Good Communication For Meaningful Change
Dr. Elizabeth Hanson recalls a moment that reminded her of the frailty of life, the importance of compassion, and the impact of good communication.
Dr. Hanson:
Because you see this patient and you're like man, that was my patient. What did I do wrong? What did I miss? What happened? I was talking to this person an hour ago or two days ago, and now they're someone up there pushing on their chest trying to restart their heart, and they might die in the next few minutes.
Dr. Oden:
Hi, I'm Dr John Oden. This is Memoirs in Medicine, a podcast featuring the personal stories of healthcare professionals.
Dr. Spiro:
And I'm Dr David Spiro. On each episode, one healthcare worker will share a moment from their career that has profoundly affected them and provide one suggestion, no matter how big or small, for improving the practice of medicine.
Dr. Oden:
Through storytelling, we hope to highlight the humanity in healthcare and create a space for candid and respectful discussion.
Dr. Spiro:
To protect patient privacy. Some details may have been changed, but the stories are real. Welcome to Memoirs in Medicine.
Dr. Oden:
My name is John Oden, I'm a pediatric endocrinologist at Arkansas Children's Hospital, and with me is my partner in crime, david Spiro.
Dr. Spiro:
Hello, hello, good afternoon, evening or morning, depending on what time you're listening to this podcast. David N Spiro, sansa, mark no one knows that and I'm a pediatric ER physician at Arkansas Children's UAMS and really honored to be here, and I cannot wait to bring on our next guest, dr Elizabeth Hansen, who I had the honor and pleasure of working with. Hello, dr Hansen.
Dr. Hanson:
Hey everyone. So I'm super psyched to be here. I've never been on a podcast before and when Dr Spiro told me about this thought it seemed like a really great opportunity and really excited to be here.
Dr. Oden:
Yeah they are a lot of fun.
Dr. Spiro:
They are fun. So, Dr Hansen, can you briefly explain to everyone who you are like. You're a fellow, but some people may not know what fellow is and how you got to where you're at. And tell us where you're from too, because you're not originally from Arkansas?
Dr. Hanson:
Sure. So I grew up in North Carolina, did my undergrad in my medical school there and then I moved over here to Arkansas for residency the post-medical school training. I did my residency in emergency medicine and when I graduated a few months ago in June, decided that I wanted to do a fellowship in medicine critical care so fellowship being additional years of training in whatever subspecialty basically you want to do. So I decided I wanted to work in the ICU for a little bit. So I'll be there for this year and next year.
Dr. Oden:
So Dave and I are pediatricians and you are an adult doctor.
Dr. Hanson:
Yes, I do, I do adults, I work with adults.
Dr. Oden:
Ooh.
Dr. Spiro:
Yeah, it's funny because I would not like to take care of adults.
Dr. Oden:
They have stinky feet and it wasn't the stinky feet for me, it was the bags of medication. They would come in and I would just be like man. That's just a lot of stuff to write down.
Dr. Hanson:
So funny story that is going to come up in a little bit actually.
Dr. Oden:
See, yes, yes, I've got to hear this story. This is going to be good stuff.
Dr. Spiro:
So, dr Hansen, go ahead. We want to hear this story. Yes, Sure.
Dr. Hanson:
So I'll first say Dr Spear had asked me to kind of join tonight because I emailed him recently about a patient experience I had. And, dr Spear, you and I had worked together quite a few times at the Children's Hospital and I had remembered, when you told me one time, that we have this unique opportunity in our line of work, what we do to change someone's life and like, really change it, not just treat their pain or make them feel better but we have this opportunity to turn something around sometimes. And so I had this experience with this patient and I had told Dr Spear about it via this email and he said, hey, why don't you? You want to come join this podcast and kind of tell your story. And so this is a story. So this is a story of Mr Smith, whose name will be changed for confidentiality purposes.
Dr. Oden:
Obviously he's, here.
Dr. Hanson:
And so I met Mr Smith. I actually was about a month ago exactly and it was late in the evening. I was on call for the hospital, meaning I was there to take admissions for the medical ICU. And Mr Smith is a guy who has a number of medical problems. He has a history of cocaine use, he has multiple chronic issues, he has kidney disease, he has to get dialysis three times a week, he has cirrhosis, so he has liver disease. He has to get fluid removed from his abdomen, you know, once or twice a month, and he has really terrible heart failure. So he essentially has three organ systems that aren't working very well at all and you really need all three of those, as you guys obviously know.
Dr. Spiro:
And how old is this patient?
Dr. Hanson:
He is in his 40s, I think he's got a middle-aged.
Dr. Spiro:
That feels young to have all those problems.
Dr. Hanson:
Yes, it's a lot of problems and it's a very unfortunate situation to already be having all of those problems. He has a number of I guess you could say social factors playing into that as well. From what I had read and what he had told me, he was kind of intermittently homeless, was living with his brother for a little bit sometimes didn't have anywhere to stay. He just had a lot of things that were kind of tough for him at the time.
Dr. Spiro:
Can I just share a quick anecdote, because you said the word homeless? Sure, when I was a young child I grew up in New York and we'd go into New York City and we would see a lot of homeless people. My grandmother would tell me those people are bad people, they're all drug addicts. I just had this very negative stereotype. Then I got to medical school and all of a sudden they were my patients and they were incredibly nice people. They all had a story to tell. They had oftentimes very sad stories. I realized that what I was told as a child was not right. John, did you have any negative stereotypes about homeless people before you started medical school?
Dr. Oden:
No, but I grew up in a Houston suburb, Homeless people were not something that I really was exposed to until I mean, truthfully, until we moved to Little Rock. Well, Dallas, I guess a little bit, but Little Rock has more kind of exposure to homeless people than just about anywhere I've lived.
Dr. Spiro:
Beth, please go on.
Dr. Hanson:
No, that's it. You make a very interesting point and I agree with you. There are a lot of kind of stereotypes around someone being homeless and it's hard to kind of ignore those and get rid of them, especially when we're treating patients who we have the stereotypes about Right. But so Mr Smith kind of had been kind of intermittently homeless. So he came to the ER initially about a month ago when I met him and he had told the ER staff that he was having pain all over. He basically said he had done cocaine a few days beforehand and had slept in a wheelchair all night long. And then he came to the ER saying that his body was just aching and hurting all over. And this is where that comment about the medicine comes in. He brought in a bag of medicines and said he didn't know which ones he was taking but they were all the medicines that belonged to him and yep, so fairly, not an uncommon thing. So he then said that he had had dialysis, but it was like three days earlier and he had left halfway through it and from what it looked like in his chart, he didn't even really have a stable dialysis center to go to. It looked like he was kind of coming to the emergency department for dialysis just whenever he didn't feel good. And so the day I met him he had a very low blood sugar. His heart rate was like in the 120s 130s. It was pretty high, and his potassium was 8.7, which you know you're not familiar with kind of normal potassium levels. 8.7 is really high like high enough to cause you to have a cardiac arrest or to cause your heart to malfunction and stop. And so the treatment for that for him was to get emergent dialysis. And so he got some medicines in the ER to kind of stabilize him and lower his potassium as much as they could. But the medicines can only do that transiently, as you know. And so we then admitted him to the ICU and emergently dialyzed him, and so that up in the ICU is where I actually met him for the first time, and so we talked a little bit. He didn't really say a whole lot to me, he was kind of out of it, which was probably because his potassium level was so high and he was so sick at that time. But he kind of was just telling me like you know, everything hurts, you know I did some drugs and everything hurts, just leave me alone. And that was fine. You know he was very sick at that time.
Dr. Spiro:
So and Beth, I have a question for you. So do you think, in healthcare let's talk about nurses, doctors, the people on the team this is someone that's coming back frequently to the ER and to the ICU. This is someone who you've described as being homeless and also uses drugs and other things on the street Do you think there's a bias, an inherent bias, negative bias from the healthcare personnel let's just say nurses and doctors towards people who are repeat visitors, who are nonadherent with their medical care?
Dr. Hanson:
Sure, I guess I would say there is a I guess I would be an inherent bias. You know you, working in the ER is you know, sometimes you just get slammed with patients, one after another, all day, over and over again, and sometimes it's the same thing over and over again and you get so tired that you get I guess impatient would be maybe the way to phrase it. And I don't think those inherent biases change the medical care that is given to patients like this, because I think as a physician you know like this is what I have to do, these are the medicines I have to give, the steps I have to take. But I think you probably have a lot of frustration and stuff with a patient like this, and whether or not you show that when you're taking care of them, I mean, I think that's probably individual to each person. I hope it doesn't affect their medical care per se. But I do think you're definitely right, there's 100% inherent biases and they're inherent. So a lot of times we probably don't even realize that they're there, I've just seen eyes roll.
Dr. Spiro:
That's all I'm saying. Like sometimes I will see the eyes roll from the nurse or from the doctor, Like oh my gosh John. He's back here again, John. What were we gonna say?
Dr. Oden:
Well, I was just gonna say I don't think it's unique to ED or ICU. I think we have an outpatient clinic. We have kids that patients that we would see that have obvious barriers to their care and one of them being just kind of that, choosing not to take care or participate in their care. And there should be this idea in medicine and I say this in the warmth and comfort of my home and not in the hustle bustle of clinic, cause in the hustle of bustle clinic I'd probably just as guilty as anybody else but there really should be this idea in medicine that when you have an individual that's not taking care of themselves, there are always, always, always a barrier and maybe we can't help with every one of them, but we certainly should be looking for them and addressing the ones that we can.
Dr. Hanson:
Yeah, certainly.
Dr. Spiro:
So let's go on with the story.
Dr. Hanson:
So we take Mr Schmidt to the ICU, we emergently dialyzed him, and this was a Friday evening and I actually didn't have to work on Saturday or Sunday. I was off for the weekend and when I came back Monday he was off of the list of patients I had in ICU, so I assumed that meant he was got better after the dialysis, went to the general medicine floor and then went home, and so about probably a week and a half later I was on call again. I was sitting in this little patio that the hospital has and it's kind of like in the middle of the hospital, so it's surrounded by, it's right outside the ICU, surrounded by a bunch of hallways that all have these big glass windows on them so you can see into the ICU and into the hallways, basically. So I'm sitting out there and I had two residents that were on call with me and I noticed they're just speed walking down the hallway, kind of like on the other side of the windows, towards the main elevators. Right after that a respiratory therapist rushed by and then behind her a nurse runs by with this huge backpack on and I'm sitting out there. I'm like man, that's the code, blue backpack, like they must be run into a code blue.
Dr. Spiro:
For those that don't know what is a code blue mean.
Dr. Hanson:
Oh sure, so the code blue is the terminology that we use in the hospital when any patient in the hospital has any kind of event like a cardiac arrest or their heart stops. They stop breathing, their blood pressure drops and they need to be basically emergently evaluated and resuscitated. Right. And so I saw all of them running towards the elevators and followed them up there and ended up on one of the general medicine floors where we walked down the hallway and there's this huge crowd of people outside of room, which is pretty typical when you have one of these code blue events, because everyone involved kind of rushes to the room. And so I peeked my head in the room and there's someone doing chest compressions, so pushing it on the chest, trying to restart the heart that I assumed had stopped. There's a couple of nurses trying to get IVs in and pull labs. There's someone who's writing down all the events that are happening. Someone else trying to get medicines. There's a anesthesiologist at the head of the bed who is putting a breathing tube down this patient, who clearly is not responsive. And then I look at the patient and I realized that it's Mr Smith, the same guy that I had just been treating like a week and a half ago. So I know, you know, dr Spear, I'm sure you've been to enough codes and, you know, done enough for Cessations within the ER itself, but I don't know. For me it doesn't matter how many I go to, they're always a little bit unsettling.
Dr. Spiro:
Why are they unsettling? Tell me more about that.
Dr. Hanson:
Yeah. So I think for me, you know, even the ones that we say get go smoothly or they get run really well, I always get just a slow knot in my stomach. Like you walk in the room, your heart starts beating a little faster, your stomach kind of gets this nod and it you know Well, you know lump in your throat like man. What is this about to be? And for me, when I look into a room and see a patient that I know who's coding, one that I've either seen before or treated before, or one Maybe I was one-hour treating an hour ago and then something happened and they coded, that feeling is like a hundred times worse. Yeah because you see this patient and you're like man, that was my patient. You know what did I do wrong? What did I miss? What happened? Why are you know? I was talking to this person an hour ago or two days ago and now there's someone up. They're pushing on their chest trying to restart their heart and they might die in the next few minutes.
Dr. Oden:
Beth, you are not alone in that feeling. I get that and I'm not in an ICU and I'm not an eddy doc, but we take care of some pretty sick kids and you know you always feel like there was. You know, if you're involved in a kid that did not do well or passed away, there's always something that kind of makes you think, overthink and outthink yourself.
Dr. Spiro:
Yeah, that is something, and I don't know what it's called, but it's like physician guilt, because I it happens in the emergency department. We see patients that come in. We saw them three days before and Maybe we didn't make the right diagnosis, or we made the right diagnosis and there's a bad event Right, and your heart sinks into your stomach because it's the first thing you think of is Did I, did I mess up? And and and it's? It's a horrible feeling and it and it weighs on us sometimes as physicians.
Dr. Hanson:
It does. And and I think the other part of that too is that we treat so many patients and we have the empathy for our patients and there are connections kind of made with our patients. But even these patients that you know, I saw mr Smith for a few hours the night that I initially admitted him and then when I walked in that room, inside with coding, I just felt like man, that like I had a connection with that guy, like you know. Why is it him? Why isn't it someone? I don't know? And so I think there is there's something about when you treat a patient and then you see them again. Right feels like you have some kind of connection, and so there is that guilt. That's that, that, oh, that's my fault. What did I do wrong? So it's just interesting.
Dr. Oden:
That is very interesting and I and I will say that the even back in my residency, which was a while ago, I can still remember every patient I interacted with that ended up passing adult and Pediatric. It's just something that gets kind of seared into your mind as part of that experience, as being a doctor is just something that you have to bear.
Dr. Hanson:
Yeah, so Luckily mr Smith did not die that night, so he he regained pulses, which is the goal of resuscitating someone with this. One of these cardiac events and we discovered, kind of assumed actually, and ended up, you know, being correct to that his, his code event was because his potassium level was really high again and brought him back down to the ICU and I actually had to put in a Dialysis catheter because they can't do this continuous dialysis through his fistula that we needed to do to get his potassium down. So I put this dialysis catheter in and we dialyzed him again, just like we had a couple weeks ago, and you know, by the next day it might have been two days later he was pretty much back to normal. He, his labs looked better, we were able to kind of wake him up even when he was on the ventilator and eventually, you know, within probably two days, we were able to pull the breathing tube out and he was basically back to normal and and so we're, you know, walking around seeing all the patients the next morning and the ICU team talked about him, talked about His labs, and had decided he was stable enough to leave the ICU and go back to the floor. So I walk in the room and Like, hey, mr Smith, you know, everything's looking pretty good today. Labs are back to normal, you know, or at least your baseline. So you know, I think we're gonna get you out of the ICU today and get you to the floor and kind of looks at me he's got the TV on in the room, says huh, okay, sounds good, it's great. So I didn't really feel like I had anything else to say and so I'll walk out of the room getting ready to go see the next patient. And then I have no idea why this thought occurred to me, but I thought of you doctor's bureau and how you had told me that there are times when you have patients that you feel like this is a time where I need to talk with them and make a change, like the patients who come in that are teenagers that have gunshot wounds, that that's an opportunity for you to talk to them and potentially make that change. And so I turn back around and I looked at mr Smith and I said mr Smith, do you know why you came to the ICU? You know you're on the general medicine floor a few days ago and now you're in the ICU. Do you know why you came down here? Did anyone tell you that? And he just looked at me and he said no, he had no idea what had happened to him in the past few days. No idea. He didn't know about his cardiac arrest, didn't really understand why he was intubated. Just no idea, none at all. And so I said, I mean, I just kind of stood next to, I said mr Smith, you're in the ICU because you're up on the floor and your heart just stopped. You had we call this a cardiac arrest. Your heart stopped. You basically died. We did some chest compressions and gave you some medicines to try and restart it and you came back to life. You died and came back to life and Literally no one had told him that.
Dr. Oden:
Wait, wait, beth. So this is a guy that is he's familiar with the medical community, so he's not bashful, right.
Dr. Hanson:
No, yeah, I mean he's in the hospital, you know, all the time.
Dr. Oden:
He didn't ask no like, why am I doing here? Okay.
Dr. Hanson:
Didn't even ask. Yeah, he just was kind of going along with it.
Dr. Oden:
I guess with a flow Okay.
Dr. Hanson:
Yeah, and and no one had ever said to him hey, man, your, your heart stopped up there and we had to pound on your chest and restart it.
Dr. Spiro:
I but wait a second. Hold on a second here. We spoke earlier on in this episode about this inherent bias against homeless people and folks that are maybe using illicit drugs on the streets. I always tell students that the core element of medicine is bi-directional communication. What went wrong here with this patient? Why did it take days later for the fellow trainee like you, beth, to come in and actually tell them that?
Dr. Hanson:
So that's an excellent question. I'm not sure I have a good answer. I kind of. You know, when I was thinking about this I kind of thought back on it and I'm not sure if we just get so focused on treating all of the things and getting the person stable enough to get to the floor that we don't see kind of the bigger picture there. You know, we go in and talk to our patients in the ICU every single morning. We go back in the afternoon frequently and talk to them. We call their families and update them and tell them what's going on. But I think we I guess I'm not sure I think we just get focused on the little details you know, like, oh hey, you know we did dialysis and your potassium is better, so I think we can get you to the floor. You know, everything's looking better today, or I'm not sure it's an inherent bias or if it's just an oversight on our part. You know, seeing the trees instead of the forest, because I think this actually happens with a lot of patients. You know, and I think that's why, dr Spiro, I know you've seen patients in the ER who they come in and they say, oh, I was in the hospital last week and they gave me some medicines, but I'm not really exactly sure what it was for. Yeah. You know, we just forget about kind of the big picture and sitting down and taking that time to explain what's going on. I mean it's a fault on our part for sure.
Dr. Oden:
Well, this is so. This is an intensive care unit and so that, by definition, individuals that are participating in medicine in that particular environment, that's. You know, you have to be focused about getting a person to a certain point and then discharging them to another part of the hospital. You very rarely do you kind of discharge a patient and have to explain everything to them and tell them about their medications in the intensive care unit right, yeah, that could be definitely a component of it. Yeah, I think you do have to be wary of bias and those individuals, because I'm undoubtedly, in many cases, people who are either homeless or you know they're frequent flyers. They get admitted a lot and you know, nursing staff are just kind of rolling their eyes and doctors are rolling their eyes. They're saying, well, they should know what's going on by now and they'd leave it.
Dr. Hanson:
But you know, yeah, I mean I will say I should say to you it may have been that someone else you know told him what was going on at some other point during his ICU stay and he just didn't remember.
Dr. Spiro:
Maybe he forgot.
Dr. Hanson:
Yeah, maybe he forgot, but you know, I just thought what if? I mean it seemed like he didn't, he was pretty unaware of it.
Dr. Spiro:
What was your big takeaway, beth, from this story? Like if you were to tell someone who's out in the public or you had to talk to a friend of yours about this story. What's the take-home message?
Dr. Hanson:
You know that communication is huge, like connecting with someone and communicating with them is that, I think, makes a huge difference. That makes all the difference sometimes and it seemed like no one had really done that with him, and I mean I certainly hadn't done it either until the day I went in and told him about his cardiac arrest. So that's on me just as much as it is on the rest of the ICU team. But you know I'm not naive. I don't think that that one conversation is going to change. You know I don't think he's going to go out, you know, the next day and be a whole new person. I know that. But I do think there was a moment after I told him that where he kind of looked a little surprised and you know, you got to think, you know, maybe it'll trigger something or change a little something for the better for him.
Dr. Oden:
Yeah, Maybe that realization planted a seed.
Dr. Hanson:
Yeah.
Dr. Oden:
Yeah, it's very possible.
Dr. Spiro:
One of the words I use now it's different because it's children and their parents, but at least once a shift I will see because we work at a quaternary care hospital I'll see a child with chronic health problems like multiple. Maybe they have cerebral palsy or they have some other neurodevelopmental problem and parents taking care of these children are spending 24, 7, 365 managing these families. And the word I've been using lately is hero and I will actually tell a mother you are my or father, you are my hero today, and half the time they start to cry. And well, just to for everyone's, do you want to tell everyone what you just finished? You just finished a 12-hour shift, correct?
Dr. Hanson:
I did.
Dr. Oden:
Oh, you need to get some rest, that's for sure.
Dr. Spiro:
To get some rest and do some self-care. Well, I just want to say you know, I get to see residents and fellows and all sorts of folks and Dr Elizabeth Hansen, beth Hansen, you're a very special young physician, a trainee fellow, and you've got an amazing career ahead of you and I think we are incredibly delighted to have you on this episode and honored that you're willing to share the story of Mr Smith and your experience with him. John, what are your thoughts?
Dr. Oden:
Well, Beth, thank you for using that story that. You know, we tend to have a theme and I'm always very surprised at what the theme ends up being. I mean, we've had discrimination, we've had, you know, white privilege, we've had other things. This one, I think, the theme. I'm going to say this. I think the theme is communication. It's a beautiful story that really illustrates how communication can be done, perhaps better. But it brings up a lot of questions too, and I'm going to pose those questions and I don't think there's no way that anybody has all the right answers. But one of the main ones that comes to my mind is how do you develop in a medical community on the various complex levels that we practice in intensive care, intermediate care, primary care, outpatient, inpatient, you know, over the phone, virtual, whatever. How do you develop a communication plan or the steps in communication to deliver the complex information we have to do to the various levels of families that we treat? How do we tell, for example, in my line of work, how do I tell a four-year-old that they have diabetes and tell a single mom of that four-year-old that they have diabetes and then shift gears and go and tell a 17-year-old they have diabetes? It should all be different, right, it should all be different. And it should be done on various levels. So it shouldn't just be done by the doctor, but it all should be done by the nurse, it should be done by the primary care physician, it should be done by the discharge group. The discharge papers, all that stuff should have everything in there that that individual needs. But even though we live in a very high-speed, high-fidelity kind of environment, kind of a community, we still haven't gotten it right after all these years and that's kind of a sobering thought. So thank you very much for bringing that up. I think that's what I'm going to say is our topic for the day.
Dr. Spiro:
Yeah, and I'll just end with that For me, the reason why I'm able to stay in this is that it allows me to practice being vulnerable and allows me to practice compassion, and both of those two words make me feel very human and understand the frailty of the human state in this incredibly honored place, that we get to be physicians and healers. In our role, and whether it did or didn't, I think, beth, you were a healer for that particular patient in that particular moment and I'm frankly very honored to have you here and honored to have worked with you and our work at Arkansas Children's.
Dr. Oden:
Yeah, I would second that. But I would say both of you guys are heroes To do what you do and step in and participate in codes. As an endocrinologist, I haven't done a code in 20 years and I would just pass out.
Dr. Spiro:
Yeah, but you do other things that are incredible, dr Odin.
Dr. Hanson:
Yes, absolutely.
Dr. Oden:
Yeah, I get to prescribe testosterone. That's a lot of good stuff.
Dr. Hanson:
Hey man, that's life changing for some people.
Dr. Spiro:
It is. It is. That's right. That's right. Thank you for saying that. All right, well, let's wrap it up. Everyone, thank you for joining us and I hope you all learned something today, and we look forward to episode number five.
Dr. Oden:
Yeah, thanks for listening.
Ending:
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