One of the things we’re taught in our ethics classes is that we, the medical staff, don’t get to decide what treatment a patient gets. The patient does. We can recommend until we’re blue in the face, and suggest as strongly as possible, but ultimately, it comes down to the patient’s choice. It shouldn’t be any other way, but sometimes it can frustrate both staff and patients, and patient care gets nowhere.

Before you get to this blue-in-the-face step, however, I’ve learned it’s important to make sure everyone’s on the same page, and everyone’s communicating on the same level. If a doctor understands a disease process differently from the way a patient does, each party may interpret the other’s actions, behaviors, or treatment suggestions as hostile, insulting, or punitive.

Take for example, Mr. Gouda . (Not his real name, but I’ve been craving cheese lately.) Mr. Gouda presented with all the classic–I mean, classic –signs of a small bowel obstruction. (A small bowel obstruction is when the small intestine gets blocked, either because it’s twisted, crimped, or squeezed from something outside of the intestinal tube. It’s usually caused by scar tissue from prior surgery or hernias.) He was throwing up, not pooping, not passing gas, and had lost his appetite.

The treatment for a small bowel obstruction is, for the first few days, watching and waiting (later it can be surgery). Give the patient some IV fluids to re-hydrate them (they’ve been throwing up and not eating), and also give the patient an NG tube–a tube that goes down your nose and into your stomach, which sucks out air and fluid that’s built up in the intestines. The only problem is this: having an NG tube placed is incredibly uncomfortable. Probably the most uncomfortable thing we do while people are fully conscious. We stick a tube up your nose, pass it down your esophagus as you gag, telling you to “Swallow, swallow” until it’s down in your stomach.

In the ER, they had tried to place Mr. G’s NG tube without any success. He hated it so much that he was willing to keep throwing up as opposed to having another tube placed. Please note that this was not normal vomit. This was feculent vomit. Translation: partially digested food, starting to look (and smell) more like poop than food. He was more willing to throw up poop than have the discomfort of another NG tube. That’s, uh, pretty severe in my book.

So we go down to talk to Mr. G, who absolutely refuses the NG tube. He says “Just put me out and do it!” We tell him that we can’t–if you’re unconscious and gagging, you can vomit and have it go into your lungs (this is called aspiration) and you get a really, really severe pneumonia and can die. Next, he asks us why we can’t just give him “some medicine to dissolve the blockage,” and I start to realize we’re not on the same page. This, my friends, is the key. That same visit, the team kept arguing with him, both sides got frustrated, and we gave up for the night.

Mr. G had thought, totally understandibly, that this “small bowel obstruction” was a blockage in his intestines. Something like a clogged drain. You pour down the Drano, dissolve the gunk, and voila, clean drain. There’s even a medical correlate: if you have a blocked heart blood vessel, you can insert some medicine inside the vessel to break up the clot.

My colleague and I went back to Mr. G the next day and explained that the blockage was external–like a kinked garden hose, or a clamp over a tube–and everything instantly changed. I get the feeling that he thought we wanted to do the NG tube just as punishment for being a “difficult” patient, but he finally understood that we couldn’t have him drink some substance–the obstruction was outside his intestines. Once he understood that, he was totally willing to try the NG tube. Our chief placed the tube, much easier than the ER resident, and two days later Mr. G was out of the hospital, with a referral from us for a primary care physician.

It’s always important to make sure everyone’s on the same page. We all have different definitions of words, especially in the medical field.

4 Comments »