RECIPROCITY

 “What is tolerance? It is the consequence of humanity. We are all formed of frailty and error; let us pardon reciprocally each other’s folly – that is the first law of nature.”Voltaire

Just as there many facets to the lives we live so are there many facets to human emotions. Hospitals are multifaceted; in one room a family is celebrating a new baby who has been born, news of a full recovery of a family member while in the adjacent room, a family is grieving for they have lost a baby/pregnancy/parent/partner. You get the gist, right? The common denominator is a healthcare team trying to manoeuvre all this simultaneously while not wishing to display the roller coaster of emotions they might be going through. This leads to mental, emotional and physical fatigue. To cope most health workers find some really dark humour in unpleasant situations.  What some organizations and people outside our field forget is that we are humans with real emotions. We get angry, we get sick, we get frustrated, we get sad and we get overwhelmed among other emotions and feelings. We are human beings with emotions and blood running through our veins.

A couple of years ago I received a 4-year-old girl as an emergency while working in the Emergency department. Her eyes were jaundiced, her abdomen very distended, her skin very dry and itchy and when she cried there were no tears. For us that meant she was very dehydrated and whatever health issue she had grossly affected her liver. The team was all hands on deck and we did all we could but unfortunately, she never made it. The child's mother was informed and when I took her to view the body, I got overwhelmed. My throat felt tight, my eyes became glassy and I felt faint so I got a colleague to stay with her and quickly excused myself. I needed to step away immediately. I went to the farthest room I could find and tried closing the door not sure if I fully did and just cried my heart out. You know the ugly cry we all experience every so often. My heart felt broken I just couldn't make sense of it all. It was a hectic shift so as we cared for the emergency other outpatient patients continued to stream in. I must have stayed away for quite some time trying to compose myself when I had someone walk in. I was still whimpering behind the curtains and so I was quickly approached. It was a friend and he just stood there reassuringly periodically asking how he could help. I did regain composure and I walked out ready to face the next patient. I went back to the nurses' counter and the first thing that happened was a middle-aged man approaching me asking "Are there no doctors and nurses to attend to me just because of a so-called emergency." I was so irked but as expected I didn't reply as I wished. My generic response was" Apologies for the delay you will be attended to soon." As he existed we had a quick chat and educated him on what the ED is all about and what it means when a special code is called out.

It was a night shift so the next morning I analyzed the events and realized that both patients and health workers want to feel heard and appreciated but there's occasional ignorance in both parties to a large extent. For hospitals, a lot of emphasis is placed on short turnaround times but often it is not a common reality due to various factors within and beyond human control. Other times it is a very unhealthy mantra which states that a patient is always right. For patients, it is the belief that health workers should always be stoic.

 So how can we do better for the sake of humanity

1. Build awareness among those around you

Have TV monitors/pamphlets displaying basic information that's relevant to the patient groups at hand. 

2. Manage expectations

Language is a tool we often dismiss yet it can break or build relationships. Talk to the patients don't dismiss them, keep updating them. Institutions should have a program that serially educates personnel on better communication among themselves and with patients.

3. Keep evaluating institutional values and policies

There is a lot of value in having staff who are well cared for and prioritized. Physical, mental and financial support goes a long way to making staff feel valued and that's the perfect recipe for the provision of quality care.

4. Stop being self-centred

It's not always about you . There is more to life than you as one person 

In conclusion, “An individual has not started living until he can rise above the narrow confines of his individualistic concerns to the broader concerns of all humanity.” Martin Luther King Jr.

UNFILTERED

 "Your transparency will lead to other people's transformation."Trent Shelton

If there is one excellent lesson life is teaching me is that life is a journey, not a destination, wisdom does not come with age and in some instances, even the most intelligent person can be a dumb***. Yes, you read that right! Life has a way of evening out the playing field and I see this in my everyday practice. Wondering what I am going on you will understand as soon as you read through this post. 

As a young nurse( young is relative) I was always fascinated by patients who presented to the hospital with complications from poor treatment and lifestyle adherence to managing their previously diagnosed conditions. To give more insight here are a few examples a patient on TB treatment who had deteriorated to treatment failure directly as a result of noncompliance, a hypertensive patient who ended up with a hemorrhagic stroke because after diagnosis they stopped treatment when their symptoms abated,etc

I was well educated but relatively naive to the school of life so I had a very utilitarian way of thinking when it came to chronic illness. In my mind you got sick, you got diagnosed you got healed or you managed to maintain your quality of life. Well, this was how I had been. I have had my fair share of hospital visits by this time and honestly ninety percent of the time I tried to follow through. Notice that I said ninety percent. So one time I asked one of my then patients what hindered him from drug compliance and let me tell you on this day I learnt a lot. This then led me to be asking these questions what are the challenges you are experiencing with treatment or with the diseases that are currently under management.

I
would write a whole essay on this but here are a few examples.

1. Costly drugs or recommended treatment modalities 

While in placement in a rural facility, I met an elderly lady who had been diagnosed with hypertension. She had used medication for a month but then stopped because she could not afford her treatment unless her children catered for it. However, they were also unemployed so that was presently an impossibility.

2. Lack of understanding of the prescribed treatment

Still, on the aforementioned lady, she thought the medication she had been prescribed was for a few months and was only to be taken when she felt her blood pressure was elevated. This for her was whenever she developed blurry vision or swollen legs.

3. Limited knowledge of the implications of the disease process to their everyday life

One time I met a patient who had developed severe anaemia during pregnancy and she never followed up on her appointments. On delivery, she was in severe heart failure. She reported that she didn't know anaemia may lead to such severe symptoms or complications.

4. Stigma and discrimination

A young lad in his first year at the university campus was always in and out of the hospital with diabetic ketoacidosis. On his third visit, he revealed to me that he was experiencing challenges administering his insulin in a timely manner because he was often around his peers and was previously taunted when he administered it in their presence.

5. Unavailability of the drugs

Despite the development of an essential drug list by MOH patients always decry of medication unavailability.

6. Lack of continuity of care

One time a middle-aged lady with irregular bleeding told me she didn't know she was supposed to be reviewed after the completion of treatment. On her return visit the bleeding had been ongoing for about a month non-stop as she was waiting to see if it shall get better as it was not as heavy as when she sought treatment.

7. Personal preference

A patient once came in with a failing liver because he got diagnosed with an infection and he preferred herbal supplements as an alternative to the medications prescribed. 

8. Infomation overexpure

Often we find patients or caregivers who have a lot of information but not necessarily the correct treatment information. For instance, a young female presented to us with a history of irregular menses on further probing I learned she had using combined oral contraception to change her cycle dates as per need for over a year.

9. They felt disconnected from their care providers

An elderly patient shared with me that he has a challenge using medications prescribed by anyone younger than his sons. His youngest son was around forty at the time. He reported that the provider was always either on his computer and hence felt the provider was inexperienced to give him quality care. Unfortunately, on following up I learnt he had not been informed it was a paperless facility and he had never been in one.

Now before you draw assumptions it's important, to be honest. I find it challenging complying to treatment. I am very diligent at my worst but immediately I start feeling better I am more inclined to skip a dose now and then and at times even stop treatment prematurely. Being a health worker doesn't make me immune to this challenge as I  become more transparent on this I'm learning that guarded exposure to patients can help them make better decisions and do better for themselves,. So if like me you are trying to be a better health provider learnt to ask obscure questions. Life is like a coin. pleasure and pain are the two sides. Only one side is visible at a time. But remember the other side is waiting for its turn.

If interested to read materials around this area look up the resources below

Faronbi, J. O., Faronbi, G. O., Ayamolowo, S. J., & Olaogun, A. A. (2019). Caring for the seniors with      chronic illness: The lived experience of caregivers of older adults. Archives of Gerontology and            Geriatrics, 82, 8-14. https://doi.org/https://doi.org/10.1016/j.archger.2019.01.013 

O’Donnell, A. T., & Habenicht, A. E. (2022). Stigma is associated with illness self-concept in     individuals with concealable chronic illnesses. British Journal of Health Psychology, 27(1), 136-158.     https://doi.org/https://doi.org/10.1111/bjhp.12534 

Sarker, A. R., Ali, S. Z., Ahmed, M., Chowdhury, S. Z. I., & Ali, N. (2022). Out-of-pocket payment for     healthcare among urban citizens in Dhaka, Bangladesh. PloS one, 17(1), e0262900. 

IT IS WHAT IT IS

“It’s not like I planned it. I never woke up from some rosy dream and said, “Okay, world, today I’m gonna spaz.” Shannon Celebi

A few years ago a female patient was brought in unresponsive. She was a high school student who had passed out during the second term final examination. According to the teachers, she just saw the examination paper and fainted. First aid was done but there was no response hence the teachers thought it best to bring her to the hospital for further evaluation. Our initial physical assessment was unremarkable. Her vital signs were all within normal ranges and when one tried to assess her pupils she would forcefully shut her eyes. Our immediate conclusion was hysteria. Was it an appropriate diagnosis? I will let you be the judge. After about an hour of observation, she immediately got up. You must be wondering what worked? Well, a cotton wasp laden with chlorhexidine was brought to her nostrils and immediately she got up.  This response assured us that she was in good health and hence she was discharged back to school with a prescription for better exam preparations. However, this marked the beginning of her frequent ER visits and it always coincided with the exam period.

The fourth visit prompted the need for a psychiatric consult and after assessment, she was taken in for psychotherapy and commenced treatment. According to her records, she is yet to turn up at the ER again and her final diagnosis was documented as Conversion disorder. 

So what is /hysteria? 

Hysteria broadly refers to a patient responding disproportionately emotionally to the situation at hand. It was scraped from the DSM  and in its place terms like dissociative and somatic disorders were introduced. Dissociative and somatoform disorders have been linked to patients who have experienced or witnessed trauma in some way eg physical, emotional, or sexual abuse (Verywellmind, 2022,Williams et al., 2020)

1. Dissociative disorders are further divided into;

• Dissociative amnesia, which involves forgetting personal information or not being able to recall certain events
• Dissociative fugue, which involves forgetting personal information combined with changing physical locations, sometimes creating a new identity in the process
• Dissociative identity disorder, which involves having two or more distinct personalities, each with no memory of what the other has done

2. Somatic symptom disorders -  involves having a significant focus on physical symptoms such as weakness, pain, or shortness of breath. This preoccupation with symptoms results in significant distress and difficulties with normal functioning. This includes:

• Conversion disorder (functional neurological symptom disorder)
• Factitious disorder (Munchausen syndrome imposed on one's self)
• Illness anxiety disorder (formerly hypochondriasis)

How do such patients present? They may present with one or a combination of the following symptoms (Verywellmind, 2022)

• Blindness
• Emotional outbursts
• Hallucinations
• Histrionic behaviour 
• Increased suggestibility
• Loss of sensation
• Being in a sort of trance
• Developing amnesia
• Experiencing paralysis
• Fainting or passing out (syncope)
• Having epileptic-like seizures
• Increased pain sensations
• Rigid or spasming muscles

Handling such patients requires patience and an acute sense of awareness of the possibility that there's more than what meets the eye (Levenson., 2023). Their symptoms may be very different from what is stated above. Presently there is an advent of many traumatic events. There are ranging from gender-based violence, civil unrest in different regions, deaths from emerging and emerging diseases, natural disasters etc It is our role to recognize and refer where we can. Often we act as a gateway to the quality of life our patients will get and hence we should choose the best. For most people, it is not a choice for them to present as the above patients. So be kind and keep your biases aside. It doesn't hurt to have several differential diagnoses, remember "there is a crack in everything, that’s how the light gets in."  Leonard Cohen.

References

Best Documentary. (1946). Let there be light. https://youtu.be/lW4E-MxFI_w

Levenson., J. L. (2023). Somatic symptom disorder: Assessment and diagnosis. https://www.uptodate.com/contents/somatic-symptom-disorder-assessment-and-diagnosis

Verywellmind. (2022). What Is Hysteria? https://www.verywellmind.com/what-is-hysteria-2795232#toc-what-is-hysteria

Williams, S. E., Zahka, N. E., & Kullgren, K. A. (2020). Somatic symptom and related disorders. Clinical Handbook of Psychological Consultation in Pediatric Medical Settings, 169-181.