Bedside Lessons – 16. Summer Flies By

Photo by Max Griss on Unsplash

I opened the curtains this morning and there was a little fly. These have become ubiquitous in the past weeks as we have entered New Zealand’s summer. This fly was doing it’s thing near my bedroom windows and despite still being bleary eyed I tried to catch it with my bare hands. Using my whole hand did not work, the fly was able to weave it’s way between my fingers. After a few flailed attempts, I decided to change my strategy. I would try and catch it between the index finger and thumb of my preferred right hand. I went to grab it, and made contact. The fly was stunned and landed on the window sill, I promptly threw it out the window. Little did I know that this series of events would lead to a communications breakthrough later in the morning.

There was a tension in the room as we walked in. The patient was having suctioning done, but from the sounds of her breathing the fluid that needed to be cleared was deep in her main airways. As people near the end of their lives they are less able to cough, and so a tiny amount of fluid can pool, and these can result in a rattley sounds produced on breathing out. Just like when you are drinking something through a straw, at the end of a drink, a tiny bit of fluid can make a lot noise. The same occurs at the end of a life, a bit of fluid vibrating in a deep airway can be noisy, it probably doesn’t bother the patient so much but can be a source of distress to their family members, and even clinical staff.

The adult children, all of whom were parents themselves, were attentive but all looked scared with deep concern etched on their faces. Their beloved mother had been well up until only three weeks ago. Then a large brain bleed had come out of nowhere, rendering mother unconscious. Off to hospital, with many invasive procedures completed but no significant improvement obtained. The doctors and nurses had tried everything they could, but the patient remained unresponsive.

The family were told that their mother/grandmother was dying, but it took a while to sink in. It is usually hard enough to visit sick loved ones in the hospital, let alone during strict Covid-19 lockdown conditions. A very distressing time for the patient and her family. Their mother who had brought them up well, who was the beloved grandmother to their collected 7 children, was not going to be alive much longer. They hated to see her in such extreme distress, and were trying to help, but really did not know what to do.

Communication was crucial but to begin with the emotional temperature in the room was icy cold. An icebreaker was required as it was difficult to establish any rapport with the patient’s children. The patient herself had not been able to speak or respond for some weeks. Even using our mutual second-language, Mandarin Chinese, I had trouble connecting with the distressed family.

Something must have noticed and sent along a little helper, through the window. A fly was flitting around the patient and we tried to swot it away, but it was persistently dodging all attempts. I readied my special index finger and thumb technique that had served me well this morning, I was primed and ready to strike when the air in the room was disturbed by a whooshing sound.

What do I have in common with the folk I am about to communicate with? That’s the question that I ask myself all of the time. How can I find common ground with them? I deal with a lot of different people in my job. I deal with people who are about to die, some of the most unwell people on the planet and their families. What do I have in common with them, how can I highlight the similarities in a helpful manner? I will test them with exploratory questions. I have pushed them gently at times, as I often am checking out their responses to my act of assessment. What can I do to connect with this stressed out family who are losing their mother?

I had never seen a human move so fast, his hand flashed by, quicker than I had run to the Staff Christmas Dinner table last night when I was ravenous. Another two swipes and he had locked onto his target, triumphantly catching the fly that was an unwelcome visitor to his dying mother.

“I caught a fly myself this morning,” I told him. “If I’d known you were that good, I would’ve got you a pair of chopsticks to use.” It was hard to tell as we were all wearing masks but I thought I could see a trace of a smile in his eyes as he laughed at my comment. The tension of the moment had been broken and then we were able to talk more freely. I introduced myself again, and told them where I grew up, where my parents were from. Which part of Asia my family was from, which part of China we had all originally been from. I discovered that our patient was also a member of the Hakka people of China.

Rapport was established and I was able to properly communicate with them. That death was imminent according to the clinical signs we could see. The breathing pattern of the dying was explained, the rapid breathing, then slow breathing, slowing right down to a pause. The pauses would become longer and longer as someone approached death. I explained that this was what happened in the dying person, that I had looked after many people over the past 14 years in similar situations, and my staff and I would be drawing from our experience in order to try to do the best for their mother.

We made some changes to her medications and I promised that I would reassess things later on in the afternoon.

Lesson learnt:

Summer time with flies everywhere, the next time I see one I will try to let it go, as the two little visitors I received today led to an useful conversation. The family understood what was going on their brains, but in their hearts it would take so much longer to let go of their beloved mother. We all agreed that we did not want her to suffer, that we would like her to be as relaxed as possible.

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