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MEDICINE | DOCTOR FILES

As healers, we don't have the luxury of having a bad day

A surgeon's outburst in the ER traumatizes his patient's family. It also teaches a young doctor the importance of a professional manner.

December 26, 2005|Linda Reid Chassiakos | Special to The Times

It was an unusually cold night, even for December. The emergency room was quiet -- few people were eager to venture out in the icy weather. I had made my rounds on the pediatric ward and the burn unit and had settled in at the ER nurses' station with a warm cup of coffee and a tattered magazine when the call came in.

The paramedics were on their way with several patients -- all members of a family whose row house had broken out in flames. Space heater? Christmas lights? So many potential dangers in the dark of winter.

As the burn victims were rolled into the ER, I was relieved to see that many of the injuries were relatively minor. First- and second-degree burns, generally over small areas of the body -- deeply painful, but not life-threatening. Then I saw the little boy, barely a year old. His face was untouched, his natural dark brown, but, alarmingly, the flames had charred much of the rest of his exposed body, turning the skin a dull gray-white.

I ran to his side, my voice soothing, trying to calm his cries. His vital signs were stable, he was conscious and alert. It was our job to provide fluids and prevent infection, now that the fire had destroyed the capability of his burned skin to retain moisture and defend against microbes.

Starting an IV was my next step, and I was grateful for the years of experience I'd had as a pediatric resident with uninjured patients. Even so, I wasn't prepared for the little boy's challenge. At every site on the arms and legs I tried, the touch of my fingers would slough off the friable skin and prevent the needle's proper insertion.

Finally, I called for a surgeon to perform an incision and insert the IV needle from a deeper and more stable site under the top layers of skin.

On the other side of the curtain from our exam area, the baby's mother and aunt were being tended by a colleague. Pain medication and antibiotics would help them recover relatively quickly. I could only hope that the baby would have a similar chance.

The surgeon on duty arrived within minutes. I stepped back as he headed for the surgical tray the nurse had prepared for him next to the infant's gurney. Snapping on his gloves, he began looking for a site on which to work.

Seemingly irritated at the difficulty of finding a good site due to the breadth of skin damage, the surgeon finally found a spot on one leg and began the procedure, the nurse and I helping to hold still the fussing infant with gentle pressure on his unburned abdomen.

As the surgeon began to insert the plastic catheter that would carry fluids and medicine into the vein, he grunted in frustration: The catheter, impacting against tight muscle, had bent into an unusable angle.

Angry, the surgeon tossed the catheter to the floor, and then picked up the entire tray and hurled it to the edge of the exam area, shouting, with a profanity: "If we don't get some good equipment here, this baby's gonna die!"

Stunned by the surgeon's outburst, we stood speechless for a moment before being shaken by a scream from the other side of the curtain. "My baby, my baby, my baby's gonna die!"

Glaring at the surgeon, I raced to the mother's side, trying desperately to reassure her that we were doing everything we could to save her son's life. Understandably, she was not easily calmed, but the sedative effect of her pain medication soon allowed me to leave her safely and return to her child.

The surgeon, trying with a new catheter, had finally succeeded in placing the intravenous line. Relieved, we began giving the baby fluids and medicine to ease his pain.

Ashamed of his flare-up, the surgeon avoided our eyes as he peeled off his gloves and left the exam area with barely a nod at us or a glance at our now-whimpering patient. I could still hear the baby's mother sobbing quietly as we prepared the little one for transfer to the burn unit and the long weeks of graft surgery and treatment that we hoped would save his life.

The surgeon's explosion, so devastating to the patient's family, was reported to his supervisor, but no corrective action was taken. Surgeons in that era were at the peak of the institutional hierarchy, and, as long as their technical skills were acceptable, their rude behavior was discreetly tolerated despite the damaging effect on patients and colleagues.

As an impressionable young doctor, however, I was haunted by the mother's cries of despair, and the surgeon's callous disregard for his patient's family.

So, in subsequent years -- as a mentor and teacher of doctors-in-training -- I resolved that my students would learn the importance of maintaining a professional bedside manner at all times, even in the most anxious and desperate circumstances and times of frustration.

Doctors experience anger, fear, anxiety, sadness and every other emotion. But expressing these emotions in inappropriate ways at inappropriate times can profoundly "do harm" to the patients we are trying to treat.

It took weeks for the baby's mother to heal from the emotional assault she experienced on that dark December night. Along with counseling, the steady improvement and the eventual recovery of her son helped her recapture the stability jeopardized by the surgeon's outburst.

There is no question that the surgeon's skill in successfully inserting the deep IV was important to the boy's recovery. But having good technical skills and maintaining a professional demeanor are not mutually exclusive. A good doctor strives for both.

The covenant we doctors have with our patients that gives us the privilege of wearing our white coats requires that we live up to the honor and responsibility of that uniform, to serve our patients at all times with caring professionalism.

Dr. Linda Reid Chassiakos is director of the Klotz Student Health Center at Cal State Northridge and a clinical assistant professor of pediatrics at UCLA.

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