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Saudi Journal of Kidney Diseases and Transplantation
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DOCTORS DIARY Table of Contents   
Year : 2005  |  Volume : 16  |  Issue : 3  |  Page : 364-366
The Distraught Patient


Division of Nephrology, Hypertension & Renal Transplantation, King Abdulaziz Medical City, Riyadh, Saudi Arabia

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How to cite this article:
Al-Khader AA. The Distraught Patient. Saudi J Kidney Dis Transpl 2005;16:364-6

How to cite this URL:
Al-Khader AA. The Distraught Patient. Saudi J Kidney Dis Transpl [serial online] 2005 [cited 2019 Dec 10];16:364-6. Available from: http://www.sjkdt.org/text.asp?2005/16/3/364/32868
The patient was clearly distraught when I first saw him. That was unfortunately at the end of a very busy ward round. At that stage, I was not able to really concentrate. As the resident was describing the case, I remember asking myself "why is it that our "outlaying" patients are seen last and get less optimal care than our patients in the renal ward?" I made a mental resolution to start the next ward round by visiting the "outlaying" patients first.

I couldn't really follow the case history being presented by the resident. I remember picking up a couple of linguistic mistakes he had made. "Ali," I said to the resident "you should not say that the patient admitted yesterday, you should say the patient was admitted yesterday". The resident stared back at me and I am sure he did not follow a word I said as he was more tired than I was, having been on duty all night, Nevertheless, I continued; "and another thing, Ali, the past tense of "sleep" is slept and not "sleeped". I also suspect you meant the patient was "nauseated" and not "nauseating" as mentioned in your presentation"

I found my thoughts wandering again. How hampered are our medical students by being taught medicine in English when they hardly learn any English in their schools? An English­speaking medical student can instantaneously recognize what a "pepper pot skull" would look like. He will not need much imagination to know what a "rugger jersey spine" may look like. Our students on the other hand, will never have heard of "jersey" let alone "rugger".

At this stage, I realized that I could not absorb any more and I told the team that we would break for lunch and finish the ward round later. I could see the relief on the resident's face when I said that. I looked at the distraught patient, shook his hand and said "We will come back to see you after two hours". I noted that he was looking at me as a savior and as his main hope of recovery. This is what I read in his facial expression as well as the way he held my hand tight and refused to let go. That immediately put a great weight on my chest, the weight of responsibility.

The patient pleaded, "Doctor, don't forget to come back. I could not sleep all night. No one tells me anything around here. They put this tube in my neck and told me that I need a "wash" as my kidneys are not working. They are wrong, I am sure. How could I possibly have a kidney failure when I have never had any pain in my kidneys ever?"

I politely replied, "Be assured we will see soon." The resident and the other members of my team were politely waiting showing no particular inertest in what the patient or I, were saying.

My mind wandered again to the days when I had just qualified as a doctor. Those days, I was wearing my stethoscope across my shoulders for everybody to know that I am a doctor. So did my other qualifying colleagues. One would not be surprised to see some of them sleeping with their stethoscopes still hanging on their shoulders. During those days, I worked every other night and every other weekend. Complaint of "too much work" was not as much as even whispered about. The consultant was our "all-knowing" master. In return, the maxi­mum you hoped for, was a good recommend­ation at the end of your tenure. Following a night on call, I had to be up by 7 AM to prepare for the round, get the results (no computer to help you then), go to the radiology depart­ment to get the X-rays and to crown it all, I had to take the blood myself and fill the required investigation forms.

Looking back at all that, I still wonder how many mistakes I made during those long nights when the admissions in our "firm" frequently crossed the 20-patient mark. I must admit that I had great-unsaid hostility towards the "overdosers" who woke me many a time in the early hours of many mornings. I must also admit that on occasions I have prescribed a "stomach pump" unnecessarily on such patients as a form of punishment for waking me up!

My mind returned to our patient. Could it be true that nobody spoke to him about his illness and management plan? Unfortunately, it could easily be true. We, as doctors, do not give enough time or effort to speak to our patients and if we do, we do it sparingly. The other day, during another ward round, I asked a resident, who is really good at her work, why she had not explained to the patient about his illness and our management plan. She retorted, "Oh, I have been busy all week". I asked her, "Do you make it a point to speak to the patients about their condition"? She said, quite confidently, "Yes, whenever I have time"

In other words, our young medics are not taught in the medical schools that explaining the nature of illness and the management plan are an integral part of patient management. Also, it is a very good way to create a good rapport and avoid litigation or complaint on the part of the patient.

After lunch, everybody was at the bedside of our "distraught" patient at the appointed time. He was no less distraught but this time some relatives were also sitting by his side.

As I entered they said in unison to me "You know, somebody told him that he has kidney failure. This is clearly a mistake. How could it be right when he never complained of any pain over the kidneys at all?"

One of the relatives who looked particularly hostile added "And another thing, even if he has kidney failure how could anybody in his right mind really tell him the diagnosis?" he said and added for good measure and with a menacing tone "Come on, this is just simply not done. You are going to kill him by the shock of the news and you call yourselves doctors".

I knew that this situation had to be handled softly and with the greatest of empathy and sympathy to the patient and indeed his relatives. This should be done despite the almost, instin­ctive urge on the part of the doctor to return hostility with hostility, especially when the doctor is accused of mishandling a particular situation. I know with experience, that the "softly-softly" approach is not only the most humane way but it does ensure that the doctor avoids many problems and troubles on the future. I also needed the patient and his relatives to be "on my side" for optimal management of the patient himself. The quickest way to achieve this, I thought to myself, is to get the patient to trust me. To get him to trust me, I have to be truthful to him all the way. I also need to speak to him as a mature person who wants to know the truth.

It always amazes me how often doctors do not bother to tell patients about facts they need to know and when they do, it is with a conceding tone and manner. The other day, a patient came back from the endoscopy suite having refused to be colonscoped. It turned up that no one from the endoscopy team bothered to tell the patient what to expect.

I asked the relatives of our 'distraught" to leave saying, "I will address all your questions and concerns but first I need you to wait out­side while we hear the entire story and all the results of the investigations". For good measure, I held the hand of the belligerent relative and led him to a waiting room. When I was a young medical resident I would have considered this a capitulation to the bellicose relative. Now I know better.

The resident gave the history briefly and to the point. The patient had been feeling tired for a number of weeks. For one week prior to admission, he developed nausea and vomited on a number of occasions. He had lost his appetite and had lost five kilograms in weight over the same number of weeks. Many years ago, he had been told that he had high blood pressure. He never took the medication given to him and did not attend any follow-up.
"On examination", the resident continued, "The main findings are very high blood pressure, scratch marks and pallor. The investi­gations showed that he has advanced kidney failure"
"I conclude" the resident said, with confidence, "that he has chronic kidney failure as he has anemia and also as the ultrasound of the kidneys revealed that both the kidneys were small and shrunken".

The confident resident was right. Now how do we tell this to the patient? There is only one way, the truth. I explained to him, in detail, why we think he has kidney failure and how the tests for this are really quite simple, straightforward and not often wrong.

I knew that it has begun to sink when he asked, "Is there any hope that the kidney function will recover?"

I said, "Truthfully, this is unlikely but time would show if I am wrong and I hope I am. You see your kidneys are really quite small and shrunken which means that they have very little function if at all. The fact that you have been known to have high blood pressure for a long duration would also go with chronicity"

I resisted telling him that if only he had got his high blood pressure treated properly, he might not have got to this stage. He did not ask about this either.

Surprisingly, as he began to understand the situation, the "distraught" look disappeared and was replaced by a "resigned and sad look". He also obviously became more practical as he asked: "What alternative treatments do I have"? I explained to him all the options available to him and left him to think about it. As the team was about to leave he said, "Please don't mind what my brother said to you earlier. He is just as shocked as I was by the suddenness of all this".
"Do not worry, we understand. In fact we are going to speak to him now"

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Correspondence Address:
Abdullah A Al-Khader
Saudi Center for Organ Transplantation, P.O. Box 27049, Riyadh 11417
Saudi Arabia
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PMID: 17642806

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