Monday, February 05, 2007

Unexpected Reactions

Before I started volunteering at the hospital, I had theories about what would disturb me the most: seeing dead people, hearing people scream, bearing witness to tragic stories. I've done all of that now, and while none of it's my favorite part of the work, it's okay. I can handle it. Blood and other bodily fluids don't bother me; smells usually don't bother me; the occasional rude or nasty patient doesn't bother me. Granted, I sometimes think about all of those things after they've happened, sometimes for quite a while, but they don't throw me off balance. They're part of the natural order of things.

Last night, I saw a patient in end-stage liver disease whose skin was this exact shade of chartreuse. I've seen jaundice before, but I've never seen someone who literally had green skin. To say that it startled me would be an understatement.

I don't think my reaction showed. The patient was very nice, but feeling too sick to talk; later, I offered my services to family members, who said quietly, "No, we don't need a chaplain yet." (Last night's shift contained an unusually high percentage of people who believed that chaplains only show up for last rites . . . which, of course, I couldn't perform if I wanted to, since I'm not a Catholic priest. The last patient I visited became very agitated and said, "I don't need no chaplain! I'm not dying! I don't need no chaplain!" I tried to explain that I visit everyone, but the agitation continued, so I just left. I hate making people feel worse.)

I'm very sad for this patient and family; I've prayed for them. But I also can't get that skin color out of my head. It's just . . . wrong. It's not part of the natural order of things. Well, no: of course it's part of the natural order, or it wouldn't exist; but my instinctive reaction was a visceral horror I haven't felt in other situations.

There are undoubtedly deep insights to be gleaned here about racism, ostracism, and the stigma borne by people with visible skin conditions like leprosy. I haven't untangled all of that yet. But the incident has made me wonder if nurses and doctors ever have similar reactions, if -- despite everything they've seen and done -- some sights or sounds are so unexpected that they get through all the professional defenses and are burned into memory. And when that happens, how do medical caregivers deal with it, both in the moment and later on?


  1. As a medical student at a center that does a lot of multivisceral transplants, I agree, that greenish tinge of very late stage liver failure - and the worse, GREY-GREEN of CHRONIC late-stage liver failure is somehow horrifying in a visceral manner that gore & guts aren't. So it isn't just you.

  2. Interesting, to hear what had the most impact on you. I never would have thought of that.

  3. There are certain things, like some of the burn victims I have worked with, that work their way into your deepest sulci and sit there. I guess I deal with it by sitting with it, giving myself time to digest (in healthcare, that's about 5 nanoseconds), and then seeing the person. It's like a hologram or something (this is a horrible metaphor-in-progress) and you just have to refocus and see the person underneath the disease. The disease is just a screen on top of a screen (the body) and the person is somewhere deep inside, beyond physical seeing but open to being seen. There are some great (& widely mocked, by the science-minded people in my nursing courses) nursing theorists who talk about this, like Jean Watson.

    As for how you deal with it afterwards, I deal with it like any other trauma. It is traumatic for caregivers, no matter what they've seen, and you never know which ones are going to hit you hardest. I talk about it with coworkers, I use black humor, I write about it, I go home and hug my family, and when nothing else works I watch bad television and eat ice cream.

  4. Yes, there are many things that are burned into my memory, and I have many ways of dealing with this - blogging, crying, sleeping, talking to my coworkers about the event... and sometimes it gets easier and sometimes it still haunts you at night.

  5. Of course we suffer such memories. The ones that get me most are actually olfactory. It's scents that bring back bad memories. I've caught so many bad smells poorly masked by sprays of orange oil that oranges themselves have been affected for me.

    Early in my career I encountered a person whose skin was purple. He wasn't a patient; he was a volunteer. Before emigrating he had labored for a photographer, and he told me long term exposure to silver nitrate had stained his skin permanently.

  6. I must agree with Marshall, that many smells can be particularly reactionary or memory-inducing. At a hospital I used to work at, the morgue was always doused with a certain cinammon scent, supposedly to mask the smell of death. Unfortunately, we are occasionally called upon to transport stillborn babes to the morgue... I now have a permanent aversion to the smell of cinammon, including cinammon-flavored gum. Just brings it right back.

    I also had an incident recently in which I'm ashamed of my gut reaction. I went to monitor a pregnant patient who had recently undergone brain surgery. Upon reaching her room, I was so sure I was in the wrong place that I had to ask her CCU nurse where the pregnant patient was. She scoffed at me and said, "She's right here." With her head shaved and her body disfigured by all the steroids, the patient looked like a man. I was horrified. Fortunately, she was intubated and sedated, so she was not aware of my reaction. I spent some time with her family and at the bedside, they showed me pictures of her former self. Unbelievable.


  7. An ulcer that had progressed into a cavity down to the bone on an older man's foot, where you could quite clearly see the first metatarsal. While I was training, years ago but never forgot having to pack that wound. Even though I've seen worse, that one sticks with me for some reason.

    Black blood oozing from the body of a five month-old who had died in the PICU, so coagulopathic that we couldn't stop the blood loss even after his heart was no longer pumping.

    The eyes of a 9 year-old as I tried to answer his questions about whether he was going to live through the night.

    I mean, there are always images, sounds, smells, moments. I don't know how others deal with it, but I try to use it... as motivator, teacher, reminders of what to do (or not to do) next time. For the particularly disturbing moments, debriefing and supervision/mentorship have their place. I also make it a point to get away from the city when I can and spend time walking, letting go of the previous weeks/months. Everyone in an occupation which causes distress should have some process of renewal.

    The fact is though (as I'm sure you realise), when you sign up for this stuff you also sign up to deal with the personal consequences. It sucks, but so does having end-stage liver disease...

  8. Susan, what about rude, smelly patients who gush body fluids on you? Only kidding, but I do see those sometimes. I also had a purple pt. He had a bad melanoma and some kind of reaction with the radiation caused his whole body to turn this shade of magenta. He died right after we triaged him. It was so sad but very eerie to see him.


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