A Day in Casualty

May You Be Well And Happy

This article is available to download

Summary

A reflection on the Dhamma through the eyes of a doctor in the Emergency department of a large city hospital.

Content

A thirty-eight year old man walked into casualty the other night, just after I had commenced my shift, complaining of a sudden, severe pain in his back between his shoulder-blades. He said it was so bad that it caused him to writhe around on the ground in agony, unable to gain any relief, and vomit quite profusely. His only previous contact with doctors had been for problems with high blood pressure and manic-depression, for which he regularly took a number of medications.

When I came to examine him my initial impression was that he was unwell, that there was indeed something wrong. His blood pressure I noted to be different in each arm, though stable, and I discovered he had a heart murmur, something he had not been told he had previously.

Putting all this together, I was concerned that he may have been having an aortic dissection. This is a rare, frequently fatal condition which is caused by blood from the aorta the major blood vessel leaving the heart which supplies the rest of the body with blood entering a tear in the inner layer of the aorta. Because this blood is under high pressure it causes that inner layer to split from the outer layer, and an abnormal cavity is formed. With continuing high pressures that cavity enlarges and begins to track along the length of the aorta. Eventually, branches arising from the aorta, including those which supply the brain, become involved and their ability to transmit blood is severely impaired. The effects of this need little explanation.

I organised some tests for the man, who was continuing to have very nasty bouts of pain. An X-ray of his chest was normal, as were a number of blood tests I ordered. I consulted my superiors, who agreed that the man’s condition was a concern, and telephoned one of the on-call specialists to ask him to come in and perform a CATSCAN on the man. In over 90% of cases like this, a CATSCAN will tell whether an aortic dissection is occurring or not. The time by this stage was about 03.00, and the radiologist had to be convinced to come in the middle of the night! But come in he did, and about an hour later we had the result – normal.

At this stage I could easily have said “enough”, and brought the man into hospital for observation. Luckily for him I didn’t. My suspicion that there was something seriously wrong with him, far from being quelled by the normal CATSCAN, was still burning.

I phoned the on-call physician at 05.00 and related the story and my concerns to him. He agreed that further investigation was warranted and that the patient needed to be transferred to a better- facilitated hospital. I arranged an ambulance to take him to the nearest such place, where there was a more elaborate X-ray facility and, if needed, heart surgeon available.

The next night I received a message from that hospital, telling me that the man had had an aortogram (a special type of X-ray that enables the inside wall of the aorta to be visualised) on arriving, which showed that he did in fact have an aortic dissection. He went straight into the operating theatre and had open heart surgery to correct the abnormality. His life was saved.

I relate the above account to illustrate the lessons I learnt from the experience. On a gross, medical level, the importance of placing greatest weight in one’s own clinical, or subjective, impression was highlighted. Had I not listened to the patient himself, to my own physical assessment of him, had I been distracted too much by the findings of the CATSCAN and other tests and not heeded that “sixth sense” that told me he was unwell, he almost certainly would have died.

In medical jargon this is called relying on one’s “clinical acumen”; that is, that more, and more valuable information can be gained through one’s direct experience than from any purely objective source. Of course that is not to say that that which is obtained from the exterior is of no use. The medical knowledge which I had obtained over many years of study at university enabled me to assemble the pieces of the puzzle my “direct experience” of that patient presented me into a sensible form, from which I could postulate a diagnosis and act accordingly. Without that knowledge the “direct experience” would be lost, its significance unrealised. A mathematician, for instance, despite the best of intentions and many skills for doing much good in the world, would not have had the ability to deduce the seriousness of the man’s condition. Likewise, I would have had no hope teaching the man the finer (or even grosser) points of chaos theory – but, then again, this would not have saved his life!

The point is that these two types of learning, experiential and intellectual, complement each other and make the desired understanding far more profound. The acquisition of Dharma-knowledge is no different. The Mangala Sutta highlights the importance of developing an intellectual framework for comprehending the Dharma: “Patience, obedience, sight of the Samanas and religious discussions at due season – this is the Highest Blessing.” The Buddhist Texts and their translations and commentaries are present in abundance to this end, and the necessity and immeasurable benefit of preserving these and related resources is evident. But no amount of theoretical knowledge can gain one True Wisdom – make the correct diagnosis, as it were. Only direct experience, or insight, can do this, and meditation is the vehicle for realising these.

Yet not any old meditation will do. There is in western society at present a burgeoning ‘meditation industry’, as people turn away from traditional sources of comfort and security in their never-ending quest to make sense of and be at peace with this world. In our papers every day are advertisements to this end, and many dedicated and genuine people are behind the movement. Please let me say here that this article in no way intends to slander, denigrate or offend those involved. On the contrary, all beings dedicated to the alleviation of others’ suffering are worthy of the highest praise and encouragement. But the Buddha Path is clearly laid out and part of it is “Right Meditation”.

Let us return to the casualty department to illustrate the point. In most casualty departments there is a continuously frantic air. Patients moan and groan, machines whirr and go “beep”, ambulances howl in and out, and doctors and nurses rush about from one sick person to the next. When I was attempting to diagnose my patient that night this was exactly the case, yet when taking his history and examining him I had to block out these distractions if I was to help him to the best of my abilities. To do this I made a few adjustments to the environment, drawing the curtains around his bed (also providing a little privacy) and switching the light on to better focus on him. When he was speaking I did my best to concentrate on his words and gain as much insight into his symptoms as possible. In western medicine this aspect of the doctor-patient interaction is given the most importance. Finally, when examining him my attentions were directed fully to gleaning the maximum information from his body. When I placed my stethoscope on his chest to listen to his heart, for instance, and heard a faint, though definite murmur, I had to bring my hearing consciousness to the very forefront of my mind in order to distinguish the murmur from other types which could have had quite different consequences in terms of the diagnosis. Had, at any of these stages, I received an incorrect view of what was actually occurring the potential for disaster (in terms of my patient’s well-being) was high. Fortunately for him and me I have been lucky enough to have received good medical teaching.

The parallel with “Right Meditation” is that, while there are many ways to use a stethoscope, to draw out the analogy, there is only one that will make the correct diagnosis. While many beings offer many ways to freedom from suffering, only the Buddha and His Path guarantee it for all. Like a glass of dirty, muddied water, there are some methods that will still the water and let the mud settle, but the real secret to always having fresh water is to remove the mud. The Buddha outlined the way to do this and it is up to those who are interested to seek it for themselves.

Mark Shakleton