Sunday, September 23, 2007

A Loss Of Innocence

A classic cartoon from The New Yorker shows a man attempting to fix a flat tire while his confused son peers out of the automobile’s rear window. “I’m sorry, but this is real life,” reads the caption. “We can’t change the channel.”

Several months after September’s terrorist attacks, many of us still recall the horror and anguish we felt – not only at what we were watching on the news – but upon realizing that there was no way for us to change the channel and escape the harsh realities of those tragic events. The bitter irony, of course, is that in those moments, the kind of hypermasculine action-adventure scenarios that Americans so fervently embrace as escapist entertainment suddenly lost their power to excite and amuse. Instead of looking at special effects that had been doctored with CGI scripting, we were watching real airplanes flying into real buildings, killing real people with real explosions. Instead of watching Hollywood stuntmen jump from the twin towers of the World Trade Center, Americans witnessed real people falling to their real deaths in desperate attempts to escape being burned to a real crisp.

In a sudden, unexpected moment of history, the traditional television viewer was transformed into a horrified voyeur. Many did not like the feeling. But for people who work in the medical field, such harsh realities come with the territory. Unlike the carefully edited story lines on E.R., Scrubs ,or other hospital dramas, real life is messy. Good people die horrible deaths and, at times, there is no justice. Nor is there a calculated break to ease the dramatic tension with cute commercial messages from the sponsor. Life goes on. People need to be cared for with as much clinical precision as possible. What makes so many hospital dramas popular is that there is a never-ending source of seemingly unbelievable human interest stories to drive their plot lines.

Some of my favorite transcribed reports over the years have focused on:

  • The frightened woman who brought her obese child to the ER because the daughter kept complaining of excruciating stomach pains. Although the mother insisted her daughter was a virgin, it was obvious to the physician that the baby’s head was already crowning.

  • The illiterate Mexican man who sought out the services of a witch doctor in Tijuana, only to be given a “magic potion” which made his entire body turn green. Somehow, he managed to drive all the way back to the Bay area before his family could convince him to go to the Emergency Room.

  • The hysterical woman who was brought to the ER after being found wandering naked on a downtown street (but who was eager to be released from the hospital because she had a temp assignment that Friday).

  • The retired cowboy who insisted on having a portable commode in his hospital room so that he could sit by the window and watch the traffic.

  • The retarded pregnant teenager who had been pushing little plastic boats into her vagina so that her baby could have some toys to play with before it was born.

Each patient brings a story with his medical record and, for many medical transcriptionists, the drama offers a vicarious thrill to one’s professional calling. While many transcriptionists enjoy the challenge of working with difficult accents, researching new terminology, and acting like an armchair Jessica Fletcher in search of a diagnosis, the human element of each patient’s situation has a particular effect on transcriptionists. The impact varies depending on the type of report.

  • H&Ps can be great entertainment. In some cases they provide the narrative and setup for a challenging medical case that may include a fascinating history. With some patients, there is an amazing story to be told that, were it not for issues regarding a patient’s right to privacy and the confidentiality of medical records, could easily provide fodder for the tabloids.

  • Like H&Ps, consultations appeal to the amateur detective in the medical transcriptionist who is curious about the course of treatment and eager to learn how to nail a difficult diagnosis.

  • Operative reports have a very methodical rhythm, meticulously describing a journey in and out of the human body. Certain types of surgeries feel like “search and rescue” stories with instrument counts. Ironically, heart transplants are often made to sound like glorified exercises in plumbing.

  • Discharge summaries can, of course, be the most interesting. Not only do they provide a full narrative, they offer a sense of closure to the transcriptionist – a feeling of having accompanied the patient on a hospital adventure and returned the patient safely to his family upon discharge.

There is, however, one report type that catches many medical transcriptionists off guard. The first time an MT transcribes a death summary is a perversely voyeuristic rite of initiation. And nothing in the training to become a medical transcriptionist prepares someone for the emotional impact that a death summary can deliver when the patient is either an infant or a young child.

While some MTs will complain that they cannot transcribe therapeutic abortions because the procedure violates their religious beliefs, putting the finishing touches on a death summary has a curious way of taking the wind out of your sails. The first time it happened to me, I had to stop work, walk away from the computer, and go the bathroom to break the mood before I could resume transcribing. It may be easier when the deceased is an elderly patient who suffered through a long terminal illness (I recall one patient who was admitted twice a week to the same hospital for months on end). But the sadness of the moment tugs at your soul when the patient is a child.

Interestingly enough, in classic Greek dramas, the onstage gore was kept to a minimum. A soldier, or some messenger from the gods might arrive to explain how a hero or villain had met a particularly gruesome death. Even in a play like Oscar Wilde’s Salome, when thePrincess of Judea triumphantly tricks King Herod into giving her the head of John the Baptist on a silver platter, audiences know that the severed head is a stage prop. It is the words the playwright gives the title character that reveal the depths of Salome’s depravity to the horrified onlookers in Herod’s court.

Because they have such a unique power, words can exert an incredibly strong grip on people with large vocabularies. That’s where transcribing a death summary becomes a curious experience. The transcriptionist is not present at the actual death. Nor must the transcriptionist witness the blood, gore, shrieks of agony or gurgling gasps for air that might accompany a patient’s death. Those assaults on the senses are shared by physicians and nurses.

What a transcriptionist hears are merely words – words which can create such a haunting image that the transcriptionist may not easily forget the situation. I recall a particularly grisly murder/torture/child abuse case in which a teenage youth was viciously attacked and sadistically tortured (often in front of his younger cousin). The deceased was frequently beaten with a belt, pots, plates, and spoons. On some occasions he would have chili sauce or chili powder poured into his eyes and over open cuts. On other occasions he would be forced to eat his own feces -- as well as dog feces. If he complained or misbehaved, he might forced to kneel on raw rice on the kitchen floor while five-gallon water jugs were placed on his back. Or he might be forced to lie in a bathtub filled with cold water and bags of ice for 15 minutes at a time.

One day, his torturer wrapped the power cord from an iron around his neck and, using it like a noose, lifted him up off the floor while insulting him and telling him that he was going to die (the coroner’s report stated that the young man eventually expired from asphyxiation). When the teenager finally stopped breathing, his body was left to rot in a junkyard.

What kind of monster could do something like this? His mother.

Often, in a crisis, you will see people act according to three distinct patterns of behavior. One group becomes helpless and hysterical. A second group-- even if paralyzed by fear -- can become very docile and obedient. The third group miraculously swings into action telling those in groups 1 and 2 “You get on the bus. You grab her hand and go over there.....” They are the rescuers, the strategists, the people who can see through the panic and gore to establish priorities and execute a clinical course of action.

There is, however, a fourth pattern of behavior and I think that most medical transcriptionists usually fall into this category. These are the people whose professionalism makes them understand that the their skills are needed and that the crisis at hand is not about them. Their job is to keep doing what they do – and do it as accurately and professionally as they can under the circumstances. It is in those key moments that hospitals and MTSOs must rely on the intelligence and language skills of medical transcriptionists, for there is no time to worry about whatever emotional baggage may have accompanied them to work.

When transcribing such gut-wrenching reports, it is important to remember that medical transcriptionists must sometimes function like news anchors. We don’t make the news. We merely document it. While a story may have a severe impact on us emotionally (witness Dan Rather’s teary-eyed appearance on the David Letterman Show shortly after the World Trade Center tragedy), our job is to deliver an accurately transcribed report. Whatever rage and sadness we experience must be tempered with empathy for the deceased so that, if no one else gave the patient a break in life, at least some anonymous medical transcriptionist can try to respect him in death.

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