In Awe

16-03-2019 01:03

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Dr. Stephen Winter, Senior Consultant for the WCHN/UVMLCOM Global Health Program

Medicine in a crowded hospital ward in a resource-constrained country can be emotionally overwhelming. Patients generally enter these hospitals with advanced diseases, often accompanied by severe comorbidities such as advanced HIV or malnutrition. Mortality rates are much higher than we experience in our home hospitals. During my visit to Zimbabwe two years ago, it was not unusual for two or three patients to expire or experience a severe event such as a grand mal seizure during the course of rounds on a single day.

As educators, we often worry about the potential emotional impact of such events on our medical students who rotate through these hospitals, especially early-year students who may have never witnessed the death of a patient, and set up systems to mentor and monitor them. But I think we rarely consider the emotional toll on trainees and young faculty at our partner hospitals who always seem to approach these situations with stoicism and acceptance of the local reality. Today, I learned that the reality is quite different.

As we discussed a patient at the bedside during ICU rounds, a nearby patient unexpectedly developed pulseless ventricular tachycardia. His Vietnamese resident jumped into action from rounds and lead successful CPR on the patient. She had cared for him over the past month after a fall left him with paraplegia from a high cervical spine injury. She left the unit to speak with the family and returned a few minutes later, barely holding back her tears. “The family wants to take him home,” she said – the local equivalent of hospice for a ventilator dependent patient. “Why am I doing this? Half of my patients die. Maybe I shouldn’t be a doctor.”

Less than twenty minutes later, I received urgent text messages from another young physician with whom I was working that week, one of our Vietnamese Global Health Scholars who had worked with us at Norwalk that year. “Where are you? Can I talk to you?” We had been taking care of a young woman who had been unsuccessfully extubated four times in the previous two weeks. We developed a plan to extubate her five days prior, and she was doing amazingly well off the ventilator and planning on going home that day. But the night before, she suddenly coded and died under the care of a covering resident. My friend had come in that morning to face the distraught husband and try to provide comfort to the family. He too was fighting back tears, convinced that he had made a mistake that led to her death. When we met, he was clutching the multi-volume chart to show me a minor omission he had made in her care, certain that he was responsible for her death.

We often worry about our students undergoing emotionally fraught experiences, but who worries about the emotional distress our scholars and their colleagues must endure on a daily basis? Who worries about the repercussions of our mistaking their stoicism for lack of personal impact, as if they are somehow immune to bearing witness to so much suffering?

Together, we have discussed means of working through feelings of despair, helplessness, and blame that sometimes accompany our lives as doctors, and celebrated the many clinical successes from their skills as physicians. Yet I worry about these deeply compassionate young doctors who often lack an outlet for their own emotional distress as they minister to the distress of patients and their families. I wonder where these wonderful young physicians find so much resilience and inner strength. I am in awe.