MEDICAL MAL-PRACTICE: A CASE STUDY

© 2015 
Krystiane Cooper, LCSW, RPT-S

The narrative below is a scenario that is all-too-familiar for trauma survivors treated in medical settings.  Consider this story and the medical literature that follows.  What can the medical profession do to improve awareness in this critical area of patient care?


Today was interesting.  I'm on my own with the kids for a few days.  I had arranged for some sort of acid-reflux related procedure at the local hospital with my new ENT (all singers have one).  Anyway, I carted the kids down to the doctor. 

We blithely made our way to the ENT suite and were promptly met by my doc.  Kids had to stay in waiting room (anxiety rose).  Nurse took vitals -- my BP yesterday at my GP: 102/70.  Today at ENT: 118/90.  Hmmm.  This was BEFORE I knew anything about the procedure.  I'd had vocal cord scopes before, so I figured it'd be no big deal.  ERROR. 

So I casually asked the nurse to explain the procedure, which is called, as you may have already guessed, a TNE. Yup.  A trans-nasal esophagoscopy.  So, I immediately started to half-joke with her that I was having images of GTMO. She laughed nervously.  My anxiety continued to rise.  Enter random 21-year-old med student.  All smiles, my doc walks in, has me sign a release, blah blah blah. 

I continued to make jokes, because that's my thing.  Hospitals make me absolutely batty, so I do the stand-up routine just to manage the anxiety (I joked my way through 3 childbirth experiences, and one of them was a c-section).  I HATE being a patient in a hospital (home is another story:  give me a bell to ring and a steady stream of peppermint tea, oatmeal, and cable TV).   Yeah. 

Nasal anesthetic, uncomfortable.  Next, the spray on the cords.  Fine, but bitter.  Last drug: some awful capsules which I was required to break between my teeth, suck out the liquid, and spit out the remaining capsules.  Picture a combination of Bill-the-Cat and Calvin making a face.  That was me.  But still joking through it.  Doc started to insert the scope into my nose, and though I'd done something similar many times before, I started to panic when I realized the scope was, like, 4 feet long. 
 
Got it through the nasal passage -- again, uncomfortable, but ok.  As the doc started to push the scope down and attempt to get past the glottis, I had a tremendous gag reflex.  Mind you, I hadn't eaten or had anything to drink for 12 hours, so I wasn't going to puke, but you get the idea.  Some people have a very strong gag reflex - but the doc continued to push - my head naturally jerked backward, and the doc instructed Junior Doc to hold up my head and push it forward.  Panic.  I reached out for the nurse's hand and squeezed it as tightly as I could. 

A little background here for you:  I have what is generally referred to as a "trauma history."  You know, perhaps, that trauma survivors often have a very difficult time with dental & medical procedures?  This is usually because the body stores traumatic memory in not only the brain, but in the muscles that were activated by the fight-flight-freeze response to the trauma, and were flooded with near lethal levels of adrenaline and corticosteroids.  The near-shock reactions cause a re-wiring in the brain (at not only the synaptic but also molecular levels), such that the brain responds in the same way to a similar reminder of the trauma (a "trauma trigger") as it did to the original event.  You know all of this, right?  “Shell-shock?”

Clearly, the forced instrument nearly in my esophagus, combined with the forcing down of my head and neck by two men in positions of power?  Yep.  Triggered.  I began to cough and gag, my head was pounding with pain, tears streaming down my face, nose running.  I could not understand, let alone follow the doctor's directives to swallow, fill my cheeks with air, or breathe normally.  My eyes were squeezed tightly shut, I dared not open them, even when directed to do so.  I started to hyper-ventilate, shake, and cry.  I said, "I can't" to every request.  When my eyes did open, they pleaded with the nurse for mercy.  I was about to pass out.  I started to pray, but could not form words, even in my mind.  (Another fun fact: when the brain is under tremendous stress, it is essentially cut off from language. The all-too-familiar "silent scream" is clinically referred to as "speechless terror.") After what seemed like an hour (probably 15 minutes) of tortured struggle, the doc relented.  He told me he'd try again another time when I could be sedated.  

I felt like a failure!

He removed the scope, and I continued to gag, cry, whimper, and shake.  He asked me to wipe my face, which was soaked with tears, sweat, and snot.  Once done, the cheap-o tissues had left shreds of paper all over my face.  He sent me to the sink to wash it off.   As I began to stand up, my legs still shaking, I realized something quite mortifying.  I had lost control of my bladder.  Yup.  Peed my pants out of fear and survival reflex.  I hadn't even realized this had happened.  I had had no awareness of anything but helpless fear.  Classic trauma response.

Thankfully, in addition to having not had anything to drink for 12 hours, so there was no evidence on the treatment chair; I'd worn a large long-sleeved t-shirt on top of a short-sleeved one.  Since I was also still sweating like a dog, I quickly took off the long shirt and wrapped it around my waist, hoping none of the adults in the room had seen the results of my absolutely overpowering weakness.

Made my way to the sink, washed my face several times with the industrial grade sand-paper towels.  As I continued to cry, feeling absolutely terrified and overwhelmed, I said to my doctor: "Are you familiar with the Sanctuary model?"  Blank stare.   I explained briefly that it was a trauma-informed model of care.  "Oh yes, we see a lot of trauma here in this hospital," he replied, then naming various injuries seen in medical "trauma centers."  No, no, I said, "Not physical trauma.  PTSD trauma. That procedure was very triggering, as I imagine it might be for many trauma survivors.  If you had asked me on your consent form if I had a trauma history, you'd have realized I’d definitely need sedation to get through that procedure." 

More blank stares.  No connection.  I wiped my face again, thanked the nurse, and quipped to Junior Doc that I'd presented that performance just for him, for educational purposes.  A chuckle. 

I went out to find my kids - all greeted me with concerned faces, as I continued to cry in dramatic chokes.  We walked together to the bathroom, where I attempted to re-group.  Elevator.  Walk to the garage.  Elevator.  My 9-year-old son all the while asking what had happened, adolescent daughter totally quiet, but compliant; little one telling me it was going to be OK.  I told them the procedure didn't work, and that it was awful, but that my health was fine - I was just upset.

Got to the car, kids assembled around me, hugging and consoling me from all sides.  I kept trying to breathe, but the tears continued.  I tried to shake my head, hard, several times, to get rid of the images and sensations and feelings of the past hour.  No luck.  I leaned my head against the steering wheel and started the engine, turning the a/c on full blast.  I asked my oldest to turn on some music.  After about 10 minutes, I felt ok enough to drive home.  We left the parking garage and pulled into traffic.  I cried off and on the whole way home.

After we got home, I fed the kids and gave them permission to watch their usual hour-long allotment of TV.  I crashed on the couch for the entire hour, utterly exhausted.

I can only imagine what that procedure must be like for prisoners, people who have likely already been subjected to horrible torture, and are attempting to regain some sense of control by limiting their intake of food.

I feel calm now, as I write this from the safety and comfort of my living room, my children tucked into bed, and I am sitting in my dry and clean clothes, praying silently for those [victims of torture] I've never met.
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Afterword:  Here is the Columbia University explanation of this procedure.  Note no mention whatsoever about traumatic reactions to it.

"An endoscope is an instrument used to examine an interior part of the body. Endoscopes may be either rigid or flexible, and they have a light at the end that illuminates the area for visibility. During transnasal esophagoscopy (TNE), a thin, flexible endoscope is inserted through the nose and down the throat in order to gain view of the vocal folds, larynx (voicebox), esophagus, or other structures of the throat. Patients do not need to be sedated before undergoing TNE. Superthin transnasal endoscopes are now being tested and appear to be superior in several ways, including being better tolerated by patients and more cost effective. Because intravenous sedative medication is not required before TNE, the risk of complications is lower than with conventional endoscopy. The most common complication associated with TNE is nosebleed. [Emphasis added by this  author. - KMC]
 
This was a conference description: 

"Proper patient selection, sedation needs, and necessary equipment will be reviewed. Videotapes will reinforce lecture materials. Teaching models will provide hands-on experience in using the gastroscope. TNE training includes performing the procedure on volunteers."

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Clearly, the medical community has some work to do in educating both seasoned physicians as well as students in screening for ACES and possible traumatic reactions from patients about to endure invasive procedures.