My patient had suffered a terrible, crushing injury to his chest leaving many ribs and his sternum fractured, his lungs and heart badly bruised and his body on the edge between life and death. He was on a ventilator, the tube through his mouth into his windpipe pushed air into lungs that couldn’t draw for themselves. He was on constant medications for pain and to sedate him while we used machines and drugs to buy him time to heal. His whole body was swollen so that his eyes were unable to open. When we asked him to follow a command such as “squeeze my hand” he did nothing. He moved his arms and legs spontaneously, but we worried that by thrashing an arm he might pull out the breathing tube on which his life depended, or an IV, a catheter, a feeding tube or that he might hit a bedrail and hurt himself. So his hands were gently tied to keep them by his sides. He was horribly sick.
His wife had chronic medical problems of her own and a life that, long before this trial, had placed a lot of trouble on her thin shoulders. She would make her way gingerly into his room, threading her walker next to the IV pump and ventilator to sit near him. She listened carefully when we updated her on his condition. She asked few questions, but said she understood. His ICU stay would last many weeks. To allow her some rest and time to manage life’s other requirements we encouraged her to take occasional days off from the hospital. A regular morning call to her, from a physician, and evening calls from his nurse would keep her informed. One morning I made the call and gave an update of an uneventful night and the day’s plan to continue our supportive care.
She did not come right out with what was bothering her. She listened to the update and was quiet. I was saying goodbye when she began to talk very fast. She apologized. She was sorry to seem like she might be complaining; she was grateful for our care. She was sorry to bother me, but not sure who else to talk ask. She was sorry for his behavior, but did not understand how it could have happened. Then she explained, his night nurse had told him her husband was being inappropriate. She could not imagine what he could have done. He was not that kind of man. How could he be inappropriate to a nurse when he could not even open his eyes? He hands weren’t even free. She became indignant and defensive of her husband. It was so unlike him! He was not that kind of man. How could anyone think a man in his state would even try?
My patient’s wife wasn’t sure exactly what the nurse had said. As so often happens, there had been a lot of information, and once she heard a loaded word, “inappropriate,” her imagination went wild and she heard little more. The nurse couldn’t remember either. She was apologetic, but it had been a routine conversation for her, a blip on her radar during a busy night.
“Inappropriate” in medical speak applies to many things that have no sexual connotation and nothing to do with good manners. Sometimes it even has nothing to do with behavior. If I give a patient a blood transfusion and the blood level does not rise as much as I hope it was “an inappropriate rise in hemoglobin.” If I give a drug that usually causes sedation but the patient becomes agitated it was an “inappropriate response to medication.” If I ask someone what day it is and he tells me his name or says “yes” his mental status is “inappropriate.” If I ask someone to hold up one finger and am shown the middle finger she is completely appropriate and demonstrating higher level of function; it is a good sign.
I am still thinking about this incident. It was an honest mistake, the kind that has been tripping up doctors for centuries. It was an inappropriate use of jargon, the effect of which was to increase the suffering of a woman already in a horrible situation. In this case, there was little harm, and she appreciated my explanation and reassurance. We have continued on as if nothing happened.
I do see a dark humor in this; I need some of that in order to keep doing my job. Worse things happen every day. However, I also want this to be a learning experience, the kind you hold in your memory to prevent similar mistakes. Communication is one of the most important prerequisites to good health care; providers, especially, physicians, need to be better at it. Empathetic communication can sooth the worst outcomes. When we get it wrong, even a medical miracle can leave patients angry and traumatized. The reality is, words can do harm.
Laura Withers is a surgeon.
