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Tuesday May 07, 2019

Why Is Compassion So Important? Just Ask This Patient

Tim was on a business trip and had just finished having dinner and doing some paperwork in his hotel room. He was almost ready to turn in when he felt a sharp, epigastric pain. He thought it was likely something benign -- either a muscle strain or indigestion -- so he took an antacid and acetaminophen.

[emergency sign of a hospital]

But an hour later, the pain was worse. He called his spouse and said something wasn't quite right, but he would be monitoring it.

By 3 a.m., with no relief, he realized he would have to seek professional help. He also knew that by the time he could get in and out of an ER, it likely would be time for his 7:30 a.m. meeting. He slowly and carefully showered, dressed and went to the hotel lobby. He asked the staff where the closest hospital was, as well as which area hospital they would go to themselves. He decided to go to the latter.

The hospital was quiet, the only sound coming from the machine being used to buff the lobby floor. No other patients were in the waiting room.

Tim walked to the registration desk and told the staff he had abdominal pain. During the registration process, he asked if he could sit down because the hunched over position he was standing in was uncomfortable. They told him not to worry and that he would be sent to triage soon. So, hunched over, he continued to provide his information.

Tim eventually was taken to triage. A nurse took his vitals and asked why he was there, and he explained it was because he was experiencing a level of pain he had never felt before. He wanted to describe the pain but was told he should wait to discuss it with his assigned nurse. He insisted on telling them about the pain anyway, explaining that if 10 is the worst pain of one's life, it would be an 8.5. Again, he was told not to worry and that he would be taken care of in the ER.

He managed, with difficulty, to stand up again, and was asked if he would like a wheelchair. After some quick mental math, he joked, "If I get in a wheelchair, I will have to sit down and get up and repeat that when I get to the bed. I am in a lot of pain, so I'd rather just walk a few steps to my bed."

The nurse then took Tim on a long tour of the emergency department because the bed, unfortunately, was on the other side of the building. Tim gingerly sat down on the edge of the bed and waited.

He heard nurses discussing their weekend plans, family members, grandchildren and recent vacations.

After half an hour, the pain was so great that he felt nauseated, but he couldn't locate an emesis bin in the room. He realized he would need to walk, slowly, to the nurses' station to ask for one.

"What? What do you want?" a nurse asked.

Tim -- trying to smile through the pain -- said politely that he felt nauseated and needed an emesis bin. The nurse got him the basin and walked away without a word.

And then Tim waited some more. At this point, he wished he had stayed at the hotel.

On the wall in front of him, mocking him, was a sign that said, "We are here to make sure you are comfortable," with a pain scale to help patients describe their level of pain. He would have laughed had he not been in so much pain.

More than an hour after his arrival, the same nurse walked in and said, "I'm going to take your vitals now and draw your blood."

Tim smiled and said thank you.

The nurse hooked him up to a monitor, got a phlebotomy kit and said, "So what's your problem? You have stomach pain?"

At this point, Tim realized there was a good chance that if his condition was serious, no one here would figure it out soon enough and he might have to take charge of the situation.

"Yes, I have epigastric pain, but I'm concerned that this is atypical," he said. "I've never had this pain before, and I would really like it if you checked to make sure that there's no cardiac involvement."

After the look she gave Tim, he apologized and clarified that he was a doctor and just wanted to make sure it was nothing serious. She left the room to confer with others.

Tim was wondering whether she would examine him or even ask him what his pain level was when the ER doctor arrived.

"I hear you're a doctor," she said. "What's the problem?"

Tim once again explained that he just wanted to make sure everything was OK and get back to his meeting. The ER doctor said, "Well, if you think it's cardiac, we'll have to get an EKG. But it may be something from the digestive system."

The doctor touched Tim's stomach, and he winced in pain.

"OK, I'm going to run some tests," she said. "It seems you are in a lot of pain. I will get you some pain medicine. What would you like?"

Tim said he wanted the lowest dose of whatever medicine was administered, titrated up if necessary, because he was not comfortable with the side effects of decreasing sensorium. He wanted to attend his meeting later in the day.

The doctor ordered medication and said they would get a chest X-ray and CT to rule out any serious pathology. Then she left.

A tech arrived, and Tim completed the EKG with difficulty because it was hard for him to lie down. When it was done, the ER doctor returned and thrust the paper in front of Tim asking him to interpret the reading. Tim said it was normal. The doctor agreed but still had not asked about his pain level.

Tim finally received a dose of short-acting pain medication, and then everyone left the room, which was unfortunate because he immediately felt dizzy and realized both of his bed rails were down. No one came into the room again until the medication wore off 30 minutes later.

The pain, which had gone down to a six, was now returning to an eight. Feeling dizzy again, he looked at the monitor and noted that his blood pressure had dropped to 80/60. Alarms went off, but no one came.

"I hope I don't die," Tim thought.

He laid back and elevated his legs, hoping to bring up his blood pressure.

There was arguing outside Tim's room. The nurse told the CT tech that Tim was scheduled for a scan, while the tech questioned whether the labs had been ordered.

Tim used all his strength to shout from his room to them in the hallway that all the labs were in order and that they should check the records. The nurse stepped into the cubicle and said she didn't realize he could hear them.

Tim told her the pain had returned.

She said he had to get his CT scan now and left.

"Let's go," the tech said. "Follow me."

Tim shuffled in his hospital gown behind the tech. Each step was painful.

He did not want to complain, so he didn't point out that they should have done the CT scan immediately after he had received the short-acting medication. Instead, with great difficulty, he slowly and gingerly sat on the table.

He needed to lie down and be still for about 20 minutes. The pain was excruciating, but he complied.

The only outward sign of his pain was a single tear that trickled down the corner of Tim's right eye. When the scan was over, one of the techs noticed and asked if he was OK.

He replied that he was not. He was in pain.


He was guided back to his cubicle.

Before he returned to the bed, he realized there was a box of tissues near the sink counter. Tim's nose had been running since his arrival. He had been using his gown to wipe his runny nose, and once he had the tissues in his hands, he was so grateful that he actually let out a sob.

"I really just would like to go home," he thought.

Eventually, the ER doctor returned and stated there was something concerning on the CT scan, and she was going to call a surgeon.

She asked whether Tim would like something else for the pain. Tim said he would.

The ER doctor left and never returned. A new shift was starting with a new nurse and doctor.

"What do you normally take?" the new doctor asked.

"I am not normally in this kind of pain," Tim said.

"OK," the doctor replied, "maybe a muscle relaxant."

Tim thought this was visceral pain, but he did not want to be argumentative. The medication didn't work.

An hour later, the doctor offered a different medication. This time, relief.

Tim wanted to sleep but didn't want to miss the surgeon, so he forced himself to stay awake. The surgeon finally arrived. He said he had reviewed the CT scan, and there was nothing they would do acutely.

He touched Tim's abdomen, and there was no pain at the moment. The surgeon said Tim should follow up later with his doctor. Tim eagerly concurred and asked for his paperwork so he could go back to the hotel.

Spouses of his colleagues came to pick him up. As he left the hospital, they asked how he was. Tim said he had less pain at that point and would take care of it at home.

He wondered what his EHR note said about his seven-hour stay.

Did it say alert and oriented x 3?

Did it say HEENT within normal limits?

Did it say neck supple, no lymphadenopathy?

Did it say no visible chest abnormalities, HS1S2 normal, no murmurs, and lungs sound normal?

Did it say Tim's back was within normal limits, no CVA tenderness?

Did it say no visible abdominal deformities or scars, pain in the epigastric region, no shift, no dullness, no abnormal bowel sounds?

Did it say MSK appeared normal?

Did it say neurologically intact?

Tim asked himself these questions because other than two quick abdominal pokes, no one, not a soul, had actually examined him.

And no one had asked him to rate his pain -- before or after pain meds.

Sadly, this is a true story.

Tim was me.

Fellow physicians, we must do better than this. And so, I remind all of us to try to do the right thing for every patient every time. And teach others to do the same.

Tochi Iroku-Malize, M.D., M.P.H., M.B.A., is a member of the AAFP Board of Directors.

Posted at 03:54PM May 07, 2019 by Tochi Iroku-Malize, M.D., M.P.H., M.B.A.

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