Once Upon A Time … I Knew All This!

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This is part of a longer essay recording my year of transition from palliative medicine to acute medicine. I write to console myself and to capture the extraordinary in the ordinary.

 

Once Upon A Time … I Knew All This!

I moved from palliative medicine to acute medicine in July 2013, having practiced palliative medicine for 23 years in Cleveland, Glasgow, Dublin and Wellington. I thought the anxiety and fear would kill me! It was equivalent to leaping off a bridge into cold rough salty sea water in the Southern Hemisphere winter every day. Clearly I wanted to give myself another challenge! Did I survive? Do I have any regrets?

Initially on Saturday or Sunday on call for the weekend for acute medicine I would hold my breath as diagnoses were rattled off. I used to know all this … once upon a time.    How was I to navigate my way, knowing that I was once a registrar on top of my game in general medicine in tertiary referral and national referral hospitals? Once is a long time ago. Sepsis, fluids, CPAP, BiPAP, troponins, metoprolol for atrial fibrillation, anticoagulation for atrial fibrillation, thrombolysis for stroke, even D-dimers for PE … so much has changed. And what has happened to digoxin? How do I use BiPAP, CPAP? What do the numbers on the side of the machine mean?

Fortunately for me there is much palliative medicine in acute medicine. Such well known practice was like a calm place for me to glide my boat gently into the harbour where a person was dying. That world I knew well. It was a delight and ease for me to bring a registrar and house surgeon, junior doctors, young doctors along in a well-appointed boat. I sailed easily. It was very soon evident to me that palliative medicine applies directly to at least one third of patients admitted acutely under medicine.

Let me tell you a story where acute medicine and palliative medicine intertwined.

 

Mr W (89) came to the Emergency Department during the night. The registrar summarised the patient’s story of shortness of breath. I met Mr W on Saturday morning with Ella, the registrar for that day. He was returning from the toilet, sitting now on the side of the bed and breathless. I was unsure how different this was from the time of his admission six hours before. I thought he had heart failure. We asked the nurse to give him frusemide. I thought the tracing of his heart (ECG) suggested ongoing damage to his heart. We continued seeing other new patients.

About an hour later, an alarm bell rang in the Medical Assessment Unit – Bed 23 – Mr W’s bed. The nurse was there. He had just died. I decided immediately that CPR was not appropriate. Ella consoled the nurse, who was upset that she had left him just before he died. I phoned his daughter as the identified contact person. She cried, clearly surprised and distressed. She said her mother was just then getting his clothes ready, preparing for him to come home that day.

They arrived about two hours later. His wife was in a wheelchair, crying. She was afraid to go into the room where he lay. I encouraged them all to enter the room. Mrs W lifted herself out of the wheelchair by his bedside, leaning over him, almost lying on him, weeping, hugging him, talking to him. My heart broke at the image of this small lady leaning over this man, her husband of 65 years.

I could not understand why I was so upset after 22 years in palliative medicine. I think it is because in acute medicine, unlike palliative medicine, you are so close to the front line; because in acute medicine you do not have your palliative medicine armour on. The chaos and uncertainty, the surprise factor of acute medicine, render me exposed and vulnerable. “Palliative” comes from the word “pallium” – to cloak or shield – generally accepted as the professionals cloaking the sick person in care. But now I know “pallium” used to shield me.

The poignancy intensified. I sent them a card offering my condolences. Mrs W responded, phoning me to request a meeting. “Oh dear,” I wondered … A week later we sat again in the same room where she had hugged her dead husband. Mrs W said “The nurse phoned me that morning, said S wanted to speak to me.” As the nurse brought the phone to his bedside, “the battery died.” So they never spoke. She presumed he wanted to tell her to bring in his clothes; that he was going home. So she started to get his clothes ready. Now she wonders if he wanted to say he loved her. “Is that what he wanted to say …?”

Mrs W thanked me. They all thanked me. My heart was breaking. Acute medicine – no place for the faint hearted.

 

– Dr Sinéad Donnelly MD, FRCPI, FRACP, FAChPM

Sinéad Donnelly is from Ireland. She has worked as a doctor in Ireland, USA and Scotland. For the past seven years, she has been working in Aotearoa New Zealand. She is a specialist in palliative medicine and internal medicine working in Wellington. As an extension of qualitative research Sinéad has produced six documentaries in Irish and English, exploring how children grieve, ancient Irish traditions of dying, how families care for relatives dying at home in Ireland and New Zealand and, most recently, a documentary on a unique rural parish in New Zealand. Sinéad writes as a way of making sense of her world.