Monday, October 09, 2006

When You Know the Patient

It's happened before; I've walked into a room or looked down at a gurney and seen someone I know. My ER patients have included the occasional parishioner, university colleague, or member of the hospital staff. I've been told that technically, according to HIPAA regulations, I'm not even supposed to let on that I recognize the patient in this situation, but these patients have usually recognized me, so that hasn't been a problem.

Last night's shift was, well, difficult. The ER was getting hammered when I walked in, and staff nearing the end of twelve-hour shifts reported that it had been that way all day. Everyone was tired. Tempers were short. I spent most of the evening trying to visit patients while staying out of everyone else's way.

To give you some idea of how busy it was, volunteer chaplains have to keep a tally of patients or family to whom we've offered services: not necessarily people with whom we've had deep conversations, but people to whom we've made ourselves available, even if they then said, "No thanks, you can go away now." The spiritual-care department, like every other part of the hospital, has to do basic bean-counting. I usually average about fifty beans in a four-hour shift. Last night, my count was seventy-four, and that's actually a little low, since I counted a few large family groups as one.

Fairly early in the evening, there was a code on another floor. A bunch of us headed up there: spiritual-care staff are required to respond to codes, and last night I was the only chaplain in the building. The code featured the usual cast of thousands. As happens in many codes, the patient came to quickly. From my vantageway in the hallway, I saw the patient's feet wiggling, and heard the doctor running the code say in a cheerfully booming voice, "Are we feeling better now?" Everyone laughed.

I told the nurse who was trying to contact family to call me in the ER if anyone wanted to talk to a chaplain, and then I left, after giving my full name to another nurse who told me that she had to document the role of every single person there. (For perspective on the hideous paperwork required of nurses, see this heartfelt rant from Kim.)

I'm sharing this part of the evening because it was a typical code: the patient didn't die -- at least in the codes I've seen, most patients don't -- and the initial tension of hearing "Code Blue" on the overhead dissipated pretty quickly.

I went back downstairs, talked to some other patients, and then went to the logbook to try to get a room number for someone who was being admitted and wanted a spiritual-care visit upstairs. The logbook contains labels with the name, diagnosis and destination of every patient admitted from the ER.

Looking for my patient's name, I saw another name. It looked familiar. I squinted at it. It looked very familiar. I scanned the diagnosis, which sounded very scary. I scanned the destination: OR.

My stomach dropped. "Oh my God," I told the nurse standing next to me. "I know this guy."

"Yeah, that'll happen."

"Can you tell me what's wrong with him?"

"Of course not. You know I can't, because of HIPAA."

I did some research and learned that my friend was out of the OR and in ICU. I went upstairs, wondering what HIPAA violation I was committing by going to the bedside of a friend who hadn't asked me to be there. My friend was out of it, on a vent, but his nurse told me that he'd opened his eyes and responded to simple questions, and that the surgery had gone well.

I still didn't know the story behind that scary-sounding diagnosis. I knew I couldn't ask the nurse, because of HIPAA. I asked the nurse to call me in the ER when the patient's wife showed up. I went back downstairs and did my scattered best to visit another few patients until the call came through; then I raced back upstairs.

It was good news. The scary-sounding diagnosis was actually much less scary than the terse notation in the logbook made it seem. My friend's going to be fine. I prayed with him and his wife -- I think maybe he squeezed my hand while we were praying, although that could have been an involuntary reflex -- asked if there was anything else I could do, and left when I learned that there wasn't.

Once again, some moments of panic (more moments, in this case) were replaced with relief. But do I need to explain that in this second situation, I had nothing resembling the professional objectivity I'd maintained so easily during the earlier code?

Back downstairs to the ER. More patient visits. And then, at the very end of my shift, I hear another code on the overhead.

Back upstairs. I'm on my way into the unit where the code is when I get waylaid by a hysterical visitor. "That's my relative's room number! What does Code Blue mean? What does Code Blue mean? What does Code Blue mean?"

As the previous case illustrates, a code can mean a lot of things. Sometimes codes turn out well; sometimes they don't. So I said, "I don't know. Let me go inside and see if I can get some information for you."

"I want to go in there. Let me in. Let me in."

"I have to ask if you're allowed back there," I said, and headed for the unit intercom.

"No, the visitor can't come back here during a code," the unit nurse told me. The relative, predictably, was furious. I was allowed in because I was staff. But as I headed into the unit, I was pushed backwards by a bed, surrounded by medical staff, being pushed out. The patient had been bagged and was being taken into emergency surgery.

A nurse stopped long enough to give the relative a terse and not very encouraging report. The relative then waylaid some ER staff who'd reported to the code and were heading back downstairs. "The nurse said X. What does that mean? Tell me what that means. I don't understand what that means!"

The ER doc said, gently, "I can't tell you. I don't know enough about this patient's situation. I'm sorry."

I can't imagine what it must be like to hear a code called on a loved one's room number, and then to see that person -- helpless and unconscious -- being wheeled down a hallway by grim-faced caregivers, and then to be told repeatedly that no one can tell you anything definite. This is the layperson's version of "when you know the patient." If you're hospital staff, at least you also know other people in the building. You have sources of support. But a visitor facing this situation must feel incredibly isolated.

This is what chaplains are for. The unit nurse asked if I'd wait with the relative for word, and of course I said yes. But the relative didn't want me there. The relative wanted a priest. The unit nurse said she'd call one. I said, "Would you like me to pray with you until the priest gets here?"

"No." Angrily. "I have my own prayers. I'm waiting for the priest."

So I left, reminding myself of that ever-useful CPE lesson. Chaplains are the only people in the hospital that patients or family can tell to go away, so if somebody dismisses you, tell yourself that you've just empowered that person.

I left, trying not to take the anger personally, reminding myself of the brief flare of anger I'd felt at the nurse who couldn't give me information about my friend because of HIPAA. The visitor was angry at me because I'd blocked access to the patient, because I didn't know enough or wouldn't say what I guessed, because I couldn't offer definite answers. Mainly, the visitor was angry at what was happening, and I was a convenient target. I know all that. But I was also frustrated and sad, because the only help I did have to offer had been rejected. I was trying to make the visitor feel less isolated. The visitor wasn't having any.

I hope the priest was helpful and comforting. I hope the patient pulled through. I wish I were more hopeful about that.

And I find myself wondering how I would have reacted if my friend had been in that patient's situation: in very serious shape indeed, with a very uncertain prognosis. Would I have been any less hysterical? And what if my friend were in that situation and I were a member of the medical staff, a nurse or doctor halfway through a twelve-hour shift, with other patients to care for? How would I wall off my feelings enough to keep doing my job?

It happens. How does anyone handle it?


  1. Oh, Susan, how scary! You, your friend and those involved in the codes are definitely in my prayers.

  2. I always call it the look. Whenever we hear a code we'd look around and you could just tell by the face which perosn was the mother. It's possible that other family members get upset or yell but moms just sit with the look.
    Ive been there. Now I know (thanks to you) why a chaplain came and found me.
    The truth is that she annoyed the crap out of me, didnt take the hints (a lot of the time I can be too subtle) to leave. Whatever I talked about with her I couldnt say, I was too mad at her for still hanging around even though I wanted her gone.
    In retrospect though, it really didnt matter because it's not like she was keeping me from anything except sitting there with the look.
    And honestly, the only thing I found that helps is when you can predict it in advance, to take a valium or something.
    Sadly, worry and angst in the waiting room does not affect patient outcome.

  3. Nickie: Thanks!

    That Girl: Yep, I was clearly annoying the crap out of these people, too. Please do remember that you can always ask the chaplain to leave. My fear is sometimes that people who find me annoying aren't doing that because they're trying to be polite (which is the last thing anybody with a coding relative should have to worry about, although I'm always impressed by how many people manage it).

    Most effective line for losing the chaplain: "I'm sure there's someone else who needs to talk to you more than I do."

    We hear this all the time, and laugh about it.


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