Thursday, May 28, 2015

Doing Everything Right

A few weeks have passed since my kidney stone attack and my visit to an Emergency Room.  Time brings healing and perspective: it brings the ability to reflect on the experience and to hopefully gain new insights.  The time since my suffering this “minor” medical bump in the road has given me a chance to think about how everything can be done right, while feeling wrong. 

When I teach, I often share my definition of a minor illness as an illness someone else has.  Everything I or someone I love has is major.  My point is that when we treat people who are suffering, we must put ourselves in their shoes and try to understand what they feel and how those feelings impact their lives.  We must see the situation through their eyes, understanding their story and their perception and not only their pathology.  Indeed a minor illness that impacts one’s ability to work and one’s ability to meet responsibilities can be very major to the person in need of care. 

I suffered my first kidney stone attack in 1977 when I was an intern.  I ended up needing surgery (minor surgery but major to me) to remove the stone.  Through the years, I have had episodic attacks of kidney stones, especially when I allow my water intake to fall down.  I force myself to drink water in order to keep free of stones and the renal colic that ensues.  I do everything right but the stones still occasionally  occur. 

My latest kidney stone attack began with the all too familiar severe cramping pain in the left side of my abdomen radiating to my flank.  As is often the case with my kidney stone attacks, it was accompanied by a shutdown of my intestines.  A common complication of kidney stones is that the normal peristalsis, or motion, of the intestines stops.  This is called Adynamic Ileus or Ileus and the resulting obstipation (defined as intractable constipation), bloating, nausea, vomiting and total abdominal pain that comes with it can be more distressing than the severe cramping stone pain. 
For the next two days, I drank as much water as I could, avoided food as my intestines were just not working, and watched my urine for signs that the stone might pass.  While the cramping pain was only occasionally severe, the obstipation, bloating and nausea were especially troubling.  The entire time, however, I was confident that this was another bout of kidney stones and the stone would eventually pass.  By the second day, the pain, obstipation, bloating, and nausea were getting worse and had me doubled over. I made my way to the Emergency Room when the pain and the severe obstipation became unbearable. 

I presented at the front desk, immediately telling the clerk that I was in severe pain and needed a specimen jar as I needed to use the restroom.  A sense of urinary urgency often accompanies kidney stones and I knew that a urine sample would be needed.  My sense of pain and my symptom of urinary urgency were not matched by the ER clerk’s attitude or speed of response.  I waited patiently and after about ten minutes had the specimen jar in hand and was able to use the restroom.  The ER clerk did everything right but it didn’t feel right to me, the patient. 

After about twenty minutes in the empty waiting room, I was taken back into a room in the ER where the nurse started an intravenous line, drew blood, and took my vital signs.  I was then seen by the nurse practitioner.  He took one look at my extremely distended, tight abdomen and became energized as he thought that I had an intestinal obstruction or a perforation.  He asked me if I wanted an evaluation for obstruction or perforation. At that point, while I was relatively certain that I had an Ileus and not an intestinal obstruction I believed that it was good to make sure that the more urgent problems were not present.  I also believed that I was in no shape to be my own clinician.  The necessary tests were done to ensure that I had not perforated part of my bowel, while we waited for the blood and urine tests to return.  The nurse practitioner was doing everything right.

When the labs came back, the results showed that my kidney function was impaired, a surprising result which, while possible with a kidney stone and with some degree of dehydration, was a bit worrisome.  Meanwhile, I was receiving intravenous fluids to counter any dehydration I may have had from my limited intake over the previous two days.  The nurse practitioner was asking my opinion for every decision often in an open ended manner.  What pain medications I wanted, what test I wanted done, how best to proceed were all asked at each step.  He was following a model of patient involvement and shared decision making: doing everything right.  The problem was that at that point I did not really want to be asked which pain medication I wanted or exactly what I wanted my diagnostic evaluation to be.  I just wanted the correct pain medication for my situation and the clinician’s expert judgment to assess and treat me.  While I am a true believer in shared decision making, that was not necessarily the right time to use it.  I was in pain, I was distended, and my bowels were functionally if not mechanically obstructed.  I was not necessarily thinking all that clearly.  The nurse practitioner was being respectful of my status as a physician which was the right thing to do….but possibly at the wrong time. 

With the lab results in hand, I was able to have my CT scan but without the contrast usually used to better delineate a stone.  In the face of renal impairment, contrast infusion can be dangerous.  The CT scan showed a small stone present, and also showed distention of my intestines consistent with an Ileus with no signs of obstruction or perforation.  With that result, all of the activity and interest in me as a patient came to an abrupt halt.  In the eyes of the nurse practitioner and the ER nurses, I was no longer a real emergency.  The door to my room was closed, I did not see much of my nurse practitioner and the alarms on the IV monitor, and the BP monitor seemed to go off regularly with impunity unless I pressed the button to call someone in.  All of this was consistent with the norms of emergency medicine.  The “true” emergency, mechanical bowel obstruction or perforation was “ruled out” in medical parlance so they saw their job as done. However from my perspective, I was still suffering.  I still had the stone, was still in pain, still had severe abdominal distention and obstipation with Ileus and had known renal function impairment.  But all interest in me had stopped since, in the eyes of the staff, I was no longer an emergency.  They were doing everything right. 


I had received about 2 liters of fluid and wondered, with some presumed dehydration, whether I should receive another liter as eating and drinking was still difficult, but the staff at the ER would have none of it.  I did not have a “surgical abdomen” so they wanted me out of their emergency room.  I was discharged and I left.  Two days later, on Monday, I was able to see my personal physician and my urologist and received the medication and counsel I needed.

In the following two days, my pain, obstipation and distention continued as did my difficulty eating. After the third day of drinking as much water as my nausea would allow, my stone passed, my ileus and resultant obstipation cleared up, and I was back to work.  A CT scan two weeks later, and repeat lab data showed that the stone, the kidney impairment and the ileus were gone. 

There are those who would say that the care I received in the Emergency Room was perfect for the function they are charged with performing.  They gave me hydration, they diagnosed the problem, they “ruled out” a different problem that would have meant urgent intervention and they sent me on my way.  They paid strict attention to the medical facts and protocols.    

But I want more.  In an emergency situation and in an emergency room, while it is important to be in the moment, the truly great physician, or nurse practitioner should also think past the moment and see the situation through the eyes of the patient.  The ongoing uncertainty, fear and pain should be addressed even if addressing those concerns is a purely human and not medical science endeavor.  They must think and plan for the day after the ER visit and not only what happens within those four walls.  If all they do is everything right in the moment, they have become technicians and not the healers that our health professionals should be.