July/August 2001
HEALTH BYTES

Ritual healing, healing ritual
By Marc Ringel, MD

      He came to see me one morning because his belly hurt. That night he was dead. Though it wasn't his intention, this man taught those of us who cared for him in his last moments much about how ugly death can sometimes be and how to make ourselves stronger for having faced it. 

      He had seen me once before and I hadn't been able to do anything more than any of the multiple other doctors he'd consulted about his chronic pain. He took many drugs and still, day after day, he woke up in pain, spent his waking hours in pain, and went to bed in pain. Some days were better than others. But none went by without lots of hurting. He was depressed, an expected result of a life defined by physical pain.

      When he consulted me on the day of his death, his chief complaint was abdominal pain. To be sure, his legs, the source of his chronic misery, hurt too. But this day he had a new discomfort in his belly. I examined him, ordered blood tests and an x-ray. I concluded that his belly hurt because he was constipated, a common complication of the narcotics he'd been taking for the condition in his legs. I addressed the constipation and refused his request for increasing the narcotics to dull the hurting in his abdomen, explaining that more pain medication would only make matters worse.

      The last words I heard him speak were, "But doctor, I'm in pain. What are you going to do about it?" I had no answer.

      The next time I saw this man he was laying in a pool of blood. He'd rung the doorbell at the emergency room in the middle of the night. An aide accompanied him to the ER. On the way down the hall he apologized. She wasn't sure for what. Then he sat down on a gurney, pulled a small caliber pistol out of his pocket, and shot himself in the temple.

      The aide fled the emergency room, screaming for help. The registered nurse and respiratory therapist on night duty ran in to find the patient slumped over, bleeding from his head. They called me at my apartment. It took me about five minutes to motivate from dead sleep to dressed and on my feet at the bedside. I took my position at his head.

      A mask over the patient's nose and mouth delivered oxygen and an IV line brought him fluids. He had wires attached to his chest to monitor his heart rhythm and a tube through his penis to drain his bladder. An automated device checked his blood pressure every minute while another continuously monitored the oxygen level in his bloodstream. All the tubes and instruments told us that the systems that keep a body going were still functioning.

      But he never said another word; never even muttered or groaned; never moved a limb. His pupils were fixed and dilated. There was good reason to suspect our patient was brain dead. Nevertheless, we called the Air Life helicopter and did what we could to keep heart beating and lungs expanding and contracting.

      Another nurse arrived, as well as a respiratory therapist, the chaplain, the director of nursing, and a city policeman. The nursing director busied herself mostly with the two aides who had been on duty, young women who were pretty freaked out by what they'd just experienced. The extra RN helped out in the ER while keeping her other eye on our few inpatients. At one point the cop responded to a patient call light and went down the hall to help an elderly patient to the bathroom because the nurses were tied up.

      After what seemed like an eternity (actually about 40 minutes) the helicopter arrived and relieved us of our charge, whose condition had changed little since I'd first laid eyes on him on that gurney. Most of us staff stayed in the emergency room to clean up. The wall behind the gurney was sprayed with the blood, on the floor was a big puddle of it. There was debris everywhere: clothes, packaging for sterile instruments, supplies, bandages. It took us about an hour to return the area to a state such that the only physical sign left of the disaster was a faint reddish-brownish smudge on the painted wall.

      I slept a couple of hours in a hospital bed. Later that morning, after change of shift, all of us who'd been involved in this grizzly incident sleepily retreated to the hospital conference room where the chaplain led a discussion, called a debriefing, about what had just happened. We took turns talking about how we were feeling. "Numb" was the word most chosen.

      Late morning, a call came to our nursing station from the intensive care unit at the hospital that had received our patient. A CT had shown his brain damage to be far too extensive to allow for any hope of recovery. The patient's family had decided to turn off the machines that were keeping his body alive and he died soon thereafter. Finally, he had no pain.

      The wall was repainted. Still, whenever I walked by the emergency room and looked in I saw the gurney and my mind recreated the whole bloody scene.

      I'm a seasoned doctor, with decades of experience. Over my career I've seen untold amounts of gore, pain and blood. But something about this episode got to me enough to send a chill down my spine every time I saw the place where it had happened. 

      A security consultant was called in. He suggested many improvements in our safety procedures, which were carried out, including installation of a television camera at the ER door. The two aides who'd been on call that night took some days off, wondering if they would ever return to healthcare or, for that matter, to any job that required working the night shift.

      What were we to do? We'd had a very good immediate debriefing for all involved in the incident, one of the standard palliatives for the post-traumatic stress afflictions of survivors. We cleaned up, repainted, tightened security. The director of nurses continued counseling the traumatized aides. After a few weeks, we were still not getting over it.

      At the suggestion of our hospital administrator, a committed Buddhist, we decided to conduct a healing and cleansing ritual. All the players who'd been involved that night—the nurses, aides, respiratory therapist, chaplain and policeman—gathered around the bed where the deed had been done. A nurse had prepared a smudge stick, a fragrant bundle of sage and juniper held together with a golden string. I had harvested the juniper from a bush in my backyard, following her directions to say a prayer of thanks to the bush while making an offering, a small glass of my best Scotch, which I poured on the roots.

      The smudge stick gave off copious smoke, which, miraculously, didn't trip the alarm and bring the fire department to join our ritual. The smoke had a wonderful aroma, redolent of a prairie campfire. For lack of an eagle feather, the nurse wafted the smoke around the emergency room and over each of us with a big brown-black turkey feather.

      This time, instead of talking about our feelings, we each said a prayer: for peace of the patient, his family, of ourselves, of each other. It was as if the smoke particles had made visible the light among us, just as they do the beam of a floodlight. That evening a bond that had begun in trial by fire was cemented with smoke of ritual.

      It's many months later. We're all back to work, including the two aides, who still do night shifts. The emergency room feels just fine.

      What happened? All of us had been traumatized by a very ugly, painful, tragic event. We coped and supported each other; took whatever steps we could to improve the environment. Finally, we healed ourselves and our workplace with the help of ritual and prayer.

      Rituals don't have to hearken back to Native American, Buddhist, Hindu or Judeo-Christian roots. Healthcare, even straight allopathic medicine, is full of healing ritual. The rigmarole that goes on in the operating room, though justified by the principles of asepsis, is laden with ritualistic meaning. So is the archaic Latinate symbology of the written prescription. These routines serve more than a utilitarian purpose. They invoke faith, trust, magic and healing. How much more potent our rituals can be when we use them consciously to accomplish such worthy ends.

      Marc Ringel, MD, is a family practitioner and writer based in Greeley, Colorado.