My first reaction when a patient kicked my chief resident was simple: I laughed. “Donna” had been admitted to our surgical service for weeks with multiple enterocutaneous fistulas that drained from her intestines on to the skin of her abdomen. The only thing that made this condition somewhat manageable for Donna was the use of a complex series of bandages that she applied and removed with very specific techniques. It was when my chief resident quickly tore these bandages off that the patient kicked her.
The chief stormed out of Donna’s room and demanded a new set of labs. After some convincing, Donna allowed me to draw her blood, but an hour later, the lab informed me that the samples had been lost. I was furious and tired, but more than that, I was convinced Donna would be aiming a kick at me when I asked her for more blood. I walked hesitantly into her room and told her what had happened. She sat up in bed and said, “No. Goodnight.” Feeling defeated, I left her room. The next morning, the covering resident told me that the results had come back 30 minutes after I left. The labs were totally normal.
Ignore at your own risk
My first interactions with Donna taught me that some patients are difficult to deal with because we don’t adjust our care to their unique needs. We tear off their bandages because we’re in a hurry, and we draw their blood whenever we’re not quite sure what else to do. These daily annoyances can frustrate patients.
Over the next two years, Donna was readmitted to the hospital again and again. An attending surgeon rarely saw her and even the residents tried to avoid rounding on her, passing messages to her through nurses. In addition to being largely ignored, she never seemed to get better. Long periods of slow progress were offset by sudden infectious catastrophes that would commit her to an intensive care unit stay and extra weeks or months in the hospital.
After getting to know Donna better, I realized that the daily annoyances of the hospital are tolerable to patients when they feel like they’re getting healthier or they at least think someone has a larger plan for their care. But when patients feel as though they’re not improving or that no one is paying attention to them, all the blood draws and glucose checks become a kind of torture, and patients may not see what we believe are the obvious consequences of refusing these tests.
The night Donna refused my second blood draw, her decision ended up having no effect, but she often refused blood draws and computed tomography scans even as she was becoming septic. As surgeons, we must recognize that our role is not only to decide which tests and interventions are indicated, but also to explain as much as we reasonably can to our patients about why more lab work is necessary. If we can help patients to feel more involved in their own progress, they’ll be less likely to act as impediments to their own care.