it back out. I’m not surprised, that stuff tastes awful, kind of like Kool-Aid that someone has spilled salt into instead of sugar. Nurses held the boy’s arms down, and I shoved the tube into his nose. His mother coaxed him. I put the liquid into the tube with a syringe. We watched on the screen as the shadow of the fluid moved out of his stomach and into his intestines. He wasn’t blocked. I pulled the tube out and praised the boy for doing such a great job. He smiled in relief. The procedures I do often don’t feel good. Sometimes I wonder if we surgeons will be forgiven for what we do to the body. But once started, nothing feels as good as being finished. It is better to rip the Bandaid off fast.


lainy said...

A good doctor wouldn't care the way you do. The world needs more doctors like yourself. There is usually some bad in all the good. Hopefully these children will remember you didn't want to hurt them, but help them.

Jen said...

Great post...one of the hardest things to explain to my daughter when she was much younger and had cancer was why all of the doctors and nurses who were so nice to her also had to hurt her. She eventually understood, and I think that she'll very much enjoy reading this.

(and that contrast liquid is vile...she always said that the worst part about her entire cancer was trying to drink it and then having to get a tube put it anyway. You nailed that one).

emergencyemm said...

Beautiful post, hope your day is going well.


ChefSara said...

Thanks for being honest with those kids! I hate being told "it won't be so bad" and finding out that it is. I would much rather be told that this will hurt, only to be pleasantly surprised that it's not as bad as I was expecting...

Holly said...

I think my kids always appreciated the honest docs, like you, more than the the ones who treated them like "Oh, this is gonna be fine. Won't hurt a bit. Be over in a second."
AS you well know, Children aren't stupid, just short. A Smart parent will explain that they have to go through some pain in order to get better.

Pigasus said...

I was precepting as a paramedic and it was one of those hellish scenes with our 2 y/o male patient screaming his head off over trauma he did not deserve. My preceptor turned to me and said "kid's got a good airway..."

I agree with you that patients deserve the truth. I particularly object to lies told for the convenience of the provider.

Why does causing discomfort bother you when it's part of helping the patient? I can understand empathy but I hope there's no guilt. Guilt over necessary interventions wastes energy better spent elsewhere.

Again, thanks for doing this.

Chris said...

It has been so rewarding to me to hear what you all have said here. It has been a bit of a relief and confirmation of my beliefs to hear from parents who have seen this trauma from the other side. I can't say that I feel guilt when the healing treatment I have chosen causes pain, at least not for a long time now. I do feel an empathy, the kind where I feel a ghost of the pain I am causing on my own skin. Agreed, there is no sound sweeter than the cries of a child who has hit is head, and no sound more frightnening than their silence.



Beth said...

I've been reading your blog for a little while now and every day you tell a story that amazes me more than the one from the day before. I'm not really surprised that you're a pediatric surgeon. All of the peds surgeons I've encountered in my life thus far have two sides: the no-nonsense, do whatever it takes side and the endearing, compassionate, pensive side. As a current peds resident, I know all too well what it's like to put a kid through a procedure. I think about it every time I do a blood draw, an LP, or something more serious, like a chest tube or an intubation.

Thanks for your stories and be safe.