Abstract
Personal narratives in which medical students and clinicians reflect on their education and practice, or recipients of health care reflect on their journey though the system can provide valuable insights which can usefully be shared. In this paper, a medical student describes the effect of a humanities-based student-selected component on her understanding of anatomy and dissection, and a junior doctor in Iraq learns some painful lessons about medicine and society during a night shift in the casualty department.
Introduction
The value of reflective writing is increasingly acknowledged both within the medical school curriculum and in clinical practice, yet there are relatively few opportunities to publish personal stories and narratives in clinical and academic journals. It is, however, through the best of these stories (usually unadorned with footnotes and references) that we are allowed glimpses into unfamiliar worlds and different ways of thinking, or situations or events that, on the surface, may seem wholly unexceptional. This is not the first reflective piece in Clinical Ethics: Eleanor Updale took her own experience of being admitted to hospital as a medical emergency as the starting point for her paper on the ethics of the everyday 1 and went on to reflect on some of the significant ethical issues that are all too often neglected in the literature. With 209 full-text downloads since its publication in April 2008, this piece clearly resonated with our readers. Sue Eckstein's own experience of surgery was the inspiration for a short, sharp editorial 2 on the importance of empathy within the NHS and email responses to it suggested that her experiences, too, struck a chord with a significant number of readers.
The pieces that follow appear to have little in common with each other. In the first, Rachel Turner reflects on her experience as a first-year medical student. She tells how her experience and understanding of the dissection room and her general practitioner (GP) visits were enhanced by the metaphors she had explored, the stories and poems she had read and written and the films she had seen during a humanities-based student-selected component (SSC). In the second piece, Nabil Al-Khalisi, an Iraqi junior doctor working in very difficult conditions in Baghdad, reflects on a life-changing experience he had during a night shift in the casualty department. The needless death of a small child was a painful reminder that, however skilled a doctor might be, in the face of prejudice, intolerance and lack of education, there is only so much a health professional can do.
What links the pieces is the way the authors are able to take personal experiences, which have a particular meaning and resonance for them, and reflect on them in ways that gives them wider meaning and significance. Just as refraction is the change in direction that occurs when a wave of energy passes from one medium to another of a different density, so there is a refractive, as well as reflective, quality to these narratives in which experiences such as an anatomy lecture, a dissection lesson and a late-night shift in a busy hospital are given new direction, focus and meaning.
One of the very positive things to come out of the GMC's Tomorrow's Doctors (2003) 3 was the recommendation that the core curriculum in all medical schools should be supported by a series of SSCs that would allow students to study, in depth, areas of particular interest to them. It is through these, often very innovative, SSCs that students are given the opportunity to explore a wide range of topics that would not normally be covered in the core curriculum. Medical students with an interest in humanities are able to take SSCs with a focus on fine art, poetry, film, drama, fiction or any combination of these. For many students, this provides a welcome return to subjects and pursuits they love 4 or the opportunity to engage in something completely new and unfamiliar. The SSC referred to by Rachel Turner – Bleeding Hearts and Fevered Lungs – is one example of a humanities-based SSC which Sue Eckstein runs for first-year students at Brighton and Sussex Medical School. The take-up and enthusiasm for these kinds of SSCs, and the opportunity they afford students for creative reflection is considerable and it will be a great shame if the current percentage of time allocated for SSCs is reduced from 25–33% to 10%, as proposed in Tomorrow's Doctors (2009). 5
Bleeding hearts and fevered lungs – reflections on learning from literature
Rachel Turner
I was initially wary of choosing a literature-based SSC, worrying that it might be seen as ‘non-medical’ or ‘a soft touch’. However, over the eight weeks of the SSC, I came to understand my heart, my lungs and the blood flowing through my veins in much greater depth than purely physical even though we had not studied the anatomy or physiology of these organs, or analysed science-based research papers on the subject.
It was later, in the dissection room, that I first realized that the SSC was leading me to think differently about other aspects of the course. We had previously removed and observed the lungs from our anonymous female cadaver, and I had considered the medical aspects of the organs: the sizes and shapes of the vessels and airways, the difference between the spongy feel of healthy lung and the harder, solid feel of pneumonia in one of the lobes. At no point had I wondered whether this woman knew she was dying, whether she counted her breaths as they became shallower and more full of effort during her last weeks. I knew we were to remove and study her heart in the coming weeks, but it never occurred to me to wonder if that organ which expanded from the effort of pumping ever-decreasingly oxygenated blood around her body was also large metaphorically. Was she considered big-hearted by those who knew her? Giving the gift of your body after death to strangers to make use of is surely a thoughtful and generous act. I began to put together a picture of this woman in my mind, and although most of it was assumption and guesswork, I started to feel a greater appreciation of her body.
I entered the next dissection lesson, during which we were to take out the heart, with a very different feeling to previous sessions. Our weekly SSC meetings, the poetry we had read and discussed, and the group discussion about transplant donors and recipients, had given me a new take on how non-medics might view this muscle-bound pump. I attempted to discuss this viewpoint with the students in my dissection group (who had not taken this SSC) and I was mostly met with blank looks and the same purely medical views that I had held not so long before.
During our creative writing tutorial with the poet, Jackie Wills, I scrawled a poem which I later polished a little. I think it sums up how I felt about the dissection.
I touch somebody's heart
that once was held by others dearer,
and feel beneath my fingertips
a last forgotten beat.
I point to where the pain was
in her gross distorted muscle.
In a moment I will lift it,
rip it,
take it,
hold it.
My own is in my mouth where it began.
The last line is a reference to some embryology we had learned a couple of days previously. The group of cells which are to eventually form the heart begin their lives in the same region as the embryo's mouth, and fairly rapidly descend into the thoracic region over the first few weeks. I liked the fact that the saying about someone's heart being in their mouth was no longer just metaphorical to me, but that it had also been literal for a brief moment in life.
During the term we looked at metaphors for the heart and the feelings associated with it, and the answer that I most searched for was why this particular organ, out of many others of significant size and importance, evokes such an emotional response.
Having become conscious that the work we were studying on Wednesday mornings in our SSC group was affecting the way I felt about one other aspect of the course, I wondered if it would filter into others. My answer came the following Tuesday, when on a placement with my GP tutor. A patient arrived who had been experiencing chest pains, and the GP asked me to take a history from him. Nervously, I began by asking the types of questions we had been learning in our clinical seminars: ‘How long have you had the pain; how would you describe it?’ After a while the patient became more chatty, and I began to think about the feelings that people attach to their hearts, and the feeling of pain in that organ being somehow more dreaded than any pain elsewhere. This reminded me to discuss with the gentleman his own concerns and expectations; not just how he was feeling physically but how he was emotionally as well.
As well as influencing my studies, the SSC also had an impact on my thoughts about life outside of medicine. After seeing the film 21 Grams and discussing it with the group, I watched parts of it a second time and realized that I had previously missed a lot of the imagery included, such as the flashes of the colour red and the pictures of hearts stuck to the fridge door. Since then I have found myself watching television and films more carefully and noticing the background subtleties more often.
Pondering further on images of blood and body parts, the birth of my daughter came to mind. People often describe childbirth using adjectives such as ‘painful’ and ‘gory’, but my memories of the event are of amazement and pure love. I wondered if the work we'd covered would help me to put these images together and juxtapose my reminiscences with reality, so I turned to poetry again.
My heart sighs with relief as my body finally liberates its long-held burden
and slows to an even pace, content to rest a while.
Wounded and weary, I am astonished at your reality.
You are a rose-tinted beauty.
Blood still pulses visibly along the cord
but this small astronaut no longer needs the mother ship.
You must survive within your own machinery now.
The flexing cable joining us goes from the centre of me to the
centre of you,
heart to heart,
as did mine to my initiator and back in time to join us to the
beginnings of life.
These vines of heredity branch out to create our family tree,
and every bud on every branch is a part of you.
Over that term, I had cause to feel some fairly extreme emotions. On several of these occasions, thoughts of the work we had been doing came to mind and I stopped and paid attention to what was happening to my heartbeat and my breathing. When I felt let down, I realized that the physical sensation accompanying this really was as though my heart was sinking down inside my chest. Waiting my turn to answer questions in my anatomy viva, this same heart was somewhere a little higher than usual, although not actually ‘in my mouth’ of course. These feelings could easily be given a medical explanation. Stress hormones cause the ‘fight or flight’ response; vessels constrict where needed and blood flow is diverted to the organs that might be more useful for either of these options. The digestive system is not immediately useful and blood flows away – the sinking feeling in the pit of your stomach is now explained. Usual service in the extremities is interrupted – your dry mouth and sweaty palms are not just descriptions in fiction. Long-term stress can lower the immune system and prevent the organs functioning fully – maybe you really can die of a broken heart.
Recently I fell in love. I did not actually trip, tumble or physically descend in any way, but metaphorically I did fall. Science would tell me that the skipped beats of my racing heart and the dilation of my pupils are biological mechanisms persuading me of the need to procreate without killing my partner after the act. In this instance though, I am content to choose to ignore any biological justification and just enjoy cherishing someone else's heart alongside my own.
Sami the methanol boy – reflections on painful lessons learned during a night shift
Nabil Al-Khalisi
The following is a story of an after-midnight shift in an Iraqi emergency room – one where I had a problem that was more cultural than clinical. It was midnight; the weather was cold and foggy. I sat behind the glass door of the paediatric emergency department main entrance. I was tired and confused having spent the whole day working with a senior colleague, trying to do things quickly and discharge as many stable patients as possible. My senior colleague had left me alone to face the after-midnight shift so that he could get some rest.
A busy after-midnight shift can bring up to 20 patients. The good news is that only one patient came asking for help that night. The bad news is that, after I finished my shift, I wished that I had had 30 patients screaming and shouting instead of this one.
Sami had brown hair and shiny blue eyes. He was about five years old. He was so drowsy that he was unable to walk any distance without stumbling. He arched his back a little bit and hung onto his grandfather's big hand. Sami looked curious about what was going on; I guessed he had not been into a hospital before. He kept on asking his grandfather questions but did not seem satisfied with his grandfather's brief answers.
As they opened the door, I could not help smiling at Sami. It was as if his charm cast a spell on me from the very first glance. I forgot about my excruciating headache and started talking to Sami. His grandfather was really worried and anxious and kept trying to interrupt my conversation; it was as if he knew that we were all running out of time. Sami's hands were cold and he was clearly very unwell; he smelled of alcohol and his clothes were covered in vomit. I asked him what was wrong but he just replied with a faint smile and said, ‘Nothing. I feel sleepy; where is mom?’ Then I turned to the grandfather who was shaking and stuttering. ‘Doctor, he almost drank the whole bottle, all of it, thinner, we were painting, the whole bottle!’ I suddenly realized that I was dealing with a time bomb here. A ‘thinner’ means methanol; in Iraq it is used to dilute paint.
I fetched my stethoscope and listened to the child's chest, which was mostly clear with few scattered wheezes. I ordered Ipecac solution and intravenous fluids right away and tried to talk to Sami to assess his level of consciousness; he seemed to be quite oriented but a little bit sleepy. Telling Sami that everything would be OK was a lie but I had no other choice; I had to lie to alleviate his fear.
Treating methanol poisoning is quite simple. You bring some friendly ethanol molecules that shift hostile methanol molecules away from liver cells and we are all happy and safe; no retinal damage; no liver failure; no nothing. The problem was that the list of 20 generic commonly used drugs stocked by our paediatric emergency department pharmacy in the largest medical facility in Iraq did not include ethanol. I had to figure out a way to save the child. How the hell could I get some ethanol in Baghdad at midnight? No stores were open; no pharmacies. I remained silent for a while thinking, trying to solve a problem that was 10 times more logistical than medical. I bent down and looked directly into Sami's eyes for inspiration. I touched his cheek and told myself that this kid must make it. It would be a shame if I could do nothing for him; if he lived somewhere else he would have been much better by now. I was bothered by the strong smell coming out with every breath as if Sami was an alcoholic. Then I had an idea! Let's drink some Arak (a traditional colourless, affordable, readily available, Iraqi spirit that contains up to 80% ethanol). It would be a simple but effective solution in the face of no other solution. My initial plan was to make the grandfather go and get us a bottle or two of Arak from a nearby shop as alcohol stores, in contrast to pharmacies, tend to stay open late at night.
I turned to the grandfather, took him away from Sami and tried to be assertive and informative at the same time. I said, ‘Sir, Sami is dying. We have got only one shot. He has methanol poisoning, it is very serious and we need to act fast. Methanol has only one antidote which is ethanol and unfortunately we do not have medical ethanol in here. Arak contains ethanol as its main component and we can use it to cure Sami. Bring me a bottle of Arak and I promise to do my best but please hurry up!’
After this short speech, things changed dramatically. Sami's grandfather's face turned from pale yellow to red; he became very angry and aggressive. He was taller and heavier than me. He grabbed me by the throat and started shouting, ‘You bastard! You have no mercy; you want me to bribe you? Are you trying to blackmail me? Are you bargaining Sami's life for alcohol? If he dies, you die too, understand?’
Suddenly the Facility Protection Service intervened and I was surrounded by guards who pulled the grandfather away and tried to calm him down. My throat felt crushed and I was gasping for breath. Just then I noticed that Sami was giving me a strange look as if to say, ‘What is going on? Grandpa loved you a moment ago? What did you do to make him so angry?’ At that moment I felt that time had stopped and it was just me and little Sami looking at each other. I realized that Sami's life was on the line. I had to convince his grandfather that I was telling the truth. Time was running out and I had to move fast.
In the other corner of the emergency room, Sami's grandfather had been forced to sit on the floor. The guards tried to calm him down but he kept on shouting and threatening me. I slowly walked towards him and, while the guards were still holding him down, I asked him to listen carefully. He looked at me with disgust and told me that God would punish me for my horrible acts and no one could escape the wrath of God. I said, ‘I am not asking for a bribe; this is my job and I am doing it in the best way that I can. Arak contains ethanol and we really need it. Bring it and you will see that I will not sip a drop of it. Trust me please. Sami's life is on the line here’. He replied indignantly, ‘Drinking alcohol is a sin. God told us that no benefit can come from alcohol. God knows what he is doing’. It became obvious that I had failed to convince him of my idea. I went to the lobby and called the chief resident. Fortunately, he was awake and willing to come to the emergency room right away. He examined Sami and then he talked to his grandfather, telling him that every word I had said was true and that he should do as I say. But the grandfather went mad, calling me names and shouting very loudly, ‘Corruption! You both are corrupted physicians and you do not deserve to live. God help me, if anything happens to Sami I will kill you both, I will tell the Minister of Health’. The chief resident told me to discharge the child and stay safe. He said we had done all that we could and now the grandfather would have to face the consequences of his actions. Once again I was left alone to deal with this dilemma.
While the old man was crying for help and cursing me, I was standing a few metres away trying to think of any alternatives. I thought that I could go myself and fetch the Arak, but then I realized that this was impossible because there were too many critical patients in the emergency room who could not be left alone. Then I thought that I should try to wake up one of my fellow colleagues who was off duty to buy the Arak, but I did not know if the grandfather would let us use alcohol to cure Sami. Why would any colleague risk his life at this late hour to help someone who was refusing help in the first place? I felt hopeless and powerless; I had completely run out of choices. I knew the child would deteriorate and the only thing I could do was to wait and see whether this would move the grandfather and make him listen to me. This was my last and only choice.
Time passed slowly. I watched helplessly as Sami faded, minute by minute. First he started vomiting; then he became drowsier and drowsier; a few hours later he became completely unconscious. His grandfather never changed his mind; he kept on blaming me for what was going on and promised to take revenge if anything happened to Sami. I felt so tired and confused and let my eyes close. Meanwhile the old man got tired of shouting and crying too; he became silent, just weeping every now and then. At 04:00 hours the three of us fell asleep.
Suddenly at 05:30 hours, the patients, the guards and I were all woken up by a scream, Sami's grandfather was screaming, ‘Help me, he is not breathing, his hands are turning blue. God please save him he is still so young to die, oh God, help’. I rushed to Sami with my stethoscope and checked his vital signs. I tried to resuscitate him but to no avail. He was cold and pale; his face was still as charming as before but was dead. His grandfather collapsed. I spent the next two hours in misery, remembering every little detail about what had happened. I just wanted my shift to be over; I wanted some rest and a good sleep. Five minutes before my shift ended, Sami's grandfather came up to my desk, looked me into the eye and said, ‘I will kill you. Sami must be revenged. You are corrupt, and I will never feel peace till you are dead’. I was scared he was going to kill me and left the emergency room as fast as I could.
On my way home I thought deeply about the meaning behind this event. I realized that medical training alone is not enough to cure people. It is not always about training and equipment; sometimes ignorance, illiteracy and chance get in the way. We are not only facing shortages of the most basic drugs and equipment, but we are also dealing with ignorance and prejudice. Health is a multistep process that starts with community awareness and ends with patient care. Doctors cannot tackle societal and religious values on their own. When the community education level is non-existent, there is little a physician can do to help patients, no matter how skilled he or she is.