Accident. Accident?

Mrs. K. J., 53 years old, with a fractured arm. A simple accident, I thought, and felt reluctant about the long internal, social and psychological anamnesis I had to record. What do we need to know apart from the fact that she has fallen on it, and look thoroughly at the X-ray? But duty won, so I started.

The accident happend on January 29^th, 2004, when she slipped on a frozen puddle of water late at night. She hit her arm on the corner of the house, then fell on the limb, and she probably suffered a cerebral concussion, because she woke up lying there maybe some minutes later. She felt dizzy and her arm ached, so she walked into the house, wrapped the arm into a wet towel, took a bunch of pain killer pills and went to bed hoping that the pain would ease until the next day.

It did not. So she called the driver at the firm she was working for, and asked him to drive her to the emergency department of the country hospital at 6. “It was important to get there early,” she said. “Consulting starts at 7 : 30 and I didn't want to wait too long.” After she was examined, she called her doctor friends with her left hand, so the X-ray could take place as soon as possible, and to ask about the reputation of the surgeons to choose the best.

This composure surprised me, and I was wondering unbelievingly: in such a situation, things like that would not occur to me. When I mentioned this, she answered with a small smile that she had always been such a determinate person. All right, her ways may be a little aggressive. But she did not want herself to be served, and did not push others with more serious problems aside, she says defensively.

What is the reason for this determination? I learned that she lived alone. Her husband works out of town, he only comes home on weekends, and even then he is more like a guest than real help. Her children have moved away. If she does not care for her business, no-one does, she says a little uneasily, but with a touch of defiance in her voice. She is holding a manager's job, makes lots of decisions there, starts early in the morning and often leaves her workplace late, often drops in on weekends as well. She plays an important role in holding the family together, makes parties, cooks, buys presents, goes for a visit, helps wherever she can, gives many advices. Her roles are mixed together: she is the chief in the family as well.

I imagine how it would feel to return to an empty house every day, and begin to understand why she spends so much time in her workplace and with the family. If my closer family would tear apart, it would be important for me to feel needed and helpful. This could help me feel complete in my private life and help me ease the guilt about my inability to hold the family together.

My suspicion is confirmed by the fact that she only mentions the physical and mental absence of her husband and children accidentally, and then quickly changes the subject, but speaks easily about her aunt, nephews and granddaughter, who she had often taken care of before the accident. During these moments her face lights up, her back straightens, shows me about how the girl likes to lie in her lap, but then her sight catches her arm, or the pain starts, and her face darkens, she looks like a sick woman again. She has seen her granddaughter rarely since the accident, because her daughter cannot drive and taking the baby for a visit would be difficult. It is not her daughter's fault, she says and quickly changes the subject.

There is one more thing on my mind, so I ask her: why did not she call someone in her family after the accident, or at least the other morning to take her to the hospital? Why ask a colleague instead? “They couldn't have helped anyway,” she answers. “So why bother them?” Her daughter should have stayed at home, and her sister and friends had to go to work. Her husband was on the way home. Only when she learned that she needed an operation did she call the family, and her husband even later, to keep him from causing an accident.

I feel admiration mixed with pity. How good it is to care for others in such a situation! Still it is bad to be so unused to accepting help - or even turn it down when offered - that one cannot even ask for it when it is dearly needed. And she needed it then, and later as well: it warmed her heart when friends supported her, but when they asked “What can we help you with?” her pride won and she answered “Nothing, really.”

It may be a selfish thing, I thought, but in such a situation I would call my friends and relatives to feel their support, even if this would worry them. Because I think I deserve that much. Then it occurred to me: what if this patient, behind her determination and self-consciousness, struggles with a lack of self-esteem?

So the day after the accident the X-ray was ready at 10, but it was 2 p. m. when she took her place in the sick-ward. She tells me: “I was thinking how much time, worry all this must mean for someone who doesn't know how to get around here and has no connections. I was sorry for such people.” It strikes me that maybe people like her who have connections make the protocol so long for them. But she worked hard for her priorities, and takes them for granted. Her pity for them is from the heart. This makes me think about the double standards with which people judge themselves and others, and this becomes more obvious when they become sick.

The operation took place. She answers to my questions about the feelings she had afterwards: “I was glad that it was over, but afraid how I would stand my ground with this plaster on my arm.” She spent three days in hospital, she cared for everything about her, did not let the nurses do what she could. She also helped other patients, bringing a glass of water or calling the nurses.

Once again I felt admiration about her fortitude. I thought this may have been helping her to believe she would be able to hold on and be able to do the most important things afterwards.

She really needed that fortitude. Coming home she realized that she could not perform most of her chores with her swollen, hurting, plastered arm. There were other problems as well: she could not sleep at night for the pain, and in the morning sometimes it took her an hour and a half to get up, wash herself, dress and have breakfast, because she often had to sit down and rest for some minutes. She tells me with self-irony how it feels to have a shower with an arm in a plastic bag, twisted up against the wall when it hurts so and will not turn.

I can see the exasperation in her about not being able to perform the jobs that were so natural before and how exposed and prostrate she feels, although I can feel from her voice the will to be strong. This is the reason why she still goes to work every day, at least there she can talk and do some of the things like before.

I feel tempted to tell her to stay at home and rest instead, but I feel it in her posture that this is the only field of her life where she still feels complete. Just because medical books suggest a rest, this would make her feel more incapable and useless. “It hurts at home, it hurts there, too. I'd rather go to work.” This makes me realize how important it is to see the human being behind the sickness before a doctor starts giving out orders. We cannot use the oven-ready models for everyone, we need to take the patient's personality into consideration to decide what makes them feel better.

“I think about the people living with a disability often lately,” she says.

I feel that she is telling me unconsciously: it feels good to know that it will soon end; she will be healthy again one day. I am feeling a little ashamed at how little time we in the health care spend with giving patients hope, although this is as important for their well-being as lessening pain or restoring function. This thought is confirmed by her telling me how much she was looking forward to the iron rods supporting the bone being removed, so on 23^rd March, almost two months after the accident, she persuaded the doctor to do it a week before planned. “That metal thing wanted so much to come out.” And who is a doctor to argue, I think with a smile.

But the operation, counter to her expectations, does not ease the pain, but because of the surgical intervention it becomes as severe as after the accident. Two days after the removal she feels that this makes her feel even worse, because then it was expected, but now she hoped for a better change. The same organic problem causes a much more serious mental strain when it is not expected, and she feels that her hope about being rid of the pain is fading away. Behind this lies the fear that she will never again be able to use her hand like before, and although until now she has suppressed this apprehension, it comes forward with the lack of her fortitude.

And she mentions: it is good that I visit her now, she really needs a good talk. Although it seems just an accidental remark, I can feel it from her genuine smile that it means a lot to her that someone, if only a medical student and not able to heal her, listens to her, congratulates her fortitude and tells her to hold on. And I am glad that this “medical student-medicine” exists.

Because as she says it is not the pain or the incapability that are the worst, but their mental burden. And I feel that I may ease it a little.

And not only has my presence done this. Although to my question if she sees anything positive in her illness she answers a definite “no” with a surprised look, later on I learn that the accident showed her who the people in her life that she can count on are: her old aunt came without asking and they cooked together. “Although Aunt did most of the cooking, we talked a lot,” she tells. Her old friend dropped in with food enough for an army, and the fallen leaves from the garden disappeared because of the fairies from the neighbourhood. Her colleagues who had hardly ever let her go on a vacation before undertook her jobs and prevented the “catastrophe”. Her husband who never helped with the household before now comes home more often and even cleans up. Her son visits more frequently as well, and cares for her daughter and granddaughter. I recognize secondary gains of illness in these.

There are other good things about it as well. After not cleaning the house for a month, she decided to hire the cleaning lady her family had long been telling her about. “Formerly I could not imagine someone fumbling through my belongings.” I feel that although she denies it, she wanted her beautiful and clean house to be her own work entirely. But the cleaning lady was useful, and they even have nice conversations sometimes. “I think I'll have her help with the more difficult things like cleaning windows later as well,” she says. The accident made her realize how much she needed help, and gave her a reason - maybe an excuse - to accept it while her pride stayed intact. Her attitude is also changing: she does not run and clean every microscopical piece of dirt she finds. “I realized I cannot sacrifice my health for my job and my house.” To my question asking if this means she will slow down she answers - after a short period of hesitation - yes. I think she is telling me: “Maybe. I will try.” And I hope she will succeed.

The primary gain of illness is in my opinion that - although she complains about her inability - her burdens lessened some and now she is happy to sit on the couch for a while. Before the accident, she had not been able to remain still. “Tonight there is no cleaning, no visits, and no work!” She claims, smiling.

I ask her what she explains her illness with. She agrees that it has something to do with her intense way of life, but she is not sure what the connection is. After my next questions, she reluctantly mentions the lot of stress she had in her workplace last summer, and that then her daughter moved to her fiancée, a choice she did not quite agree with. Her husband changed his job about that time, and he got home rarely and exhausted.

After the mental, emotional and physical efforts, the object loss (she saw her daughter and husband less often), it does not surprise me that short afterwards her menstrual periods ended and she was diagnosed with a nodule in her thyroid gland, which was then removed. This turned her hormonal balance upside down, which made her tired, and she had to catch up with the work that accumulated during her stay in the hospital. Her granddaughter was born, and she spent too much of her strength caring for her.

As a result, she did not have time to have the drain repaired, or clean up the puddle from the corner of the house, she did not see the ice when late at night, her head full with the concerns of the day, she was hurrying home from work. She slipped and broke an arm. In the development of the osteoporosis the menopause and the hyperthyroid state before the operation could be important factors.

I had to see that in case of such an “accidental” occurrence as a broken arm, psychological reasons and stress can play an important, maybe a decisive role, and lead to a series of not evident, but explorable clinical events.

Talking this over with the patient can help her look out for her health a little more, and achieve a better physical state earlier.

“I just want to hold my granddaughter in my arms again!” she says in a sad voice. This and regaining her ability to perform as before seem to be the most important to her.

And when she becomes healthy again, maybe she will be able to appreciate the things that she took for granted before. Maybe she will take more care of her health. And maybe she will be able to accept the help of those who were by her side through her illness, and with their physical and - maybe even more important - mental support played an important role in her recovery.

This interview taught me a lot of things about myself and others. I learned that it might be more important in what posture and with what kind of tone the patient talks than the words themselves. I realized that behind confidence and composure insecurity may be hiding.

Many times the patient will not talk about important things in her life (like her closer family), because the thought is painful for her, and she speaks about strangers more willingly.

I realized that from her hints I can guess what she expects from me and the health care system, and sometimes I can help a lot by explaining some details, showing support, or giving hope.

I realized that the patient treated me unalike through different parts of the interview. When she talked about the bureaucracy, waiting too long and being handled without care, I felt that she considered me a part of the system, and a person to be challenged. This provoked me to close myself to her views and think “Why does she think she has the authority to censure us? She does not know what she is talking about!” and I unwittingly felt part of the community she handled me as a member of, loosing my empathy. When I realized my mistake, I forced myself to open up again and realized that her criticism stemmed from her fears. When I could feel with her, she also opened up towards me, handled me more like a member of her family and reminded me of my parents (they are about the same age) instead. I recognized the transference and counter-transference in our feelings and behaviours.

Throughout the interview many, sometimes quite antagonistic feelings passed through me: awe, pity, disbelief; sometimes I listened to her quite critically. I think she awoke positive as well as negative feelings in me, but I can even accept her excessive determination and tendency to give orders because I know that the difficulties in her life called for them, and these forms of behaviour were taken up to defend her. Although she is a person who is probably a difficult patient, her fortitude, presence of mind, unselfishness with her family, great mental power are traits which make me esteem and admire for her. I feel like that although I will try not to drive the ones I love away from me, I would like to be a little bit like her as well: quick to act, in control of myself and my home, devoted.

And I hope to have many such encounters with patients from whom I can learn so much, and hope that they can learn a little from me as well.