Wednesday, February 1, 2012

If I Knew Then What I Know Now

     If you lived in Columbus, Georgia, back in the 70s, you almost certainly would remember driving by Sister Mary's dimly lit psychic/palm reader's shack on 4th Avenue, which featured a prominent advertisement for the Sister Wig shop, located on Broadway. In those days, 4th Avenue, which has since been renamed Veteran's Parkway, took you on a convoluted journey from your cozy, white-bread neighborhood to a seedy side of town just across from the Alabama state line, during which you locked your doors and held your breath as you passed the endless string of cheap hotels and liquor stores where itinerant schizophrenics, hookers, and other characters of ill repute congregated. Amidst the squalor, Sister Mary boldly advertised herself as a psychic-palm reader, an occupation with which my friend, Elaine, and I were very much intrigued. Being artists, Elaine and I were intuitive and receptive to all things other-worldly. In an attempt to discern whether this psychic was the real deal, we made a few telephone inquiries on separate occasions, and sadly, we discovered she was a total fake, the dead giveaway being the way she answered the phone. After dialing her number, it would ring a few times, and then we'd hear a screechy, "Yell-ooow?" As soon as we'd mention our interest in arranging an over-the-phone psychic reading, she'd assume a breathy, mysterious, Gypsy-like voice, bowing out with the excuse, "Well, I'd have to see yeeeeeew."
     My first personal encounter with clairvoyance occurred when I was pregnant with my twins. All of my senses were in overdrive. I was in a state of constant sensory overload, the living, breathing consummation of a dog's nose, a wild turkey's eyes, an owl's ears, a catfish's taste buds, and a manatee's touch receptors. An entirely different sense seemed to be emerging, accompanied by odd premonitions which caused me to startle at the drop of a hat. About eighteen weeks into my pregnancy, I went out for a walk with my husband. We'd just found out we were having twin boys. It was springtime in Atlanta, warm and sunny, and as we walked, we talked excitedly about baby names. All of a sudden, I froze in my tracks. From the corner of my eye, I'd just seen a giant snake crossing the road, and in stopping, had prevented my Birkenstock clog from coming down hard on a big glossy turd, lying in the middle of the sidewalk. On further examination, the snake was dead, and the turd was an intact, unwrapped Baby Ruth bar, but still, I was left with a persistent, uneasy feeling. Whether this event was a future vision viewed through my third eye or a mere consequence, it accurately foreshadowed an unbelievable set of circumstances; indeed, several months later, I became gravely ill with Listeria sepsis, and my twins were delivered eight weeks prematurely. I believe the snake-candy bar scenario heralded the awakening of my sixth sense, the eyes in the back of my head, the advent of my mother's intuition.
     I'm a big believer in the intuition I've cultivated as both a mother and a physician. My gut feelings have never been wrong. As a corollary to my own heightened sense of awareness and cognition, I pay a lot of attention to the signals I receive from patients who are about to undergo surgery. Although most people are nervous about having surgery and anesthesia, there are some patients who may actually be experiencing a premonition of death. Extreme preoperative anxiety is something that should never be ignored. If a patient tells me, "I'm afraid I'm going to die" or "We can do this another time",  I believe that a thorough examination of his or her concerns and fears is in order, without benzodiazepines (anti-anxiety medication) on board, if possible. The problem I run into are the patients who, for whatever reason, can't or don't verbalize these specific reservations; they enact them, making it difficult to tease out whether they're experiencing garden-variety anxiety or something more ominous.
     A few years back, I was supervising anesthesia residents on the Acute Pain Service. We were scheduled to perform femoral-sciatic nerve blocks on a 50ish year old woman, who was undergoing a knee replacement. She was relatively healthy, except for a little high blood pressure. There was no reason to suspect she'd have anything but an uncomplicated intraoperative and postoperative course. But, this lady was completely freaking out, to the point of irreversible hysterics. Her anesthesiologist had given her quite a bit of Versed, and because she'd undergone previous surgery without complications and wasn't "sick", we went ahead and placed her blocks. Given the degree of her distress, we assumed she'd already had a frank conversation with her anesthesiologist, and attributed her extreme emotional upheaval to simple preoperative anxiety. Despite the extra Versed and fentanyl we administered for her nerve blocks, she continued to cry her heart out, down the hall into the operating room. She never could put into words exactly what was bothering her. About an hour later, we heard a stat "any available anesthesiologist to room seven" page overhead, signalling a problem in one of the ortho rooms. Our patient had thrown a massive blood clot to her lungs, and died on the table. I'm now convinced she'd been trying to tell us something, but just couldn't find the words, and that the outward manifestations of her deep inner turmoil were harbingers of an unrecognized premonition of death.
     Another patient, a woman in her mid 70s, was scheduled for an ERCP (endoscopic retrograde cholangiopancreatography). This is a procedure, routinely performed in the GI lab, usually under general anesthesia with endotracheal intubation  (breathing tube). After the patient is anesthetized, the gastroenterologist places an camera into the esophagus in order to visualize the GI tract and to permit removal of gallstones obstructing the common bile duct.  Extract stone, turn off anesthesia, wake patient up, and off to the recovery room you go--simple! I had gone to preop the woman in her hospital room the night before, and met her daughter-in-law, with whom she lived. Aside from controlled high blood pressure and hypothyroidism, this was a pretty healthy elderly woman. The week before, she'd had her gallbladder removed laparoscopically, and apparently, one of the stones had lodged itself in her common bile duct, causing her bilirubin level to be elevated. She had done well with the anesthesia for her gallbladder surgery, but her daughter-in-law told me that for the last week, she hadn't required any of her blood pressure medication. After explaining the anesthesia for the ERCP, I bade them both good night, reminding the patient not to eat or drink anything after midnight. The next morning, as my anesthetist and I were inducing general anesthesia on this lady, she began vomiting copious amounts of what appeared to be bile before we'd secured her airway with a breathing tube. There had been no reason to suspect her as an aspiration risk; she'd been appropriately NPO (nil per os, nothing by mouth), and did not have a significant history of acid reflux. Fearing that she'd aspirated stomach acid or bile into her lungs, we turned her onto her side, suctioned her, and quickly got her intubated (insertion of breathing tube). For the remainder of the case, she seemed to do well, displaying no problems with oxygenation or hemodynamic instability. At the end of the case, we gave her a trial of extubation (removal of breathing tube), but about thirty minutes into her recovery, she required reintubation and aggressive management of hypotension (low blood pressure) and poor oxygenation. She went on to develop ARDS (adult respiratory distress syndrome), a severe acute lung injury accompanied by inflammation of the lung tissue and persistent low blood oxygen levels, which often progresses to multi-organ failure. Once I got her stabilized, she went to ICU on a ventilator and several IV drips to help maintain her blood pressure within a normal range. Over the next three days, she went from bad to worse. Her family elected to remove her from life support, and she died shortly thereafter.
     The morning she died, I ran into her daughter-in-law in the ICU hallway, where I recounted how perplexing and unanticipated the events in this case had been. In hindsight, it is possible that she had an infection brewing, and that could have been why her blood pressure was low after her gallbladder surgery. She could also have had a residual ileus (sleepy intestines, common after abdominal surgery). Her daughter-in-law looked at me, and said, "There's something I need to tell you." She described her mother-in-law as being very stubborn, a personality trait born of necessity from her experiences as a young girl, growing up in Germany in WWII. "She didn't like doctors, and it took an act of God to get her to see a surgeon about her gallbladder. When we got the appointment made for her surgery, she told me, 'This isn't going to go well for me. I think I'm going to die.' " A chill came over me. Her daughter-in-law acknowledged that she and her husband both thought his mother was just being obstreperous and difficult, ignoring the comments she'd made about a bad outcome. She was accurately predicting her own demise, but given the fact she was so hard-headed, no one took her seriously.
     I recently had an adult female patient who was scheduled for an ENT (ear, nose, throat) procedure under general anesthesia. The majority of ENT outpatients are babies and small children having tonsillectomies or ear tubes placement, and we were all amused to hear that this patient had requested that her case be done ahead of the babies because, in her own words, "I'm the biggest baby of them all." Her anxiety was truly the worst of any I've ever seen. Although she was in her mid 40s, her husband and parents were embarrassingly indulgent of her. They all displayed a shocking lack of calming techniques, effectively permitting her irrational fear of needles to escalate to the point where she was almost crazed, hyperventilating and crying so inconsolably that it frightened patients in the rooms adjacent to hers. Although she'd had surgery and IVs before, she began retching when attempts for IV placement were made, necessitating the consideration of oral premedication with Versed, like we do for small children in order to elicit their cooperation. In examining why she was so anxious, she commented to me several times, "I'm fine with doing this another time." I notified her surgeon right away, who told me that we could cancel the case, if necessary. Neither he nor I are especially fond of making assumptions about patients' emotional states preoperatively, and I demanded immediate clarification: was this her maladjusted way of getting attention, or was she experiencing some sort of premonition? I asked her, point blank, if she had a sense of foreboding. "Are you afraid you're going to die today?" This seemed to get her attention, as well as the attention of her family. She was then able to calmly convey to me that her anxiety was purely a function of her unnatural fear of needles, which her mother confirmed, saying "It's genetic...her father falls out at the sight of a drop of blood or medically-related talk of any kind." Satisfied that she was just nervous about being stuck, we gave her the oral Versed, and got her IV started without further adieu. She went on to have an uncomplicated anesthetic and recovery.
     Regardless of whether a physician feels a patient's premonition of death is due to clairvoyance or the result of hindsight or confirmation bias instead, many of us are of the opinion that in cases where a patient is experiencing anxiety that is clearly out of proportion to the situation at hand, or a vague, impending sense of doom, an immediate exploration of the patient's fears is mandatory, and rescheduling of an elective procedure should be considered. If a patient tells us, "I am going to die today", we need to listen, especially if they are calm. Although studies definitively linking one's preoperative psychological state with adverse postoperative outcomes are lacking, there is empiric and anecdotal evidence that a relationship exists. The mind-body connection is undeniably powerful. We've all taken care of patients who've survived incredible odds of some sort: trauma, overwhelming infection, cancer, or another type of grave illness. We think to ourselves, "Wow, that person really has the will to live!" We all possess this same will to live, to heal, to overcome adversity and strengthen ourselves from within, but the majority of us don't know how to access it. We're too caught up in that which is external to us. Those of us who have integrated the use of intuition to temper our practice of evidence-based medicine appreciate that our patients are more than the sum of their parts; they, too, are intuitive beings. Our third eye, on high alert from past experiences with surgical candidates who are extremely apprehensive about surgery, urges us to delve into their subconscious, to connect with these patients on a spiritual, almost psychic level, in an effort to unearth a prophecy or kernel of self-prognostication. To complicate things more, this process has to occur in just a few brief moments, before the window of opportunity is lost. In time, our intuition can be honed to zero in on more subtle physical cues, like the lady who wouldn't stop crying. Sadly, we all dropped the ball on her. The adage, "I wish I knew then what I know now" aptly describes the unpredictable nature of the bodies and souls we care for, a constant reminder of the delicate balance that exists between these two entities, for they are intextricably intertwined. Like Sister Mary, we have to "see" our patients up close and personal, and listen hard to the intuitive cues they're sending our way. They may just be sitting "on hold" with Fate.

You're Going To Be Just Fine  (a related post on why I never tell my patients "you're going to be just fine.")
Premonition of Death in Trauma: A Survey of Healthcare Providers (downloadable PDF)
Physicians Are Talking About: A Death Foretold

1 comment:

  1. Just as Dr. Raymond Moody has changed the world by getting people to take NDE's seriously, and to LISTEN to patients with respect, the empathy to listen to them pre-op is supremely important. Thanks for sharing these incredible experiences! And another thing--all turds ought to be unwrapped Baby Ruth bars!