Sympathy card?

[epsilonprodigy]

On call last night, saw an unspeakably horrible trauma which completely ripped apart a young family. We were all extremely affected by it. In situations like that, is it appropriate to send a sympathy card from the team to surviving family members?


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[Winged Scapula]

On call last night, saw an unspeakably horrible trauma which completely ripped apart a young family. We were all extremely affected by it. In situations like that, is it appropriate to send a sympathy card from the team to surviving family members?


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Your hospital trauma service may have a case manager that handles such things.

While I understand your desire to send something to the family, in cases with bad outcomes I might inquire about the appropriateness with risk management. Depending on the state you're in, expressing sympathy can be seen as a expression of guilt.

 

[epsilonprodigy]

Huh, never thought of it that way. Unfortunately this situation has declared itself before patients' arrival, but I suppose you never know how anger and grief could color someone's view.


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[PTPoeny]

I don't know how the law varies by state but my ICU sends a card with condolences from all the doctors and nurses to the family of every patient who passes away here. So it may be appropriate depending on where you are, and is definitely appreciated by many families as we get cards back expressing their gratitude for the condolences. Where I did residency one of the ICU docs would go to the funeral of every patient who died in the unit as well.

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[Winged Scapula]

I didn't mean to imply that it was inappropriate or wasn't appreciated but rather there may be hospital policy about the content of these things when they're sent as a representative of the hospital.

Almost every hospital sends these as a matter of SOP. I have been told that the content can be somewhat regimented so that statements like, "I wish we could've done more" are not misinterpreted.

Going to funerals or other ways to express sympathy to the family of a patient you've had a long term relationship with is common. This sounds like a case of "came in dead, stayed dead" where that would be a bit unusual.

Lastly, I know the OP is having a difficult time emotionally with surgical internship. So much so, that many of us have told you of our misgivings when you contemplated it as a student. It sounds as if it's not getting better for you.

 

[epsilonprodigy]

Like I said, this was a fairly unique situation, but I agree that in the absence of a longer term period of acquaintance, it would be unusual to attend funerals. (Neither my coworkers nor I had any intention of doing this.)

Regarding the comment about "emotional difficulty," only Hannibal wouldn't have had a hard time with this one. I would deem my reaction appropriate and equivalent to the other staff and residents involved. (I.e. Able to go back work immediately and shift focus, but had to acknowledge that this was one sad situation, even more so than most.)

Regarding things like meltdowns in the OR, flagrant verbal abuse and using retractors as projectiles-yes. I continue to have a "difficult time emotionally" tolerating that sort of thing but that's a horse of a different color.


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[Winged Scapula]

Like I said, this was a fairly unique situation, but I agree that in the absence of a longer term period of acquaintance, it would be unusual to attend funerals. (Neither my coworkers nor I had any intention of doing this.)

Regarding the comment about "emotional difficulty," only Hannibal wouldn't have had a hard time with this one. I would deem my reaction appropriate and equivalent to the other staff and residents involved. (I.e. Able to go back work immediately and shift focus, but had to acknowledge that this was one sad situation, even more so than most.)

I think you're reading too much into my comment or perhaps I wasn't clear as I was dictating my response while doing something else.

My comment about funerals was in response to the user above who commented that his ICU attending would attend them. I merely mentioned that it would be appropriate in that setting, but not yours. I was not implying that you were planning on attending the funeral.

I would have no way of knowing whether your experience was one "only Hannibal wouldn't have a hard time with" but I'd venture that many of us here have seen something similar, even without knowing what it was. My comment was meant to convey to you that you see horrible horrible things in residency, especially in things like GS and EM and if this one was especially emotionally taxing, most hospitals would have a debriefing and offer counseling, free to charge, to all staff involved, including residents.

Regarding things like meltdowns in the OR, flagrant verbal abuse and using retractors as projectiles-yes. I continue to have a "difficult time emotionally" tolerating that sort of thing but that's a horse of a different color.


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Of course, but given that you have posted frequently about other things (that many of us did not find unusual or outside of SOP) and we have been concerned, since you were a medical student, that you would be emotionally able to handle a surgical residency, it doesn't seem callous for me to point that out and inquire about how you were doing. I was truly concerned that you were still struggling emotionally and I have to a admit I was wondering if the question about sending the sympathy card was more about how you were handling the trauma rather than the family.

 

[Birdstrike]

On call last night, saw an unspeakably horrible trauma which completely ripped apart a young family. We were all extremely affected by it. In situations like that, is it appropriate to send a sympathy card from the team to surviving family members?


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It's normal to have the impulse to want to do this, and shows empathy. It means you're human. But in ED and trauma situations, I've never known an individual doc or nurse to personally pen and send a card in this type of scenario. Although I don't work in EDs anymore, the outpatient office I now work in (multi-specialty) does send out a condolence card when a patient of the practice is known to have died, usually one of the primary care provider's patients, and the office manager sends it. In this setting, there is continuity of care and a long term doctor and staff to patient relationship, so it's more conducive to that. I'm sorry you went through this. I never got used to this stuff in my 11 years in EDs and trauma units, especially when I comes suddenly and unexpectedly to young people and families. It's hard, there's no doubt about it.


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[Psai]

Like I said, this was a fairly unique situation, but I agree that in the absence of a longer term period of acquaintance, it would be unusual to attend funerals. (Neither my coworkers nor I had any intention of doing this.)

Regarding the comment about "emotional difficulty," only Hannibal wouldn't have had a hard time with this one. I would deem my reaction appropriate and equivalent to the other staff and residents involved. (I.e. Able to go back work immediately and shift focus, but had to acknowledge that this was one sad situation, even more so than most.)

Regarding things like meltdowns in the OR, flagrant verbal abuse and using retractors as projectiles-yes. I continue to have a "difficult time emotionally" tolerating that sort of thing but that's a horse of a different color.


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Huh I thought throwing retractors wasn't a thing anymore with all the tjc people roaming the halls and administrators sitting at their desks

 

[Winged Scapula]

Huh I thought throwing retractors wasn't a thing anymore with all the tjc people roaming the halls and administrators sitting at their desks

Its not.

 

[hello1234!]

I may be in the minority here, but I for one think it would be completely inappropriate and bizarre for an intern on their own without direction from the hospital or their attending to send a letter of sympathy to the family in a trauma case that you only dealt with while on-call and where you didn't have a long-term relationship with the family.

 

[hello1234!]

But I should add that the fact you care so much is a trait I hope you never lose. *** I'm certainly not a surgeon nor do I think I could have handled the training. I like my outpt IM world.

 

[epsilonprodigy]

-I wish throwing things wasn't a "thing," but in my experience, it has been. Case in point: we currently have a bright blue keyboard on one of our computers to replace the one that an attending recently ripped off and smashed against a desk.

-I am unclear about why my response to this situation was deemed evidence of my supposed poor coping. The discussion about possibly sending some sort of acknowledgement was had between several staff members. This is also not my first rodeo- working in the PICU, ER and as a sexual assault examiner before med school, I saw my share of difficult situations. This is not to minimize the experiences of others, but rather to point out that my response wasn't born out of naïveté.

-Apparently there is a debriefing session scheduled, which I've never known this hospital to do before.

Just a bit more post call rambling. Actually my last- I have decided to delete my account. SDN has been helpful at many points, but too often, we all just end up ragging on each other. It's far too easy to get sucked into the negativity, which is the last thing anybody needs in residency. So, SDN-ers, goodnight and good luck.







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[AdmiralChz]

-I wish throwing things wasn't a "thing," but in my experience, it has been. Case in point: we currently have a bright blue keyboard on one of our computers to replace the one that an attending recently ripped off and smashed against a desk.

-I am unclear about why my response to this situation was deemed evidence of my supposed poor coping. The discussion about possibly sending some sort of acknowledgement was had between several staff members. This is also not my first rodeo- working in the PICU, ER and as a sexual assault examiner before med school, I saw my share of difficult situations. This is not to minimize the experiences of others, but rather to point out that my response wasn't born out of naïveté.

-Apparently there is a debriefing session scheduled, which I've never known this hospital to do before.

Just a bit more post call rambling. Actually my last- I have decided to delete my account. SDN has been helpful at many points, but too often, we all just end up ragging on each other. It's far too easy to get sucked into the negativity, which is the last thing anybody needs in residency. So, SDN-ers, goodnight and good luck.







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Good luck to you as you continue your training. This was a bad situation, but to be honest it is not uncommon in specialties that have a basis in emergencies (GS, EM like WS said above).

I know this is a stressful time, and surgery intern year can be brutal, but your exceedingly defensive and at time aggressive language makes me wonder if you aren't doing well with it. A GS residency absolutely is NOT for everyone, and changing to a different specialty if it comes to that isn't a sign of weakness it's a sign of maturity as you seek a better fit for your career.

Anyways, my point is don't be afraid of the advice of others. And don't trick yourself through difficult times.

 

[Winged Scapula]

-I wish throwing things wasn't a "thing," but in my experience, it has been. Case in point: we currently have a bright blue keyboard on one of our computers to replace the one that an attending recently ripped off and smashed against a desk.

-I am unclear about why my response to this situation was deemed evidence of my supposed poor coping. The discussion about possibly sending some sort of acknowledgement was had between several staff members. This is also not my first rodeo- working in the PICU, ER and as a sexual assault examiner before med school, I saw my share of difficult situations. This is not to minimize the experiences of others, but rather to point out that my response wasn't born out of naïveté.

-Apparently there is a debriefing session scheduled, which I've never known this hospital to do before.

Just a bit more post call rambling. Actually my last- I have decided to delete my account. SDN has been helpful at many points, but too often, we all just end up ragging on each other. It's far too easy to get sucked into the negativity, which is the last thing anybody needs in residency. So, SDN-ers, goodnight and good luck.







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In no way did I say this was evidence of your "poor coping". You've clearly mentioned before that you are struggling and I was merely inquiring and hoping that you were doing better.

Obviously I didn't communicate that better and I"m sorry but I'm not sure what more I can say as you seem intent on assuming that I am "ragging" on you.

 

[rokshana]

In no way did I say this was evidence of your "poor coping". You've clearly mentioned before that you are struggling and I was merely inquiring and hoping that you were doing better.

Obviously I didn't communicate that better and I"m sorry but I'm not sure what more I can say as you seem intent on assuming that I am "ragging" on you.

your communication was fine...and your clarification should have fixed anything...you probably just hit a nerve.

 

[Crayola227]

I think if someone really means to express concern and not risk shaming someone, doing so by asking about their welfare privately and not publicly is best, like by PMs

just a tip

 

[DrfluffyMD]

*

 

[Winged Scapula]

I think it's useful to be intouch with the more touchy feely side of medicine even in a procedural specialty.

My attending was impressed when I was able to talk the family out of getting an endograft to repair hemorrhage in a terminal cancer patient when pallative care couldn't. Meanwhile my partner is all like "another case is another case" in her surgical training.

I have also heard another surgery resident telling a patient "I am a surgeon, I cause pain" before doing a painful exam.

I really think a bit more humanity and emotion in a difficult situation can be useful, but I also recognize the common bond of surgical training, where even today, can occasionally frankly be abusive and to me as an IR trainee, that perhaps colored the experience of many surgeons.

For example, my partner has been told that expression of sympathy or emotion is a weakness in a surgical residency. I really don't think that should be the way and I tell my junior colleagues that since IR deal with many end of life scenarios, knowledge of pallative care and empathy is a must.

One of my life long goal is to change the way surgeons are trained by training IR physicians to share their clinical burdens and by training IR physicians to participate in the nonoperative aspect of procedural care such as clinica and consults. For example, IR residents can be trained to staff an initial cholecystitis eval and admit that patient since we have cholecystostomy to offer, sharing the burden of the surgery resident that would have dealt with that patient. Of course we will refer to surgery for elective cholecystectomy. IR started as a consult service, but I recognize that surgery have both operative components as well as nonoperative clinical components whereas the previous IR training only have procedural components. IR must become a primary specialty to survive.

Maybe then surgical trainees don't have to go home at 9pm everyday and can be a bit more intouch with their emotions because other procedural specialties are chiping in rather than dumping all admits on gen surg.

Apologies if this is a bit of a tangent.

I think you misunderstand (our) concerns.

Empathy is a valuable trait in a surgeon as patients come to as quite vulnerable and we have the ability to help them through the process. We were never concerned that the OP was too empathic to be a surgeon.

You must however, be able to separate yourself from the horrific things you see to be able to do your job to help people. Someone who cannot do that is ill suited to a career which can be high risk, fast paced and unfortunately, sometimes with colleagues and patients who are difficult.

As for your comments about IR, I think you know how surgeons and other clinicians feel about non clinical physicians diagnosing and managing clinical issues; this is not the appropriate forum for that discussion.

 

[DrfluffyMD]

I think you misunderstand (our) concerns.

Empathy is a valuable trait in a surgeon as patients come to as quite vulnerable and we have the ability to help them through the process. We were never concerned that the OP was too empathic to be a surgeon.

You must however, be able to separate yourself from the horrific things you see to be able to do your job to help people. Someone who cannot do that is ill suited to a career which can be high risk, fast paced and unfortunately, sometimes with colleagues and patients who are difficult.

As for your comments about IR, I think you know how surgeons and other clinicians feel about non clinical physicians diagnosing and managing clinical issues; this is not the appropriate forum for that discussion.

Point taken, but changes are coming. Agreed this isn't the appropriate forum.

 

[DrfluffyMD]

.

 

[Winged Scapula]

Please review the TG13 guideline for acute cholecystitis. In some scenarios patients would not be getting surgical therapy in an inpatient sitting. You should also review this guideline regarding whether cholecystostomy are "unnecessary" or not.

Oh my.

You might wish to understand your audience before you go referencing things that *aren't* guidelines and lecturing surgical fellows.

 

[DrfluffyMD]

.

 

[Winged Scapula]

I am sorry, just going by validated literature here. I happen to have experiences that suggest otherwise (early surgery isn't always better, despite what the recent surgical guideline maybsuggest) I don't wish to "lecture" a surgical fellow, but we should all work together and strive toward patient's well fare rather than holding on to petty interspecialty arguments.

Some patients do better without surgical managements, across multiple disease processes. Another big example is uterine artery embolization and the artificial slow adoption of that due to OBGYN's hold on their patients. The literature and evidence are there.

Again, I am signing off on this thread because this is irrelevant to the discussion. Please do not try the surgical hierachy crap on me as I am NOT a part of that and "surgical fellow" means nothing to me. I only strive for wellfare of our patients.

Your implication that only you (and by association, IR) strive for the welfare of patients is offensive. We all want what is best for our patients.

Surgery has become increasingly non-operative and surgeons, including myself are well aware of that. I recommend many fewer patients for surgery now than I did even as recently as 5 years ago.

I only mention that @SouthernSurgeon is a fellow to advise you that he has completed a general surgery residency and knows what he is talking about not because the hierarchy is important here. Pulling out an old guideline that doesn't prove your point isn't helping your argument. Cholecystostomy tubes have been around for ages and treating cholecystitis without surgery is hardly ground breaking.

Whether OB-Gyns are resistant to new techniques is irrelevant here. All specialities wait for data and proven treatments before forging ahead with something new.

But I do agree that this is not the format for such discussions.

 

[TraumaLlamaMD]

If I have a patient sick enough to need a cholecystostomy tube, that patient is too sick to be admitted to IR.

Aaaand closer to the original topic, I absolutely agree with SS here - IMHO, surgical attendings need to be prepared to field what I consider some of the most emotionally challenging discussions in medicine. Many family members and even other physicians see a long-shot ex lap in a dying patient as a risk that should be taken, because "why wouldn't you? He'll die if you don't" - it becomes our job to help them realize that in many situations the life quality gained after such procedures is not what they're hoping for. It's not that we don't want to throw a Hail Mary, it's that the end result is often not a touchdown but a prolonged ICU stay with little chance of independence again. Being able to communicate this reality to patients and family members in a way they can be at peace with is an emotional skill I really admire.

 

[DrfluffyMD]

I apologized if I offended any of my surgical colleague here. Will remove my previous posts here. Again, IR training is changing and we strive to manage our patient not matter "how sick."

 

[xffan624]

If I have a patient sick enough to need a cholecystostomy tube, that patient is too sick to be admitted to IR.

Aaaand closer to the original topic, I absolutely agree with SS here - IMHO, surgical attendings need to be prepared to field what I consider some of the most emotionally challenging discussions in medicine. Many family members and even other physicians see a long-shot ex lap in a dying patient as a risk that should be taken, because "why wouldn't you? He'll die if you don't" - it becomes our job to help them realize that in many situations the life quality gained after such procedures is not what they're hoping for. It's not that we don't want to throw a Hail Mary, it's that the end result is often not a touchdown but a prolonged ICU stay with little chance of independence again. Being able to communicate this reality to patients and family members in a way they can be at peace with is an emotional skill I really admire.

Had a case in medical school with an ex-lap for an abdominal bleed on a patient that was non-responsive due to a stroke and unlikely to recover. We did it because no one had taken the time to talk to the family about expectations and they wanted everything done. The patient's abdomen was so full of blood the surgeons there wished they had been wearing the high booties (I had put these on because of my previous OR experience had been in L&D) instead of the shoe covering ones. We were able to stop the bleeding and the patient was sent to a long term facility, still non-responsive. Came back a couple weeks later with an infection and he passed away. Can't help but feeling we could have just let him pass that day and saved the family some grief.

 

[Crayola227]

Had a case in medical school with an ex-lap for an abdominal bleed on a patient that was non-responsive due to a stroke and unlikely to recover. We did it because no one had taken the time to talk to the family about expectations and they wanted everything done. The patient's abdomen was so full of blood the surgeons there wished they had been wearing the high booties (I had put these on because of my previous OR experience had been in L&D) instead of the shoe covering ones. We were able to stop the bleeding and the patient was sent to a long term facility, still non-responsive. Came back a couple weeks later with an infection and he passed away. Can't help but feeling we could have just let him pass that day and saved the family some grief.

point taken, your question is a good one

however, you don't know if that would have saved the family grief and what sort of goodbye they ended up having with their loved one later

 

[xffan624]

point taken, your question is a good one

however, you don't know if that would have saved the family grief and what sort of goodbye they ended up having with their loved one later

Agreed, but I can't help but contrast it with a similar patient during the same rotation where the surgery attending took the time and sat down with the family and talked about the risk/benefits. We ended up not doing the surgery and letting the patient pass. To me, it felt more right. But I suppose some of that is personal preference. I'm in peds now, so not something I have to deal with too often, but it sticks in my mind.

 

[epsilonprodigy]

*sheepishly creeps back onto the premises.*


I apologize if I overreacted previously. Those who have observed that I am "struggling" are correct, and it has nothing to do with sad patient stories. I truly love surgery, but I am unable to adjust to or accept the behavior and culture of my program. Perhaps this lead me into some unfair projections.

I am starting to see what others have been saying. I'm in an awkward position- wondering if simply loving surgery is enough. I have grave doubts about my ability to develop into a competent practitioner in my current program. Some people seem to be able to use the "tough love" as a motivational tool, and it ultimately seems to fortify their confidence. This is NOT me. Call me a millenial, but if all I get is abuse and insults, I start to doubt my competence and waffle. Not to mention that I'm usually terrified to ask questions due to the responses I get. This makes me feel like I'm 100% teaching myself. If I keep plugging along, hopefully I can get myself through it and become "competent." But then, there are other fields that, while they may not light my fire like surgery does, I know I could be truly great at them. I look at my attendings and realize that there's hardly one I haven't heard someone talking **** about. With how terribly this environment has affected my confidence already, I don't imagine it would get any better after graduation.

As ERAS season is upon us, I feel that I'm at a major precupice. There are a few options I'm throwing around:

1) I have a background in healthcare (before med school.) I used to work at a teaching hospital in another (noncompetitive) specialty. Although I KNOW I could excel in this field (great personality fit, great success at work their, lots of background experience, etc.) I rotated at this institution as a med student and had stellar reviews. Still have great relationships with my old co-workers from there, including the PD, with whom I worked directly for several years. Sadly, I still pooh-poohed the specialty because I loved the OR so much. In hindsight, I think I'd actually be much better at this specialty, and could be just about as happy in it if I completed a fellowship after residency in it. I am seriously considering emailing the PD to see about coming back as a resident. Of course I assume he'd want me to apply through ERAS just like everyone else. He is a really nice guy, but I can't help worry that he'd see me as damaged goods even though we had a solid relationship.

2) There are 3 other specialties that I could see myself doing. Considering putting my feelers out to the PD's in these specialties at the program I'm currently at. I can't help but feel that I should pick one, though- it might look sketchy if I reached out to all 3 at once and then they talked. Advantage would be staying put geographically in my current location, which I'm not crazy about, but am at least "settled in."

3) Trying to switch to a more supportive program in general surgery. My concerns about this are: a) I was fooled once (everyone dies laughing when I tell them I was surprised to learn about my current program's malignant reputation, AFTER matching. Duh.) b) This is obviously extremely difficult to do.

Again, I acknowledge that I was acting rather poorly in the posts above. I am a bit more ready to listen at this point, and humbly ask for any input on these options.

Oh, and- apparently deleting an account isn't that easy for a computer "genius" like me. My thought at the time was, "I need fewer naysayers in my life, not more!" But then again, if all the naysayers are saying the same thing... maybe its worth listening to?

 

[Winged Scapula]

I'm glad you're back and admire the temerity that it likely took to do so.

Being sensitive to criticism is not only seen in millennials. I too struggled in residency and at on at least 2 memorable situations, told the person who was being verbally critical of me that I did not learn by humiliation. The F word may or may not have been uttered during one of those altercations. I'm not known as a particularly sensitive person but I cried at least every other day; sometimes due to sheer exhaustion, other times due to the criticism without any seeming interest in helping me improve or to understand how. Fortunately, I had my supporters who obviously outweighed my detractors but I get what you're going through. I really do even if I sounded harsh above, I was honestly concerned. Feel free to PM if you care to do so.

There are programs which are worse than others; I'm not sure if your friends LOLd about your current program because you should have known about IT or they were simply laughing, believing that ALL surgery programs are like yours. They are not but #3 is a tough road because the grass isn't always greener and it can be tough to convince a program to take you on without the usual reasons of "wanting to be closer to family" etc. (i.e., you can't say, My current program is full of jackasses and I want to leave").

Without knowing what the other specialties are and whether you could fashion a procedural based practice out of them, makes it hard to weigh in. Anesthesia attracts a lot of people who like the pathology of surgery, the OR environment and camaraderie, but don't need to operate or are happy doing procedures. At any rate, I'm not sure we can weigh in although in #1 above, you do fairly glow when talking about it.

In the end, I don't think loving the OR is reason enough. It does get better but it takes a very long time before it does.