| Out of the Operating Room Into the Home | |||
| By Yang Yao-lin, M.D. Translated by Tang Yau-yang. Photos by Chen Hui-fang | |||
The path of Yang Yao-lin (楊曜臨) has taken him from a large medical center to a small-town hospital, from the sides of operating tables to the sides of sickbeds in people’s homes in the countryside. Instead of avoiding any involvement in patients’ lives, he is getting closer to them—contrary to what he wanted when he chose to be an anesthesiologist. But he’s found that he has gone too far to return. Generally speaking, it’s unheard of for anesthesiologists to establish long-term and stable working relationships with their patients. I myself am an example of this. A typical patient would come to my clinic for a pre-surgery consultation to learn about the potential risks of the operation and the anesthesia, and then sign consent forms to acknowledge the information in order to receive anesthesia. The patient would usually be gone in less than 20 minutes. The next time I saw him would be in the operating room. He wouldn’t really see me because I would be wearing a scrub cap and a mask. In a few minutes I would put him to sleep. The only connection between us from that point on would be his biological readings on the monitor.
After the surgery, he would wake up in the recovery room, and I would see him trundled away. We would most likely not see each other again. He wouldn’t have any impression of me or know that I’d closely monitored his condition throughout the surgery. He’d recover and go home, and totally forget about our brief and uneventful encounter…and so would I. The interaction between anesthesiologists and their patients is by nature light and transient. This nature was what attracted me to specialize in anesthesiology. I wanted to stay in the impersonal safety of the operating room; I didn’t want to see or become involved in the world in which the patients lived, coped, and struggled. I knew that prolonged involvement would lead me to become emotionally attached to them, causing me to worry about their worries and agonize over their agonies. A few years ago, I was promoted to be an attending physician at Hualien Tzu Chi Hospital, in eastern Taiwan. At that time, I was planning to leave the medical center to work in a rural area. However, it just so happened that a colleague in my department, a pain management specialist, left. That left us short-handed, so I naturally took over his work. That decision was a stark departure from my initial goal of becoming an anesthesiologist, but in eastern Taiwan, a relatively undeveloped area, few physicians were able or willing to work in pain management. I knew that I could improve the quality of life for some patients, so I decided to walk out of the operating room, so to speak. I took another step away from my anesthesiology aspirations in July 2014, when I transferred to the anesthesia and pain management department of Guanshan Tzu Chi Hospital. This is a small, rural facility which has even fewer resources. The hospital has 60 special patients who need regular medical care but who aren’t sick enough to be hospitalized. Since they cannot come to the hospital very easily, the hospital sends physicians and nurses out to care for them at their homes. Guanshan Hospital doesn’t have any resident doctors in family medicine, so this responsibility falls on all physicians there, even the superintendent. I remember seeing doctors, wearing white gowns and carrying their tool bags, making home visits to patients who couldn’t get hospital care because of their restricted mobility—but that was in TV dramas. Now I’m doing exactly the same thing in real life.
Real life On a typical home-visit day, a nurse and I drive through streets and alleyways and past rice paddies toward patients’ homes. Though I know the local area quite well, I’m often surprised to drive on paths so out of the way that I didn’t even know they existed. One of the homes that I’ve visited was a rundown traditional Chinese courtyard house. The original tiled roof, too old and leaky, was covered with a layer of sheet metal to keep the rain out. In the living room, two lit red lamps adorned the shrine for their family ancestors. The furnishings were of very early vintage, including a portrait of sorts—a drawing of a person with a photograph of his face inserted. All this was typical for a family in the countryside a long time ago. In this old residence lived a female patient, paralyzed from the waist down due to a spinal injury. Her room was about 140 square feet in size. The red sheet she was using for her comforter—adorned with red flower patterns popular long, long ago—was probably 30 years old. Everything in the house seemed old. It reminded me of visits to my own grandmother’s home when I was a child. The woman greeted me warmly, probably because all of her family was out working and she rarely had a chance to talk to anyone else during the day. I chatted with her before I changed her catheter, checked her cystostomy site for signs of infection, and checked her backside for bedsores. I looked around the room and saw that there were places that were filthy. In her condition, it was probably beyond her to keep the room very clean. Ever since I started working, I’ve lived in large, modern houses that were bright, airy, and clean. I rarely witnessed the lives of less fortunate people. Therefore it was somewhat of a shock for me to see that somebody was actually still living in such an old-fashioned environment.
Some of the patients we visit have had strokes and are permanently bedridden. They generally suffer from atrophied muscles and joint contractures. I change their breathing and feeding tubes, check their pressure sores, and change their dressings. The patients are usually deadpan during the whole process; the only interaction that I have with them is through their empty stares, which is really not much of a communication channel. The best treatment for a bedsore is a surgical cleansing of the sore followed by a skin graft. But a successful skin graft requires a lot of care, which bedridden patients are unlikely to be able to provide. The best help I can offer these patients is to keep changing their dressings and pray that the lesion will somehow cure itself. Sometimes I encounter complaints from family members. They are unhappy about the extent of long-term care their loved ones have been getting, and they vent about what a monumental undertaking it is simply to get the patient from home to a hospital. I mostly just listen as they pour out their pent-up emotions, and I occasionally say a few words here and there. I know better than to take over the conversation—they need an audience more than a lecturer. With nothing more that I can do for these patients, I do the best I can to be a good emotional dumping ground for them or their families. It’s hard, however, to maintain neutrality in this engagement. Too often, their helplessness becomes mine. Once I was at the home of a stroke victim who was confined to bed. His limbs had atrophied as was normally the case, but his head was clear and he had complete command of his speech. I saw ants crawling all over his body, but he was powerless to drive them away. He could only allow them to keep pestering him as they wandered around on his skin, taking occasional bites. I tried to wipe the ants away for him, but there seemed to be an endless number of them and my pitiful attempts failed to make much of a difference. His wife started talking to me. “I haven’t seen you before. You’re a new doctor, right? If you’ve never seen the tough life of a farmer, you’re seeing it now. He used to work too hard in the field, even on hot days. He had high blood pressure, and I kept telling him to go see a doctor, but he just wouldn’t listen. Then he had a stroke when he was in his 40s, and I’ve taken care of him ever since. He’s in his 60s now….” She kept talking, but I couldn’t bear listening to their sad story any more.
My choice I sometimes feel I’m not cut out to practice this type of family medicine. In these home visits, the most I can do is help patients control their illnesses, not cure them. I am destined to watch patients fade away and die. The process of dying can be so painfully long, long enough for me to care for them and develop emotional attachments to them. This is very different from what I was familiar with. As an anesthesiologist, I have also lost patients to death, but only occasionally. Those deaths came swiftly, in hours or even in just a few minutes. The patients were mostly still under anesthesia, and I was not familiar with their circumstances. Since I didn’t know them very well, I shed fewer tears when they struggled or died. But that paradigm fundamentally shifted when I transferred to Guanshan Tzu Chi Hospital in July 2014. After I started my home-visit duties, I soon saw far more lowly and miserable existences than I had during all my years as an anesthesiologist. I’ve come to realize that perhaps death is not always all that painful or horrifying, but a slow, suffering death is. During my visits, the world of miserable patients and their families—a reality that I had tried to stay away from and pretend did not exist—came to full life right in front of my eyes. Many patients have sorry stories behind them, and often each story is too pungent for me to remain neutral. I know that I’m not brave enough to face their sorrow, but I have somehow wandered out of the operating room into the fields of the real lives of these patients. Looking back, I realize that I’ve strayed from my original path, but I have no regrets for having gone too far to return. |
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