“And who are you?” Tracking the voice, I realise the nurse is talking to me.
“I’m the physician looking after the patient.”
I have drawn back the curtains to find my new patient slumped in bed. My hand reaches for her pulse in her neck, wrist or groin but I feel nothing. A nurse says the patient was just speaking, which doubles my consternation.
“No pulse, we need compressions,” she prompts.
In her late-80s, the patient has end-stage kidney disease and other serious conditions. Having consistently refused dialysis, she has identified her priority as spending her remaining days at home with her husband. Wanting only to be kept comfortable in case of an emergency, here she is – unconscious – and by all appearances, comfortable.
Suddenly, the room is teeming with people and a crash cart. “Wait, she doesn’t want to be resuscitated,” I exclaim.
“It’s not in her notes,” says the nurse, hands primed over sternum.
Apparently, the overnight junior doctor was not convinced the patient meant what she said and had left the morning team to revisit the issue, not expecting the patient to crash. To many readers, this will seem like a material overriding of autonomy but suffice to say this kind of back and forth is all too common in hospitals.
I rapidly summarise the patient’s situation to the gathered crowd and miraculously manage to reach the patient’s usual specialist to confirm the patient’s long-held stance against being resuscitated.
The resuscitation attempt freezes but given the rapid-fire decisions, uncertainty hangs in the air. An emergency physician wheels in a portable ultrasound and declares the patient’s heart to be barely contracting. Together, we call off the code but not before someone says, “So you are deciding to call off resuscitation.”
“Yes,” I say, my own heart palpitating.
The crowd thins, leaving a couple of nurses to attend to the patient who is still taking shallow breaths.
In the corridor, a resident is quietly typing notes. A nursing student hovers. Needing to say something to someone, I ask the nurse, “Are you OK?”
“Totally fine,” she says. I don’t believe it.
“I feel so bad,” says my trainee.
There is so much to feel bad about but I say something anodyne, making a mental note to debrief later. (Spoiler alert: it never happens.)
Before moving on, I glance inside the room to ensure our dying patient is comfortable. I am shocked to find her in animated conversation with the nurse, seemingly oblivious to her near-death experience.
This happy sight leaves me floored. Had I been too hasty to call time on her life? What could I have done differently? How will I explain this to her family?
I’m distracted by our many other patients until I hear that she, now alert and awake, says that the next time “this” happens, she wants “everything done”.
The easier thing might be to say sure, but we take the harder route of a sympathetic conversation about her goals of care. Sure enough, she reverts to her original decision to avoid futile measures.
This specific sequence of events is uncommon but not unheard of. I daresay if the patient had died, it would have been a routine occurrence but the fact she survived against our expectations creates complicated feelings.
In the days ahead, I feel a jumble of doubt, lament, guilt and worry. I feel wound up even though I get exercise and sleep. Something feels heavy. And because I can’t name it, I don’t know how to deal with it. But worse, when I stay silent my team stays silent. Which means all of us keep going without ever discussing an event that any reasonable-thinking person might say deserves some form of reckoning. It’s only when a friend points out that this is how vicarious trauma occurs that I stop to think about this condition experienced by those who do intense emotional work over sustained periods.
In healthcare, the cost is frequently borne by nurses, first responders, social workers and doctors. Vicarious trauma is bad for the provider and bad for the patient because a provider who is not whole cannot provide care that is whole.
Another friend observes that one hospital invests in a skilled therapist to help professionals address issues ranging from ethical dilemmas to interpersonal conflict. They seldom engage the therapist, but when they do it’s a gamechanger for the collective good. I find the idea entirely sound and sadly fanciful. Between inaugurating another building and quietly engaging a therapist, the building usually wins.
To be fair, hospitals today are more interested in provider wellbeing. However, the sessions on offer are brief and of variable quality. They might suffice in a crisis but not for the kind of slow-burning things that add up to vicarious trauma. For this, providers need experts who spend time getting to know them, their colleagues and their specific environment. This kind of longitudinal investment in provider health has not been a priority but might just be part of the answer to stemming burnout.
I feel bad that the intended debrief with my team didn’t happen. I just didn’t feel equipped for it. Eventually, we all moved away. But in doing so, I suspect we shifted the cost to future patients.
Ranjana Srivastava is an Australian oncologist, award-winning author and Fulbright scholar. Her latest book is called Every Word Matters: Writing to Engage the Public