Sunday, October 14, 2007
I've posted here before about the work I'm doing with the University of Nevada School of Medicine, helping them integrate more narrative medicine into the curriculum. Since I have a PhD in English and volunteer in an emergency department, the UNSOM folks like having me there, and I certainly like being there; it's a place where I can integrate several areas of my life that otherwise seem far-flung.
In the ED itself, I think of myself as practicing a kind of narrative medicine, encouraging patients to tell stories and listening carefully to what they say. But I'm well aware that most of the medical staff has very little time to do anything similar (which is why chaplains are so important!). In the ED, narrative medicine seems like a luxury better suited to slower-paced specialties where caregivers develop relationships with their patients over time.
And that's a real shame, because for patients able to speak at all, turning their fear and worry into narrative can have powerful healing effects.
A few weeks ago, I gave a very basic lecture on trauma theory to my freshman composition class. Trauma -- used here more broadly than medical caregivers define it -- is any event that overwhelms the individual's ability to cope. Trauma takes many forms, but all of them share certain characteristics.
1. Trauma is unpredictable and uncontrollable.
2. It threatens the individual with death, not-being.
3. It threatens and undermines meaning, toppling previous belief systems.
4. Because it is so overwhelming, the individual carries it inside even when it appears, to outside observers, to have ended. It is always now and always here.
5. Because it is so overwhelming, it is extremely difficult to talk about: partly because it defies language, partly because the individual fears invoking it again, and partly because often, no one wants to listen, or is able to understand.
And yet talking about the trauma, shaping it into narrative -- a story -- is essential, because narrative is the opposite of trauma:
1. Storytellers control what happens in the story, so telling a story about the trauma gives the victim control over it, the very control that was lacking in the event itself.
2. Telling a story is a way of asserting survival and existence: "This happened to me, but I'm still here to talk about it."
3. Telling stories is how we make meaning of what has happened to us, shaping chaos into coherence.
4. Telling a story about trauma externalizes the trauma, moving it from the victim's brain and body into public space. Story-telling helps survivors birth their own experience.
5. Shaping the trauma into language, taming it into a tale, helps survivors "rejoin the land of the living" by casting what has happened to them into shared language. Stories build a bridge of words and images between the trauma and the rest of life.
This is why I believe that narrative is as vitally important in the emergency department as it is anywhere else in medicine. Of course, many ED patients are unable to speak, and of those who can, some may be so overwhelmed that it will be days or weeks before they can begin processing what has happened to them. But we've all met ED patients or visitors who compulsively narrate what has brought them there, who repeat the same tale to everyone who enters the room: even if the doctor's already heard it, even if most of the details have no possible bearing on anything medical.
"I was eating a tuna-fish sandwich, and he just keeled over into his tomato soup, and then I was trying to pull his face out of the bowl and call 911 at the same time, and oh, gosh, these slacks are covered with tomato soup, aren't they?"
"I was in Home Depot buying nails when I felt this crushing pain in my chest, and one of those guys pushing a huge lumber cart asked me if I was okay, and I couldn't answer! It was so scary not to be able to talk. It reminded me of that time in third grade when the other kids pushed me into the water and held me down, and the guy with the lumber was kneeling down next to me, and I didn't know how I'd wound up on the floor, and I'd dropped my nails and I wanted to pick them up, but he kept telling me just to stay there, the ambulance was coming."
Compulsive repetition of such stories isn't just a sign of shock. It's an essential coping strategy: the speaker is desperately trying to regain control by turning the event into a known, predictable narrative.
If your ED has a chaplain, social worker, or someone else whose primary job is to listen, by all means try to have that person visit the room.
If you're a medical caregiver and you have two extra seconds, by all means listen, and try -- without interrupting -- to give some active sign that you've heard. Body language and facial expressions count for a lot here.
But what if there's no chaplain or social worker in sight? What if the department's so busy that you don't have two extra seconds to spend listening to anyone?
One easy answer is, "There will be someone to listen later, in or out of the hospital," and of course that's true. But I suspect that the earlier this process begins, the better. And so, if patients or bedside visitors are able to write, why not encourage them to start putting their stories down on paper? I've linked here before to this article about the healing effects of writing. I've often told my ED patients about this, and they're almost often intrigued. Several times, I've given a patient pen, paper, and encouragement to write the story down. It seemed to help.
If nothing else, writing is something to do, something to focus on during an overwhelming time in a chaotic environment. And paper always listens, even when people can't. The paper will contain the story until other people can make the time to listen too.