ON EMPATHY

ON EMPATHY

It’s important to get all of my prejudices out on the table. And being an admitted alcoholic bears no relationship to my own sense of hopelessness, depletion, exhaustion and yes, disgust when I have been required to take care of alcoholics during my stints as a resident many years ago. And then when I was out in private practice, this was replaced by an overwhelming sense of helplessness when alcoholics would ask if I could help them to get sober. I never learned how to do that. My initial training was only geared to “tuning ‘em up and getting ‘em out”.

Francisco was  twenty four when I first saw him in the emergency room more than thirty years ago. Through repeated admissions for the same diagnosis, decompensated liver disease, I got to know him pretty well.

He was a handsome guy, with a fine physique, well muscled and a winning smile when he wasn’t all tanked up and bloated with fluid retention from his diseased  liver. Twenty four and he had liver disease that caused him to accumulated fluid in the abdomen which we call ascites.

Ascites is the serum part of the blood  that gets exuded into the abdominal space as a result of the normal osmotic shifts of fluid. And each time Francisco (Poncho, for short) was admitted, his abdomen would have achieved such distended proportions that the fluid would push up against his diaphragm decreasing his ability to breathe. So he would be admitted for shortness of breath and acute liver failure until we could stabilize and then discharge him.

It became almost a ritual that for the first few hours of Poncho’s admission to drain a few liters of fluid out of his abdomen just to make him more comfortable, make it easier for him to breathe and to decrease the chance of him coming down with a hospital acquired pneumonia. And in the meantime we placed him on fluid restriction to reduce his fluid retention, give him good food, vitamins and especially vitamin K to prevent him from  vitamin K deficient bleeding disorders that attended his liver disease. And I dwell on this aspect of Poncho’s care because that is the kind of care that I could give him.

Each time he came in. Every 2 to 3 months.

And with each admission, the level of emotional involvement of the nursing staff of the emergency room (and me, to be sure)would drop. His admissions and reports would become “routine”- his admitting history and physical would be “routine”, and the empathy quotient for him dropped until he became a cipher, a boring copy of himself, an annoyance even. For Poncho never got better.

Because we could never treat his real problem, just his acute problems, which sooner or later we would be unable to treat at all. His trajectory would ultimately lead to acute pancreatitis and death, or acute heart failure and death, or cirrhosis and death, or portal hypertension and finally death. And that death would come sooner rather than later.

What of AA or a Twelve Step Program? Well what of it? Thirty years ago I was only vaguely  aware of it except to know that AA was for drunks; and I was as ill informed about AA as anyone else; for I believed that this meant that AA had active drunks in it. So why would I send a hopeless alcoholic patient to AA?

I’m sure that part of my ignorance was self willed because even at that early time, when my drinking was quite under control, I still had my concerns that perhaps I liked my wine a bit more than the rest of my peers.

My point is that as Poncho became a regular, our familiarity with him wore thin. We got tired of him, less tolerant of him and his treatments became like a revolving door. And although his care was not at the expense of anyone else, the services spent on his behalf were legion.

During my time there alone he probably racked up more than two hundred thousand dollars in hospital expenses in 4-6 admissions (in 1978 dollars).But Poncho’s wasn’t the most devastating case of alcohol abuse that I took care of.

Sam was a forty-five year old accountant who was as affable as they come. A family man, he had success written all over him – Until one day when he started to vomit up coffee ground blood. And then he had runny black stools. And before you knew it, Sam was vomiting up lots of red blood and he was rushed to our hospital and admitted to ICU where he was endoscoped and found to bleeding esophageal varices.

Varices are like varicose veins of the esophagus which result from the buildup of pressure in portal venous system which drains the liver. The chronic ingestion of alcohol causes scarring of the normal tissue of the liver as it tries to metabolically detoxify the alcohol that is ingested. The scarring causes the blood to back up from the liver to the esophagus causing the swelling of the veins around the esophagus. Any minor trauma or sudden rise in blood pressure can cause fatal GI hemorrhage.

Even nowadays, with improved treatment, it often takes heroic efforts to stop such catastrophic bleeding and save the patient. In the 1970’s these methods were just being developed.

Not in time for Sam, however, and he died from circulatory collapse from the acute blood loss.

I felt badly about Sam. Was that because he was white and middle class and not a young Hispanic  or was it just that in him I imagined that I saw a reflection of myself; and if this disease could take out Sam, then perhaps I should  have some guarded concern for me?

But true alcoholic that I was, I waved away danger with the flick of hand.

Time has passed and of course I am one of the lucky ones, here with my diagnosis, alive and intact and my health still preserved. No major crises or hospitalizations… yet. But I still wonder about that notion of mine and my colleagues’ ebbing empathies about treating chronic relapsers. I always had the notion that seeing so many drug addicts and alcoholics just depleted all the stores of feeling that I had for their suffering. They just seemed not to want to get better.

At  a meeting in the rehab center I brought up this inconvenient and uncomfortable truth to the group who seemed to think that they could continue to be brought to busy emergency rooms, either strung out or actually OD’d on some drug or alcohol and command the attention and sympathy of the medical staffs. I tried to warn them that even the most empathetic of medical caregivers can shrug at the hopelessness of the situation and finally become inured to the pain that is out there. It is a protective mechanism for them.

 And as they do not know that I am a physician, my news may not have carried as much impact as it might have, had I revealed my profession. But I said that if they did not wise up to the fact that repeated visits to the ER can result in the battle fatigue of these staffs, then they had no right to expect the unwavering compassion from people who do not understand the way they think, the way they act and what they are doing to their minds and bodies.

I was roundly criticized for this and deemed to be “non empathetic”. And perhaps this might not have been the wisest news to present to patients in the first few days of their detoxification or recovery from substance abuse or from being brought back from a suicide attempt or accidental overdose.  This is, after all, a sensitive time for them.

But reality is reality. And within days, they are going to be thrust out into that real world; that uncaring, uncompromising, cold and critical and un-empathetic world.

Perhaps they should understand that they might pull the overdose stunt just once too often to pray upon the sympathies of those in whom they entrust with their care.  And who could blame someone for thinking that sneaky, insidious, almost frigid thought of “why should I care for someone who has so little regard for himself? ”

© res 8/8/2011