Protect our healers

In medicine, we love talking about case reports, which are essentially brief, patient based medical stories. Today, I want to start our post with a case report of sorts.  Follow along, and you will see how it ties in with our topic of the day: when we abuse physicians.

The case

Her name was Ana*, she was 7 years/old, and she was a perfectly normal and healthy child. One day, Ana was having lunch at school and a piece of food got stuck in her throat and occluded her airway. Her small body collapsed to the floor as her brain suffocated from lack of oxygen and she lost consciousness.

Everyone around her screamed and ran for help. 911 was called. Someone who knew how to provide CPR appeared and initiated resuscitation. Then, the ambulance arrived, the paramedics placed a breathing tube and, at some point, her heart started beating again. Sadly, she had been “down” (meaning without receiving adequate blood supply and oxygen to her organs) for at least 20 minutes, perhaps even longer.

At the hospital

By the time I saw her, she was full of tubes and connected to a breathing machine. She was not responding to any outside stimuli. I knew right there what the outcome would be.

As the family walked in, the crying began:  the horror of the situation began to sink in for them. I limited myself to saying that we were still working on stabilizing her. I also started to plant the seed for what was to come: that her brain had been without oxygen for a long time and that I anticipated a significant degree of brain injury.   

Throughout that night, when the family asked how she was doing, everyone taking care of her emphasized to the family that she was not waking up and that her brain had sustained significant injury from the lack of oxygen.

The next morning, I returned to see that her vital signs had stabilized. As I expected, her sodium was starting to increase and she was producing more urine than normal. All signs that it was time to start testing if there was any brain function.

So, I spoke with the family, and I told them what we would be doing that afternoon. I went through each step of the test and what it meant. I explained to them that if she failed all parts of the test, then that would mean her brain was dead and it would never come back. They appropriately asked the difference between that and being in a coma. So, we discussed the differences between a vegetative state, a coma and brain death.

Speaking of brain death

The brain is our most oxygen dependent organ. After about 4-6 minutes without adequate oxygen, our brain cells begin to die. Once they die, they never come back. Once all those brain cells are dead, we say the patient is brain dead. You have cardiac death (when your heart stops beating) and you have brain death. Both of them mean the same thing: death.

Brain death is a hard concept for many people to understand. You can see the heart beating on the monitor and, while connected to a machine, you can see the person breathe. In fact, they just seem to be in a deep sleep.

Unfortunately, the brain is the command center for all our bodily functions, and, once you are brain dead, the rest of your body will start to fail. Your brain will no longer tell your lungs to breathe, so you need to be connected to a breathing machine 24/7. Then, your body will start to lose its ability to maintain blood pressure, to maintain body temperature, maintain normal sodium levels and slowly everything begins to fail.

So, brain dead equates death. Having 0 brain function is not compatible with life. Once a patient is confirmed brain dead (through a series of very rigorous tests), most places will discontinue all treatment. Why? Well, to put it bluntly, treating the patient and keeping him/her alive would be equal to keeping a corpse on life support.

Back to our patient

For a patient of Ana’s age, she would need two of these very thorough examinations, each performed 12 hours apart by two different physicians. So, I would complete the first exam and then the next day, one of my colleagues would perform the second.

I began testing that Saturday afternoon. As suspected, she failed every single part of the test. When we took her off the ventilator (part of the test), she did not take a single breath for over 8 minutes.

I told the news to the family and decided we should all sit down in a family meeting with our social worker, as clearly this was a lot to process and we needed all hands-on deck. That afternoon, I saw a glimpse of what was to come. Parents, grandparents and uncles came to the meeting. We had around 8 family members there.

The family meeting

I told them they should get their family/friends to the hospital for tomorrow, because once the other test was performed, per our state law, the death certificate would be signed and she would be disconnected from artificial life support within 24-48 hours.

They said: “What do you mean, our baby isn’t dead, look, she is warm, her skin is soft, she looks pink.”

This broke my heart, because it is such a difficult thing to digest AND understand. I said how sorry I was that this happened, but once brain death was confirmed, the child they knew was gone. I again explained to them brain death.  Then the uncles stood up and got closer to me.

The grandfather told me: “When my car breaks down, I fix or change the part, do the same for the body.”

I said: “We can’t replace the brain unfortunately and since it would be her entire brain that is damaged, we can’t fix just a part of it either. There is nothing we can do to change or improve it.”

At this point, I was being yelled at by multiple people. I felt intimidated. Also, I did not feel safe and neither did my social worker. I said we will talk more tomorrow and ended the meeting.

After the meeting

The following day, her brain death exam was completed and she was declared brain dead. The family started threatening staff and they went straight to the media outlets telling them how we didn’t want to treat their child and wanted to “kill her”.

Our ethics team got involved, as did our hospital administration. Unfortunately, our hospital decided to delay the discontinuation of life support because of the negative publicity this case was harnessing. So, we kept her on artificial life support, we treated each of her failing organs. Family meetings were arranged each day, trying to make head way with the family.

Meanwhile, as her body slowly decomposed, hostility towards the medical and nursing staff grew. Nobody felt safe. On more than one occasion, family members would say to the staff things like:

“Take good care of her, I know where you live.”

Security guards were called to be in the intensive care unit. Nobody wanted to go into that room.

And then

One fateful night, when my poor colleague was on-call, Ana’s heart finally gave out. Almost two weeks had passed from original testing. The family requested CPR and my colleague declined as it would be futile and unethical.

Her bigger than average uncle said to my colleague from across the room:

“You start CPR now, or I am going to kill you.”

At that point, my colleague signaled to the bedside nurse to exit the room and they both started running down the hallway, as two uncles proceeded to chase them down! They reached the nurse manager’s office and locked themselves in. They called the city police from the office. There was banging against the door. There were police cars everywhere within minutes. The family was escorted out of the hospital and cops were placed outside the unit. The next morning, police escorted the night team home because nobody felt safe going home alone.

Violence in the medical field: abuse physicians and other staff 

So, we all know violence in the workplace is a real thing, but I am not sure that people know how much of a problem it is in medicine! Even in a field like pediatrics, verbal abuse of staff is very common. People abuse physicians and nurses very frequently. The above case represents how easily things can escalate from verbal to physical abuse and how vulnerable we are.

From 2002 to 2013, serious workplace violence incidents were four times more common in health care settings than in the private industry, according to the Occupational Safety and Health Administration (OSHA). Furthermore, according to the U.S. Bureau of Labor Statistics

“Hospitals are particular hot spots for workplace violence. In 2015, medical and surgical hospitals, nursing and residential care facilities, and ambulatory health care settings were among the industries with the highest prevalence of nonfatal occupational violence, with respective incidence rates of 6.0, 6.8, and 2.4 per 100 full-time workers.”

These are from what is reported, and we know people tend to under-report these types of incidents.

Also, according the American College of Physicians:

“The vast majority of hospital violence is perpetrated by patients or their visitors, as opposed to staff or outsiders, according to the 2017 Healthcare Crime Survey, produced by the International Association for Healthcare Security and Safety Foundation.”

It is important that we deal this problem now and also, we need to take care of our healers!! When did it become OK to abuse physicians, or anyone for that matter?! I don’t just say this because I am one 😜, but because I want my healers to feel safe and comfortable when they need to take care of me! It is very hard to work and think when you are feeling threatened and we simply can’t allow this type of behavior. #silentnomore

I leave you with this hard, but real, recap video from ZdoggMD  (caution, the images are disturbing and not for children).

Wishing good health and safety for all,

*name and details changed to protect privacy