Understanding the value of service

Ako Takakura ‘04
DHMC Emergency Dept


My Tucker Foundation internship at the Emergency Department in the Dartmouth-Hitchcock Medical Center was an 8-week, full time commitment to improve patient satisfaction in the Emergency Department. During the weeks I spent in/around the Emergency Department, I found that there are many issues surrounding patient care, such as quality of care, waiting times, staff’s compassion to patients’ needs—all of these interplaying factors culminate into a patient’s total experience at a medical institution. In addition to working closely with the ED staff and volunteering a few days every week at the Emergency Department, I was also given the opportunity to shadow doctors from various departments, as well as observe the working s of other major institutions within the DHMC hospital, such as David’s house and DHART, the hospital’s air response team. Motivated and inspired by the multitude of talented professionals, compassionate and committed individuals, and the colorful characters of the patients coming to seek help, my Tucker internship experience turned out to be an amazing, challenging, and thought-provoking 8 weeks that would undoubtedly remain engraved in my memory forever.

Volunteering at the Emergency Department and interacting with the patients and staff exposed me to many issues concerning patient care. For all the patients that visit the ED, regardless of their levels of injury or sickness, their situation is an “emergency.” Consequently, when a patient with a more critical condition is seen and treated before another patient with less urgent needs, the latter feels slighted and ignored. I cannot remember how many times I have been stopped by patients on a busy day who demand to know when their doctor was going to see them. At such times, it is crucial that the ED admission policies are clearly communicated to the patients so that they are well informed about their situation. It is indeed surprising how much better the patients accept increased waiting times so long as they are informed about the entire process. According to a Harvard Business Review article, which my supervisor, John Markowitz, recommended to me at the beginning of this internship, the privilege of having information makes a customer (i.e. patient) feel as if he/she has a choice in the final outcome (i.e. longer waiting time).

In most cases, this theory is extremely effective and applicable—however, frustration comes when theoretical notions fail to generate desired outcomes. For example, a nurse was dealing with an impatient family member, who wanted their son to be seen by the doctor immediately. After explaining the triage process, the nurse said, “I’m sorry.” The mother just turned her back and said sarcastically, “Yeah, I bet you are.” I have seen patients get really upset and start yelling at the staff. Because we are dealing with human interactions where nothing can be rigorously categorized or fully understood, there isn’t a defined protocol for efficient yet compassionate health care. Each patient comes from a different background, and each must be dealt with accordingly. I feel that this complexity and dynamic interaction of human relationships are the main reasons why I aspire to become a doctor in the first place.

Another important issue in emergency medicine is that of trust between the health care provider and the patient. Without the establishment of trust, the doctors are unable to give the kind of first-rate care the patients deserve. For example, one nurse recounted his frustration with a female patient because she frantically kept refusing to put on her wristbands for identification. Later he found that she had been sexually assaulted, and she had been handcuffed at the time. The lack of communication/information, a basis for development of trust, had prevented the nurse from delivering efficient and high-quality health care. However, it is often difficult to fully recognize the needs of a patient in the Emergency Department, since his/her visit is sporadic, short-term, and very often amidst the chaotic bustle characteristic of many emergency departments.

This is not to say that the Emergency Department is devoid of intimate human interactions, however. Despite the tendency to overlook the department as a drive-thru, there are definitely remarkable instances of strong connection between patients and staff. For example, the same nurse above mentioned received a hand-made “fan-mail” from one of his previous patients, telling him how grateful she was to have met a dedicated soul like him on that fateful day.

The issue of trust is also critical to other areas of health care. Dr. Bryan Marsh, my DPCS mentor, works at the Infectious Diseases Department as an HIV specialist. He frequently deals with patients on a long-term basis. As such, his profession requires a very intimate relationship with his patients—a process of longevity. He once told me, “You see them get better, or you see them die. Either way, you are with them all the way.” Observing Dr. Marsh on several of his clinical rounds, I see that he abides by his principle religiously—it is clear to see that his patients trust in him as a confidante and depend on him as a pillar of strength and knowledge. He can ask a patient the most personal and intimate questions without offending or making a patient feel uncomfortable. His love for people is apparent in the friendly hugs, his gentle tone of voice, and the heartfelt goodbyes. Not only does he oversee his patients’ medical needs, but Dr. Marsh also appears to be truly concerned about their overall well-being. His patients sense this genuine warmth—that is why they trust him.

Dr. Marsh reminds me of William Carlos Williams in The Doctor Stories. In this autobiographical novel, Williams renders an honest depiction of life as a doctor through a series of experiential accounts. Through his scrupulous observations of patients, the readers learn how Williams as a physician thrives on the intimacy of his relationship with patients. Dr. Marsh evidently shares William’s love for humanity.

Similarly, human compassion exists in many facets of the day-to-day operations of the Emergency Department. One cannot pass an entire day without witnessing the tenderness of a helping hand. The sound of cheerful laughter is a constant presence in the workplace. I believe that in a traumatic and frenzied environment such as the ED, the warmth of personal contact is highly essential for the upkeep of morale of the staff and quality of care. One entry in my daily journal is revealing of how people seek comfort from one another in times of pain and solitude:

“Today I met an old man who had been admitted to the ED for an internal brain hemorrhage. He sat in a large resting chair right by the entrance to the TRAUMA room. The nurses had placed him there so that they could keep close surveillance over him…As I passed him on my linen rounds, he stopped me with a “Young lady” and a dejected stare.
“Help me,” he said. “I’m dying.” He was struggling to get out of the chair that was restraining him.

The charge nurse asked me to sit with him and make sure he wasn’t going to escape from his chair that held him captive. He could otherwise topple out of the chair and suffer a hip injury, or worse.

So I sat in front of him, patting his back softly. I was pained to notice the disparity between my young, healthy hands and the wrinkled, purple flesh underneath. But somehow I took comfort in the thought that each wrinkle represented a story from his bygone days; perhaps he was a wild man in his youth, perhaps he had a beautiful wife, perhaps he had children that once kissed a soft, grizzly, manly cheek. Then these lines were no longer ominous signs of death fast approaching, but triumphant landmarks of his
life—proof of his existence.

“Oh, Lord,” he muttered, interrupting my thoughts. “Can you help me, dear Lord.” He suddenly reached for my hand, which I gladly extended towards him.
“I’m going to die.” He said again. This time he looked at me straight in the eyes .
…But all I could do was squeeze his hand…”

After a while, I wrapped a big blanket, fresh out of the blanket warmer, around his tiny frame, whispered “Take care, Mr. C,” and left the room. It was frustrating to suddenly realize the limitations of my ability to help others. I felt so useless and awkward. However, now that I look back, there was not much else I could have done. I was glad to have shared a moment with this elderly man, but I was left wondering, did I really give him some moments of comfort?

My supervisor for the internship, John Markowitz, encouraged me to become increasingly aware of patient’s needs and made me consider how I could serve others in my capacity as a volunteer and as a fellow human being. He taught me that even a simple thing like offering a shivering, elderly patient a warm blanket makes a significant difference in his/her experience at the ED. John has had extensive experience working in the Emergency Department; as a volunteer for many years, then as a patient-care technician, and eventually as the Emergency Department management assistant (?). His easygoing, affable sense of humor seems to put many patients at ease. He utilizes his previous experience as the Acitvities Director at Eastman to improve patient care in the Emergency Department.

It does not take long to realize the astounding depth of John’s dedication to this mission. He is constantly coming up with new and creative ideas to further develop the patient care system—installing volunteer carts in a very accessible location so that both staff and visitors may find the volunteers easily; providing giant checker boards and picture books in the waiting room, etc.

I worked with John on the development of a protocol listing of duties a volunteer could help with in the Emergency Department. The aim was to shift volunteer priorities away from manual duties, such as stocking linens and supplies, and towards close interaction with the patients. Just by striking up a friendly conversation with a lonely patient or family member, or being available for general questions or services, a volunteer may be of great service to both the staff and the patients/family/visitors.

Volunteers themselves feel more gratification with direct contact with the patients—I remember how much I enjoyed spending time with the little children that were admitted to the hospital, or those whose parents were being treated at the ED. I often recall with a chuckle the one day I had to change a 2-year old’s dirty diapers! Or the time a little 5-year old told me matter of factly that his arm injury was “about 3 miles down his elbow.” During the eight weeks I worked as a volunteer, some of the fondest memories are the moments I spent with the patients/family members whose lives have never before crossed paths with mine—I truly felt like I was part of the local community, and I felt as though I had successfully ventured out of my tiny bubble of a community called Dartmouth College.

I also worked with John on the Press-Ganey Emergency Department Assessment Survey, a national survey conducted every 6-months to rate the quality of service of each Emergency Department. There were many things I learned from patients’ comments on these surveys; both the good and the bad. I realized that patients’ sensitivities are at their peaks in times of immense pain or trauma, and they feel an increased need for compassion and care. One of the most prevalent complaints tended to be the lack of empathy or considerate attitude from staff members towards patients’ pain and suffering: For example, “Dr. X didn’t take my problem very seriously.” Correspondingly, one of the most commended attributes of the staff was their congeniality and concern during treatment: “The nurse was very polite and seemed to really care about me.” Thus, no matter how competent a staff may be in terms of medical knowledge/ability to treat a patient, the final impression depends upon the staff’s personal qualities and social manners.

At DHMC, there is a myriad of talented and dedicated professionals all working together to provide high-quality healthcare. The Emergency Department is composed of skillful and committed doctors, nurses, technicians, and administrative staff members. However, the ED is only a part of the greater institution—I was fortunate in having the opportunity to meet people from other departments as well. One day I visited David’s House, a cozy home away from home for children admitted through CHAD, the children’s hospital at DHMC. Here I met with wonderful, caring staff that told me many stories about the sweet little children that had stayed at the house. Another day I went on a ride-along program with DHART, the hospital’s air response team. I followed the nurses, the respiratory therapist, and the pilot on a thrilling helicopter ride to a remote country hospital, where a man had suddenly suffered from a heart attack. I also shadowed Dr. Harper and Dr. Marsh on their clinical rounds at the OB-GYN clinic and the Infectious Diseases clinic, respectively. On my last day as an intern, I accompanied the Patient Care Committee to Albany, New York to observe and learn from other Emergency Departments. It was amazing to meet so many devoted people striving together to make DHMC a better place.

My DPCS internship at DHMC was an invaluable experience, exposing my mind to various social and moralistic issues prevalent in present-day society. This non-profit organization and its people helped me realize the value of service and humanitarian outreach programs. I was especially glad to have a close, intimate encounter with the residents of the Upper Valley community, and to have met so many people at DHMC with so much heart. As Dr. Marsh once told me, “Doing what I do, you may not make the kind of difference that alters the lives of millions; but at the end of the day, I get my gratification from knowing that I have touched the lives of a few.”