Sunday, May 18, 2014

Can't Breathe

"Doctor...why is it...suddenly so hard...to breath?"

"Well, we just took your chest tube out because it looked like your collapsed lung was resolved, but it looks like your lung is collapsing again. We'd like you to sign the consent form so we can put the chest tube back in."

"But it hurt...so bad last time...and it was so...uncomfortable having it in."

"We can give you some shots to make the pain better, but I don't it isn't comfortable having a tube in your chest."

"Can't you...knock me out?"

"There's no time to take you to the operating room. This is something you'll need right now."

"It was...so painful...Can I think...about it?"

"Yes, it is your choice. But right now your lung is collapsing. It is putting pressure on your heart so your heart can't beat right. Your face is already swelling up from the blood backing up. If you choose not to do this you will die today."

"Just...let me...think...about...it."

"Okay. I'll be right outside the door. Nurse, go get the crash cart."

(5 minutes pass)

"Doc...tor. Okay, I...can't breath...Knock...me...out?"

"There's no time. You need this now. Will you sign the consent form?"

"Okay."

Prolonging Life

"Hi, I'm on the hospital team that is taking care of you. I read in your chart that you are here because of shortness of breath."

"Yes, I feel like I can't breath."

"Now, I read in a note that your nurse wrote that you don't want a chest xray or an IV."

"That's right. I've lived a long life and I don't believe in prolonging my life anymore."

"I understand that and I respect your wishes, but I'm worried that you might have a pneumonia. If that's the case then we can give you some antibiotics so that you can feel better. In order to check, I'd like to do an xray and a blood test."

"Will the xray and blood test prolong my life?"

"I don't know. Until we know for certain what's wrong I can't tell you what may or may not help, but those will help guide our decisions and improve the quality of the life you have left."

"I just don't want to prolong my life."

"I understand that. I just want to help make you comfortable. Think of it like food. I know you don't want to prolong your life, but that breakfast you are eating is also prolonging your life."

"They are also giving me oxygen in this mask. Does oxygen prolong life?"

"Why don't I call your daughter and we can all have a meeting together? Is that okay?"

Thursday, April 17, 2014

Drugs

"Now I'm going to ask you about your history of drug use. Do you use alcohol or tobacco."

"Well, I'm a social drinker and smoker. I drink and smoke maybe...once a week."

"Marijuana?"

"Yeah, every day."

"What about cocaine, heroin, meth?"

"I tried meth for three months last November, but then I decided I didn't like it and never did it again."

"Other drugs like prescriptions, bath salts, or spray paint?"

"Bath salts? What can you do with bath salts?"

"If you don't know then that's a no. You didn't hear about it from me."

"But what do bath salts make you feel?"

"I don't know. I've never tried it."

"I'm gonna find out."

"I wouldn't recommend it. In fact, I was just about to recommend you stop taking all drugs."

"Oh, I don't think I have a problem. You only need to stop if you have a problem."

"I'm worried that your marijuana use might be excessive."

"But the only way I feel normal is if I do pot. Whenever I go without, I get really irritable and just angry at everybody."

"You don't see a problem with your use?"

"Nope."

Sunday, March 23, 2014

ICU

I had an experience I have never had and that is generally the criteria I use to justify the effort of posting. I held a patient's hand while she died. I've been in a thirty-bed ICU for the last month and I've seen a wide variety of patients. Most of the people transferred to our ICU have actually been IMCU patients which is a designation for lesser acuity or more stable patients. Occasionally, however, we have taken care of very sick patients: multiple gunshot wounds, necrotizing fascitis, Streptococcus pyogenes pneumonia, status epilepticus, acute blood loss anemia, and the run-of-the-mill end organ damage (kidney, heart, liver, etc).

Despite all this, this week was the first time I was actually present to witness a patient passing. She was brought into the hospital unconscious with multi organ failure. She had no family members listed in her chart, but did have a boyfriend who happened to be a few hours away. The chart indicated that on a previous hospitalization she was listed as DNR/DNI, but did not have a POLST (physician order for life-sustaining treatment). The POLST is the important part of the DNR - the part that actually gives the order to make things happen or not. The DNR is used to guide decisions that go into the POLST.

By the time I saw her, she was struggling for breath, grunting with each expiration. I could hear the crackles in her lungs from across the room. While we waited for a final order from the doctor, she was being given fluid but no medicine to maintain her blood pressure, but it went straight to her lungs. Her heart rate was fast trying and failing to sustain her falling blood pressure. She did not respond to questions or painful stimuli. Except for the nurse and I at her bedside and the occasional inspection from the doctor, she was all alone. As her blood pressure fell to more critical levels, we finally got the order to make her comfortable and to not call a code.

She was given fentanyl every 10 minutes. Her breathing slowed first and the grunting stopped. From that point, it took about two hours for her heart rate to begin to decline. I didn't know what to expect which is partly why I stayed well past my shift. The other reason, the biggest reason, was because I felt that no one should die alone. I held her hand for the last hour. I don't know at what point exactly she passed. Was it once her heart stopped or her breathing? Was it while we were waiting for the next breath, or was it shortly after she became unconscious earlier in the day? Had she left the empty, failing shell hours before? Or was she officially dead once we disconnected the monitors and no longer cared about her heart rate, respiratory rate, pulse, and blood pressure?

Her grip started to tighten on my hand during the last hour. Was it rigor mortis? If that was the case then technically she had passed, according to textbooks, three to four hours earlier despite her still-present heart rate?

More importantly, why was she alone? Where were her friends, her husband, her kids, the people whose life hers had touched? Why was she spending her last moments in the care of strangers grasping the hand of someone who was there only by chance who cared for her as a patient, but not as the person she had been? Would it have mattered if her loved ones had been present? Did she have the presence of mind to comprehend the identity of those at her bedside?

Sunday, December 15, 2013

Trained for This

Right outside my house, an elderly lady tumbled off a curb in her wheelchair in a poorly lit area. She screamed in pain for help and thought that her legs were broken. Her screams alerted a few people, including the elderly woman's daughter. She asked someone to call 911 which I did and an ambulance was dispatched. They arrived and started checking her for blood, breaks, head and spine injuries, etc. One neighbor turned to me and started commenting on their work.

"I've been trained at this. I took a few EMT classes a few years back. (inhales cigarette) The best thing to do right now is to not panic and that's why I'm smoking."

"Really? That's why you're smoking?"

"Look at them. She's showing signs of shock." (inhales cigarette again)

A paramedic calls out. "Blood pressure is 182/120, heart rate 82."

(What I think: Shock?! She's coherent, answers questions appropriately, and is not hypotensive or tachycardic. And you think he's in shock?! What did they teach you in those classes you took? What is in that cigarette you are smoking?)

At about that point in my thought process I realize that I was doing to him what my preceptors must be doing to me -

"You want to keep giving him metformin?! With a creatinine of 1.5?!"

"You don't think there's an ischemic cause for his chest pain?! With a troponin of 0.4?!"

"You want to increase his O2 sat by giving him even more oxygen? With a 50 pack year history of smoking?!"

"You want to immunize this kid even though he finished steroid treatment for croup one week ago?!"

Tuesday, November 19, 2013

Taking Pills

"Tell me what brings you in today."

"Well, I just got a positive pregnancy test and I want to know why that happened because I've been taking the birth control like I was told."

"You have been taking pills? And you just had a positive pregnancy test?"

"Yes, how is that even possible?"

"Well, nothing is 100% effective except abstinence. This chart here shows that the chance of failure for perfect use is 0.3%, but about 8% in the real world-meaning about 8 women in 100 using the same birth control as you will get pregnant in one year. Did you take a pill every day?"

"Well, almost every day. I always tried to make sure there was one there."

"...What do you mean?"

"Well, sometimes I noticed it would fall out so I'm not 100% sure there was always a pill there."

"You haven't been taking the pills...in your mouth...as in swallowing them?"

"...No."

"Okay, I think I know what went wrong."

Birth Control Side Effects

"But doctor, how can I be pregnant?! We've been using the birth control."

"Did you take it every day?"

"Yes."

"Did you take active birth control continuously or did you start your next pack of blues when the old pack of blues ended?"

"We took one pill every day in the order they came in the package."

"You keep saying 'we' took the pills. What do you mean by that?"

"Well, the pills made me kind of nauseous so I gave them to my boyfriend to take. They didn't affect him at all."

"Wait, your boyfriend was taking your birth control pills?"

"Well, yeah. I didn't like the way they made me feel."