Faux pas

As unseemly as it might appear, a patient's thank you card can be very encouraging to a doctor. Not all doctors derive comfort from such a small token of appreciation - but many do.

On a lovely August day, I received a card from my patient's family. This reminded me of that patient's recent bleeding complication after colonoscopy at another hospital. His wife requested me to speak to his surgeon. I did. His surgeon told me what happened, cautiously remarking that bleeding was under control after the second colonoscopy procedure and tranexamic acid, a medication that has been touted as a brake to the domino effect of catastrophic bleeding. When I learned more about the medication dose that my dialysis patient had received, I told the surgeon to stop it and send the patient to see me. With my patient's poor kidney function in mind, I worried that the drug would accumulate pretty quickly in his body.

My patient didn't manage to walk into my clinic the next day - he was shaky and stuttering in a wheelchair, after being intoxicated by the magic drug. He wasn't back on his feet for at least three days.

Few weeks later, I met my patient's wife who sent me the card. In passing, she told me that she owed me her life, too, when she happened to be under my care ten years ago. "Did I?" I responded, pride written all over my face. "I didn't recall seeing you."

"Believe it or not, I collapsed after being given a shot for my abdominal colic, and was then sent to the emergency room. Too much of the injection dose, I guess. You were the one who saved me at that time."

I listened, nodded and blushed. "Mm-hmm," I thought. "We're praised for making remedies for medical errors. That's embarrassing."

Don't Know

I have been learning to make use of the skill to acknowledge what I don't know that I don't know. Knowledge is different from all other kinds of resources, as we have been told, because it constantly makes itself obsolete.

Last week, one of our talented fellows asked me what's the reason of stopping salbutamol, a short-acting "reliever" medication for chest tightness, in case our patients are coughing up blood from the lungs. I took a deep breath and then told her I don't really know. Although I quoted the evidence from an article that appeared in the British Medical Journal 28 years ago, the honest answer should be kind of old wives' tale. That's what I had been taught soon after my becoming a doctor.

Looking back, I reflected on what I had learned about the need to suspend any dogma, however hard earned it may be. Be flexible and admit I don’t have all the answers. To borrow an idea from Nance Guilmartin, the more we think we know, the less we truly know.

Murmur

Medical students don't want to miss out on examining patients with abnormal heart sounds or heart murmurs, because these patients often appear in the final examination. The students are expected to feel the pulse, listen with the stethoscope, and then come up with an answer to the question of which heart valves are leaking or narrowing.

The examination is not for the faint-hearted. I saw beads of perspiration over my student's forehead when I led her to examine a lady with narrowing of the aortic valve. I had a hunch (and it later proved to be pretty accurate) that my student’s heart was doing pirouettes in tandem with the noises of the patient’s heart.

When I debriefed the medical students about the lessons learned, I told them an important tactic. "Pause," I said. "What’s the most important thing to a patient when a doctor or student comes into the room – before you stick that needle in or take out the stethoscope? Stop, and see him as a person first and a patient second. A gentle greeting with a smile would do. As simple as that. Make your patient (and yourself) comfortable."

That's what I learned from my patients and recent reading of Nance Guilmartin's book.