Some of the patients on my census (and their families) are completely nuts. I was off last weekend, and my partner who covered my patients was more than happy to give them back to me. For all the good that I feel I do in taking care of patients who truly need medical care, then there are others who abuse the system.
One of these is a woman admitted for COPD who cannot stop smoking, refuses to get out of bed to sit in a chair ("I sat in a chair for 2 hours yesterday and then I got tired!), and eats like a pig. Never mind that she's diabetic; she calls the nutrition people frequently to order snacks, and is afraid to move for fear of coughing and being short of breath. She also engages in "extracurricular activities" that I have fortunately never witnessed, namely phone sex with her boyfriend. Apparently therapists have left her room because they were uncomfortable being in the room with her when she was going at it on the phone, and she hits on male nurses and doctors shamelessly, at times requesting to be bathed or cleaned by the male nurses. I'm hoping to send her home soon because all she does is eat and sleep, and she can do that at home.
10 days ago I admitted a 560 lb guy for cellulitis (had failed outpt therapy) and put him on IV antibiotics. Within days, he complained that his abdomen was feeling more "full" and he was having trouble breathing. Abdominal ultrasounds and CXR were wasted on this behemoth due to his habitus, and he got angry that we didn't have a CT that would fit him and demanded to be transferred to the county hospital where he thought they had a CT that would fit him (not anymore). He had to wait over the weekend to go to another hospital just for the CT, and during that weekend, he drove my partner nuts claiming that he couldn't breathe, he was going to code any minute, and that we needed to "fix" him. My partner created a new monster by putting him on IV lasix for diuresis (he also had lymphedema), and once he started peeing all that excess fluid out, he became happy with this method of weight loss and demanded that the Lasix be increased to q6. At one point he peed out 10L in one day, but it didn't help that he also drank 5L of sodas and water. He then claimed he couldn't walk due to his excess weight and demanded a scooter. We later confirmed he had borderline personality, but it was riduculous. He was convinced that he had CHF despite a negative echo and normal BNP, and he kept demanding to see a specialist. I flat out told him no. Finally, it took me, the case manager, the RN, and the floor supervisor to go to his room to confront him and say that there was absolutely NO indication for him to be in the hospital and that he was being discharged that same day. He agreed, but threatened to return if the PO lasix didn't get his fluid down as fast as the IV lasix did. When I dictated my H&P, I listed examples of his behavior and said that he should not be admitted unless it was a true emergency. After confronting him, I realized I'd developed quite a backbone since I dealt with my drug seeker about 2 months ago. I've grown up =)
Another woman has an extremely controlling family consisting of 9 children, each with different opinions. They live in the north part of the city, but in the past few months keep changing hospitals because they were "not happy" with the care they were receiving. Honestly, the problem is not the hospital but the family. The last hospital had discharged the patient to hospice for multiple medical problems including CHF and CVA; when she had a CHF flare, they refused to take her back to the previous hospital and came to mine to start anew. The family members were very demanding; they wanted her to go to one particular acute rehab despite the fact that she'd already used up her rehab days and Medicare wouldn't pay for the rest. One day the patient told me she wanted to go home with hospice; 5 minutes later, her daughter (and MPOA) talked her out of it and then told me, "Mom wants rehab." It seemed strange that her children keeping telling me how clear-minded the patient was and how she can make her own decisions, and yet when she wants to go home, her children put their foot down. When I asked the patient where she wanted to go, she said rehab. They again demanded a particular rehab, and the MPOA seemed okay with us referring her to a rehab center up north. Then today, one of the sons (whom I'd never met) called the CEO of the hospital claiming that the patient had been "manhandled" and accused our techs of physical abuse, even mentioning names of senators in order to get her to that particular rehab. This was AFTER the MPOA decided on another rehab. Don't these siblings talk to each other? It's disgusting how manipulative they are. One thing I have to do tomorrow is tell them that the patient is going to be discharged either home or to a different rehab and that they need to make a decision, pronto. After dealing with the lard-ass in the previous paragraph, I feel almost ready to confront any difficult patient or family member who's taking advantage of our system.
*sigh* Weekend can't come soon enough. These people drive me nuts.
Wednesday, January 23, 2013
Monday, January 14, 2013
Watching Life Slip Away
Shortly before Christmas I got a patient in the ED who had undergone PEA arrest but responded after 1 round of CPR and 1 dose of epi. His cardiac enzymes were negative and his EKG was ok, so when his wife asked what caused the PEA, I said it was most likely PE since he had a history of Protein C/S deficiency and wasn't therapeutic on coumadin. Later, the pulmonlogist called me up and said that the PEA was most certainly not caused by a PE. "If he had a PE, he wouldn't have come back after just one round of CPR and epi," he said. "People with massive PEs don't make it."
Last Friday I admitted a 48-year-old woman with metastatic breast cancer who came from her oncologist's office for dehydration and intractable back pain. Apparently she was in her normal state of health (driving her daughters to school, walking around fine) until 1 week ago, when she caught a cold and suddenly became weaker and had some witnessed syncopal episodes at home. Her CXR was clear, and her lumbar x-rays confirmed widespread metastatic disease. She asked me what the plan was now, and I said she'd probably need to talk to her oncologist to discuss goals of care. Before I left her room, I noticed that she looked slightly winded, but when I asked her about it she said her breathing was fine. Even still, I ordered a chest x-ray for the morning to see whether she had developed pneumonia.
Yesterday (Sunday), the on-call oncologist paged me to say he'd just seen my patient, and she "didn't look good." I immediately ran downstairs to her room, and she looked horrible. Her skin was pale, her hands were cold, and though she was able to follow commands, her speech had become terribly slurred. "What's wrong?" I asked, and she said, "Can't...breathe." Her X-ray that morning had been clear, so I quickly left the room to order a stat CTA chest. "She needs to go to the ICU," the nurse said, and I agreed; with a clear CXR and her history of breast cancer, she likely had a PE. I went back to her room after the orders were in, and I was immediately horrified by how much worse she looked. Her eyes looked blank, and suddenly, right in front of me, she stopped breathing. Her SpO2 rapidly dropped from the 80s to the 70s in seconds, and I immediately grabbed her wrist to feel for a pulse. Nothing. "Should I call rapid response or a [Code Blue]?" asked the nurse. I told her to call a code.
The woman had become unresponsive, and was only taking breaths every 8-10 seconds. Once she was hooked to the monitor, we saw her HR fall to the 40s and then asystole. By then CPR had started and the ED attending arrived to intubate her. Critical labs showed a K of 7.8 (it was 5 earlier that morning) and bicarb of 10, pH < 7. We regained a pulse and made arrangements to transfer her to the ICU. The ED attending and I stepped outside the room to write our notes when suddenly the Code was announced overhead again. My patient had once again lost her pulse, and another round of CPR, epi, atropine, and bicarb was given before she was stabilized enough to transfer to ICU. Fortunately during this time her mother called the nurse's station and was told what was happening, and she immediately drove toward the hospital.
I wish I could say my patient got better, but not long after she arrived at the ICU, she lost her pulse again and CPR resumed. The on-call cardiologist poked his head into the room to see what was happening (one of my partners saw me and thought yet another of my patients had coded), and when I explained the situation, he said I could pace her, but unless I fixed the underlying cause (presumed PE), she would continue to deteriorate. There was no end to this at all. Fortunately her mother arrived at the ICU, and the nurses encouraged me to bring her to the bedside to let her see what was happening. By that time the patient was stable again, and the mother said that if it was just her, she'd want to withdraw care, but that decision would have to be made by her 20-year-old son. I spoke to her son by phone and explained the situation, asking what his mother would want in this situation. "We talked about it a little, but never really made a decision," he said. I then encouraged him to come to the hospital as soon as possible. ("Drive safe," his grandmother said.)
I had taken the mother to the pre-op room to talk, but when we arrived back at the patient's room, she had lost her pulse a fourth time and CPR was resuming again. "Is she getting oxygen to the brain?" her mother asked. "How long has this been going on?" When I told her this was the fourth time she'd dropped her pulse in one hour, she was shocked. "Oh no," she murmured. "She wouldn't want this." She immediately called her grandson to let him know what was happening, and he said he needed to talk it over with another brother. By that time my patient was hooked to a pacer and maxed out on Levophed, Dopamine and Epi, yet her BP was only 55/32. This was a losing battle, and I think everyone was silently hoping that someone would make the call to stop the code. And that someone had to be me.
The patient's son called back, and after listening for a few seconds, her mother nodded and said, "I want you to tell the doctor what you've told me" and handed me the phone.
"My brother and I talked it over, and we know that my mom did not want to be a vegetable. She wouldn't want to be hooked up to life support."
"Okay. Right now, there are machines breathing for her and keeping her heart beating. Are you saying that you want us to stop everything we're doing?"
"Yes."
"Thank you," I said. Beside me, the mother nodded as I handed her the phone, then turned to the nurses and techs in the room and said the words everyone's been waiting to hear: "Stop everything."
The pacer and pressors were turned off, and almost immediately both HR and BP fell to zero. The patient's mother approached her and whispered, "I don't know if you can hear me, but I love you so much." That almost brought tears to my eyes. Time of death was called at 13:02, and I asked RT to extubate her before her son arrived. I felt horrible for the rest of the day and wondered what I could have done differently. A PE had not been on my differential when she arrived in the ED with generalized weakness, anorexia, and intractable back pain. But even then, I couldn't have given her anticoagulation because there was a questionable subdural hematoma on her CT head. It was a near hopeless situation. Maybe if I had more experience, I could have anticipated this earlier, but now it's too late.
We will never know what happened, but it's most likely she died from a massive PE. When I talked about this with the pulmonologist who attended the code with me, I remembered what the other pulmonologist had said: "People with massive PEs don't make it." Now I know what he meant, and this is yet another in a growing list of experiences that I will take to heart so that next time, I don't make the same mistake again.
Last Friday I admitted a 48-year-old woman with metastatic breast cancer who came from her oncologist's office for dehydration and intractable back pain. Apparently she was in her normal state of health (driving her daughters to school, walking around fine) until 1 week ago, when she caught a cold and suddenly became weaker and had some witnessed syncopal episodes at home. Her CXR was clear, and her lumbar x-rays confirmed widespread metastatic disease. She asked me what the plan was now, and I said she'd probably need to talk to her oncologist to discuss goals of care. Before I left her room, I noticed that she looked slightly winded, but when I asked her about it she said her breathing was fine. Even still, I ordered a chest x-ray for the morning to see whether she had developed pneumonia.
Yesterday (Sunday), the on-call oncologist paged me to say he'd just seen my patient, and she "didn't look good." I immediately ran downstairs to her room, and she looked horrible. Her skin was pale, her hands were cold, and though she was able to follow commands, her speech had become terribly slurred. "What's wrong?" I asked, and she said, "Can't...breathe." Her X-ray that morning had been clear, so I quickly left the room to order a stat CTA chest. "She needs to go to the ICU," the nurse said, and I agreed; with a clear CXR and her history of breast cancer, she likely had a PE. I went back to her room after the orders were in, and I was immediately horrified by how much worse she looked. Her eyes looked blank, and suddenly, right in front of me, she stopped breathing. Her SpO2 rapidly dropped from the 80s to the 70s in seconds, and I immediately grabbed her wrist to feel for a pulse. Nothing. "Should I call rapid response or a [Code Blue]?" asked the nurse. I told her to call a code.
The woman had become unresponsive, and was only taking breaths every 8-10 seconds. Once she was hooked to the monitor, we saw her HR fall to the 40s and then asystole. By then CPR had started and the ED attending arrived to intubate her. Critical labs showed a K of 7.8 (it was 5 earlier that morning) and bicarb of 10, pH < 7. We regained a pulse and made arrangements to transfer her to the ICU. The ED attending and I stepped outside the room to write our notes when suddenly the Code was announced overhead again. My patient had once again lost her pulse, and another round of CPR, epi, atropine, and bicarb was given before she was stabilized enough to transfer to ICU. Fortunately during this time her mother called the nurse's station and was told what was happening, and she immediately drove toward the hospital.
I wish I could say my patient got better, but not long after she arrived at the ICU, she lost her pulse again and CPR resumed. The on-call cardiologist poked his head into the room to see what was happening (one of my partners saw me and thought yet another of my patients had coded), and when I explained the situation, he said I could pace her, but unless I fixed the underlying cause (presumed PE), she would continue to deteriorate. There was no end to this at all. Fortunately her mother arrived at the ICU, and the nurses encouraged me to bring her to the bedside to let her see what was happening. By that time the patient was stable again, and the mother said that if it was just her, she'd want to withdraw care, but that decision would have to be made by her 20-year-old son. I spoke to her son by phone and explained the situation, asking what his mother would want in this situation. "We talked about it a little, but never really made a decision," he said. I then encouraged him to come to the hospital as soon as possible. ("Drive safe," his grandmother said.)
I had taken the mother to the pre-op room to talk, but when we arrived back at the patient's room, she had lost her pulse a fourth time and CPR was resuming again. "Is she getting oxygen to the brain?" her mother asked. "How long has this been going on?" When I told her this was the fourth time she'd dropped her pulse in one hour, she was shocked. "Oh no," she murmured. "She wouldn't want this." She immediately called her grandson to let him know what was happening, and he said he needed to talk it over with another brother. By that time my patient was hooked to a pacer and maxed out on Levophed, Dopamine and Epi, yet her BP was only 55/32. This was a losing battle, and I think everyone was silently hoping that someone would make the call to stop the code. And that someone had to be me.
The patient's son called back, and after listening for a few seconds, her mother nodded and said, "I want you to tell the doctor what you've told me" and handed me the phone.
"My brother and I talked it over, and we know that my mom did not want to be a vegetable. She wouldn't want to be hooked up to life support."
"Okay. Right now, there are machines breathing for her and keeping her heart beating. Are you saying that you want us to stop everything we're doing?"
"Yes."
"Thank you," I said. Beside me, the mother nodded as I handed her the phone, then turned to the nurses and techs in the room and said the words everyone's been waiting to hear: "Stop everything."
The pacer and pressors were turned off, and almost immediately both HR and BP fell to zero. The patient's mother approached her and whispered, "I don't know if you can hear me, but I love you so much." That almost brought tears to my eyes. Time of death was called at 13:02, and I asked RT to extubate her before her son arrived. I felt horrible for the rest of the day and wondered what I could have done differently. A PE had not been on my differential when she arrived in the ED with generalized weakness, anorexia, and intractable back pain. But even then, I couldn't have given her anticoagulation because there was a questionable subdural hematoma on her CT head. It was a near hopeless situation. Maybe if I had more experience, I could have anticipated this earlier, but now it's too late.
We will never know what happened, but it's most likely she died from a massive PE. When I talked about this with the pulmonologist who attended the code with me, I remembered what the other pulmonologist had said: "People with massive PEs don't make it." Now I know what he meant, and this is yet another in a growing list of experiences that I will take to heart so that next time, I don't make the same mistake again.
Thursday, January 10, 2013
Hard to Let Go
For the past 2-3 weeks, one of the patients in our intermediate care unit had been slowly circling the drain. I took care of her for four days last week, and by that time no one really remembered the initial reason she got admitted. Back then she was awake and oriented x3; by the time I "inherited" her from my partners she was unresponsive and could only moan to show she was uncomfortable. Her kidneys were slowly failing and she could no longer swallow, depending on TPN to fulfill her nutrition requirements. Essentially, she had become a vegetable, and everyone believed she was more suited for hospice care...except one particular daughter.
The patient had three daughters; one of them was the medical power of attorney. She did not trust the medical system because one of her former neighbors was a nurse who was apparently arrested for euthanizing patients, and in her love and devotion for her mother she refused to make her DNR. My previous partners spoke to her on a regular basis to try to get her to change the patient's code status to DNR, but she always refused. "My mother would have died six years ago if I made her DNR and didn't fight for her," she said. She insisted that we were "missing something" when the patient first became unresponsive; talking to her was like talking to a brick wall. The first day I assumed care for the patient, I must have spoken to her daughter for about twenty-five minutes about overall prognosis and what the daughter wanted for her mother. Her goal: keep Mom in the hospital for the next few weeks while her house finishes remodeling, and then bring her home. Stopping the TPN was not an option; "I'm not going to starve Mom to death." She thought her mother was not a candidate for a J-tube b/c of her hiatal hernia, and she said she read about massage techniques on the Internet that are supposed to help resolve a hiatal hernia. "Does the hospital offer massage services?" she asked. Yes, but not for free. She stated that she once counted 8 people in the same day who tried to tell her to change her mother's code status, and she didn't feel that the time was right yet. She also claimed that I was the first person to mention hospice to her, which I know is not true.
I could go on and on about how frustrating it was to speak to this woman, who was pleasant enough but just did not have the brain cells to listen to us. One of her sisters accused her of "torturing Mom," and she in turn accused her sister of being after their mother's will and money. Even the patient's oncologist, who is one of the most patient people I've ever met, became so frustrated with the MPOA daughter that he refused to speak to her anymore; that was bad. I could not see an endpoint with this woman, so I tried telling her that the hospital was no longer the best place for her mother, that she'd be better off at a nursing home (ideally with hospice services). "Wait a minute," she said. "All these weeks, people have been telling me that my mother could die any second, and now you're telling me she can leave the hospital?" Fortunately I was off that weekend so I didn't have to deal with her anymore, and she was assigned to another of our partners who's very good at talking to families about hospice and end of life care. He welcomed the challenge, but even he butted heads with her daughter because he wasn't afraid to say the things that we all tried to approach delicately with her. Since hospice wouldn't pay for TPN, he tried to find the cost of the TPN that the daughter would have to pay (which she had no plans to do as long as pt was in the hospital). Even still, he did one thing no one else could do for weeks: he convinced the daughter to make her DNR.
Two days after her code status changed, I heard an overhead Code Blue to her room. I wondered what had happened, but since I was in the ER I couldn't investigate. I later learned from nurse's notes and the partner who had her last that the daughter had apparently given her mother some mouth swabs, and when she tolerated that well, offered her sips of water (after the woman was NPO for over 2 weeks!) The patient promptly began coughing, likely aspirated, and suddenly became unresponsive. Fortunately she was already DNR and no CPR was done, allowing her to pass as peacefully as she could under the circumstances. Afterwards the daughter asked if she had caused this to happen, if her mother's death was her fault. I wonder how the nurses and MDs answered her. My partner stated that he thought it was fitting that the patient aspirated on water that her daughter gave her, but it wasn't funny at all. No one should have to live with the knowledge that his/her actions let to a loved one's death.
Even still, I think everyone felt a sense of relief that this woman's suffering had come to an end. "It was her time," one person said practically. It certainly was.
The patient had three daughters; one of them was the medical power of attorney. She did not trust the medical system because one of her former neighbors was a nurse who was apparently arrested for euthanizing patients, and in her love and devotion for her mother she refused to make her DNR. My previous partners spoke to her on a regular basis to try to get her to change the patient's code status to DNR, but she always refused. "My mother would have died six years ago if I made her DNR and didn't fight for her," she said. She insisted that we were "missing something" when the patient first became unresponsive; talking to her was like talking to a brick wall. The first day I assumed care for the patient, I must have spoken to her daughter for about twenty-five minutes about overall prognosis and what the daughter wanted for her mother. Her goal: keep Mom in the hospital for the next few weeks while her house finishes remodeling, and then bring her home. Stopping the TPN was not an option; "I'm not going to starve Mom to death." She thought her mother was not a candidate for a J-tube b/c of her hiatal hernia, and she said she read about massage techniques on the Internet that are supposed to help resolve a hiatal hernia. "Does the hospital offer massage services?" she asked. Yes, but not for free. She stated that she once counted 8 people in the same day who tried to tell her to change her mother's code status, and she didn't feel that the time was right yet. She also claimed that I was the first person to mention hospice to her, which I know is not true.
I could go on and on about how frustrating it was to speak to this woman, who was pleasant enough but just did not have the brain cells to listen to us. One of her sisters accused her of "torturing Mom," and she in turn accused her sister of being after their mother's will and money. Even the patient's oncologist, who is one of the most patient people I've ever met, became so frustrated with the MPOA daughter that he refused to speak to her anymore; that was bad. I could not see an endpoint with this woman, so I tried telling her that the hospital was no longer the best place for her mother, that she'd be better off at a nursing home (ideally with hospice services). "Wait a minute," she said. "All these weeks, people have been telling me that my mother could die any second, and now you're telling me she can leave the hospital?" Fortunately I was off that weekend so I didn't have to deal with her anymore, and she was assigned to another of our partners who's very good at talking to families about hospice and end of life care. He welcomed the challenge, but even he butted heads with her daughter because he wasn't afraid to say the things that we all tried to approach delicately with her. Since hospice wouldn't pay for TPN, he tried to find the cost of the TPN that the daughter would have to pay (which she had no plans to do as long as pt was in the hospital). Even still, he did one thing no one else could do for weeks: he convinced the daughter to make her DNR.
Two days after her code status changed, I heard an overhead Code Blue to her room. I wondered what had happened, but since I was in the ER I couldn't investigate. I later learned from nurse's notes and the partner who had her last that the daughter had apparently given her mother some mouth swabs, and when she tolerated that well, offered her sips of water (after the woman was NPO for over 2 weeks!) The patient promptly began coughing, likely aspirated, and suddenly became unresponsive. Fortunately she was already DNR and no CPR was done, allowing her to pass as peacefully as she could under the circumstances. Afterwards the daughter asked if she had caused this to happen, if her mother's death was her fault. I wonder how the nurses and MDs answered her. My partner stated that he thought it was fitting that the patient aspirated on water that her daughter gave her, but it wasn't funny at all. No one should have to live with the knowledge that his/her actions let to a loved one's death.
Even still, I think everyone felt a sense of relief that this woman's suffering had come to an end. "It was her time," one person said practically. It certainly was.
Wednesday, January 2, 2013
When Everything That Could Go Wrong, Goes Wrong
About one week before Christmas I picked up a new patient from night float, a 48 year old woman named A.M. who presented to the hospital with a 5 day history of headaches. Her PCP had prescribed Fioricet with no relief. The admitting diagnosis was hyponatremia (Na of 126), and while she did seem confused at times and held her head at a stiff angle, she was mostly oriented x 3. I put her on NaCl for the day and later spoke with her husband by phone about what I wanted to do for her. He asked when he thought she'd be able to leave the hospital, and I said once we find the cause of the hyponatremia, maybe a few days.
The next day her sodium had dropped even lower despite being on IVF, so I consulted nephrology to evaluate her. She was diagnosed with SIADH and transferred to the ICU to get hypertonic 3% saline. I told the patient and her husband that she was not going to the ICU because she was sicker, it was so we could keep a close eye on her sodium. Even on the hypertonic saline, her sodium was slow to improve. It made no sense for a previously healthy woman to develop SIADH out of the blue, so I looked up causes of SIADH as a refresher. One thing jumped out at me: infection. Specifically, meningitis.
Suddenly everything became terribly clear. The headaches, the stiff neck, the "new" onset fever of 103 and her WBC jumping from 7 to 21 in less than 48 hours. The woman had meningitis; I was sure of it. I immediately ordered an LP, which was delayed b/c she'd been receiving Lovenox for DVT prophylaxis, but it showed a WBC of 400 and glucose of 12. Even still, her CSF didn't grow any organisms. I consulted ID, who believed that because she'd received Augmentin as an outpt for UTI, her meningitis was likely partially treated even before she came to the hospital. I explained the findings to the patient and her husband, who seemed surprised but accepting of the news. Her husband asked if he needed to be vaccinated against meningitis; fortunately the answer was no.
Over the next few days, the patient continued to spike fevers of 103 on a daily basis, but her WBC was falling and her sodium (I wish I hadn't let myself get sidetracked by the admitting diagnosis) improved. The MRI showed that her ventricles were slowly getting larger (compared to prior CT), and the ID attending warned me to be on the looking out for neuro changes. Then on Christmas Eve, her right pupil was noted to be more dilated so I called neurosurgery to see her. He didn't seem too impressed at first; except for a few instances of confusion where she asked her husband to hand her papers to grade (she was a teacher), she was fully awake and oriented. In any case, she was still getting Lovenox for DVT prophylaxis, and the neurosurgeon called me to flat-out say that "Lovenox and neurosurgery don't mix. My hands are tied." I felt horrible (you'd think I would have discontinued Lovenox after the LP), but again, the patient was stable and symptomatically improving so everyone felt that watchful waiting was the right approach. The neurosurgeon did, however, give the nurse a list of warning signs to watch for and to call him if anything changes.
That night everything went to hell. According to the RN, the patient was in her usual state of health at 10pm, eating KFC and talking to her sister on the phone. Then within 5-10 minutes she became completely unresponsive and her pupils became more dilated. The neurosurgeon was immediately called, and by the time he arrived my patient was on the verge of brain death (both pupils fixed and dilated). According to reports he immediately rushed her to the OR, shaving her hair off while doing so, and proceeded to place a ventriculostomy even before the rest of the OR team arrived. (It was very "Grey's Anatomy," as one RN put it). As he later told me, had he been even 2 minutes late in placing the ventriculostomy, she would have died. In all his years of practice, he had never seen someone decompensate so quickly; usually the neurologic changes are more gradual, easier to pick up. My partner said he was cursing himself for not putting the drain in sooner (and he even apologized to me for not doing so), but surely he'd forgotten about the Lovenox. Had he placed the drain in that morning, there was a risk of bleeding. Neurosurgery and Lovenox don't mix. There was nothing either of us could have done, yet in ways we both felt responsible (me for the Lovenox, him for believing it was safe to watch and wait, which really was reasonable at the time).
I told the husband that perhaps it was a Christmas miracle that allowed her to survive (all this happened right before midnight on Christmas Eve), but even then I didn't know how much she could improve. She was intubated and moved her arms and legs to painful stimuli, sometimes opening her eyes, but I wondered if she would recover. Most people showed signs of improvement immediately after the procedure, but she did not. I thought about her two children, one in high school, the other in college. How would they deal with this? And her poor husband, who has rarely left her side since her ordeal began. I didn't know what to say to him. I was off for five days for New Years, and I told him I would see him again once my vacation ended.
When I returned to work New Year's Day and our entire census was redistributed, I was disappointed to learn that my partner who'd taken care of some of my patients while I was gone had kept several of them, including my meningitis patient, on her service. In some ways it was better; she was more experienced than me. One of my former patients under her care actually coded and died on New Year's Day (his second PEA code in 2 weeks), and I was (selfishly) relieved that I didn't have to be the one to oversee the code. I asked her how my meningitis patient was doing, and the news was not good. Since I last saw her, she had become completely unresponsive even to painful stimuli, and both pupils were fully dilated and nonreactive. Brain death was confirmed shortly after midnight by the neurosurgeon, and after her family members gathered to say goodbye, she was extubated and pronounced dead at 0340.
I didn't learn that she died until this morning from my partner who had taken over her care, and we were both saddened by the news. "That was a crappy case of meningitis," said my partner. I was slightly relieved that she passed overnight; I don't know I would have been able to look her husband in the eyes after everything that's happened. To think she came in with headaches and hyponatremia (in a bitter twist of irony, her sodium had shot up to 160 the day before she died), only to be diagnosed with meningitis with the worst possible outcome. I think both the neurosurgeon and I will be haunted by this case for a long time, if not for the rest of our professional lives.
The next day her sodium had dropped even lower despite being on IVF, so I consulted nephrology to evaluate her. She was diagnosed with SIADH and transferred to the ICU to get hypertonic 3% saline. I told the patient and her husband that she was not going to the ICU because she was sicker, it was so we could keep a close eye on her sodium. Even on the hypertonic saline, her sodium was slow to improve. It made no sense for a previously healthy woman to develop SIADH out of the blue, so I looked up causes of SIADH as a refresher. One thing jumped out at me: infection. Specifically, meningitis.
Suddenly everything became terribly clear. The headaches, the stiff neck, the "new" onset fever of 103 and her WBC jumping from 7 to 21 in less than 48 hours. The woman had meningitis; I was sure of it. I immediately ordered an LP, which was delayed b/c she'd been receiving Lovenox for DVT prophylaxis, but it showed a WBC of 400 and glucose of 12. Even still, her CSF didn't grow any organisms. I consulted ID, who believed that because she'd received Augmentin as an outpt for UTI, her meningitis was likely partially treated even before she came to the hospital. I explained the findings to the patient and her husband, who seemed surprised but accepting of the news. Her husband asked if he needed to be vaccinated against meningitis; fortunately the answer was no.
Over the next few days, the patient continued to spike fevers of 103 on a daily basis, but her WBC was falling and her sodium (I wish I hadn't let myself get sidetracked by the admitting diagnosis) improved. The MRI showed that her ventricles were slowly getting larger (compared to prior CT), and the ID attending warned me to be on the looking out for neuro changes. Then on Christmas Eve, her right pupil was noted to be more dilated so I called neurosurgery to see her. He didn't seem too impressed at first; except for a few instances of confusion where she asked her husband to hand her papers to grade (she was a teacher), she was fully awake and oriented. In any case, she was still getting Lovenox for DVT prophylaxis, and the neurosurgeon called me to flat-out say that "Lovenox and neurosurgery don't mix. My hands are tied." I felt horrible (you'd think I would have discontinued Lovenox after the LP), but again, the patient was stable and symptomatically improving so everyone felt that watchful waiting was the right approach. The neurosurgeon did, however, give the nurse a list of warning signs to watch for and to call him if anything changes.
That night everything went to hell. According to the RN, the patient was in her usual state of health at 10pm, eating KFC and talking to her sister on the phone. Then within 5-10 minutes she became completely unresponsive and her pupils became more dilated. The neurosurgeon was immediately called, and by the time he arrived my patient was on the verge of brain death (both pupils fixed and dilated). According to reports he immediately rushed her to the OR, shaving her hair off while doing so, and proceeded to place a ventriculostomy even before the rest of the OR team arrived. (It was very "Grey's Anatomy," as one RN put it). As he later told me, had he been even 2 minutes late in placing the ventriculostomy, she would have died. In all his years of practice, he had never seen someone decompensate so quickly; usually the neurologic changes are more gradual, easier to pick up. My partner said he was cursing himself for not putting the drain in sooner (and he even apologized to me for not doing so), but surely he'd forgotten about the Lovenox. Had he placed the drain in that morning, there was a risk of bleeding. Neurosurgery and Lovenox don't mix. There was nothing either of us could have done, yet in ways we both felt responsible (me for the Lovenox, him for believing it was safe to watch and wait, which really was reasonable at the time).
I told the husband that perhaps it was a Christmas miracle that allowed her to survive (all this happened right before midnight on Christmas Eve), but even then I didn't know how much she could improve. She was intubated and moved her arms and legs to painful stimuli, sometimes opening her eyes, but I wondered if she would recover. Most people showed signs of improvement immediately after the procedure, but she did not. I thought about her two children, one in high school, the other in college. How would they deal with this? And her poor husband, who has rarely left her side since her ordeal began. I didn't know what to say to him. I was off for five days for New Years, and I told him I would see him again once my vacation ended.
When I returned to work New Year's Day and our entire census was redistributed, I was disappointed to learn that my partner who'd taken care of some of my patients while I was gone had kept several of them, including my meningitis patient, on her service. In some ways it was better; she was more experienced than me. One of my former patients under her care actually coded and died on New Year's Day (his second PEA code in 2 weeks), and I was (selfishly) relieved that I didn't have to be the one to oversee the code. I asked her how my meningitis patient was doing, and the news was not good. Since I last saw her, she had become completely unresponsive even to painful stimuli, and both pupils were fully dilated and nonreactive. Brain death was confirmed shortly after midnight by the neurosurgeon, and after her family members gathered to say goodbye, she was extubated and pronounced dead at 0340.
I didn't learn that she died until this morning from my partner who had taken over her care, and we were both saddened by the news. "That was a crappy case of meningitis," said my partner. I was slightly relieved that she passed overnight; I don't know I would have been able to look her husband in the eyes after everything that's happened. To think she came in with headaches and hyponatremia (in a bitter twist of irony, her sodium had shot up to 160 the day before she died), only to be diagnosed with meningitis with the worst possible outcome. I think both the neurosurgeon and I will be haunted by this case for a long time, if not for the rest of our professional lives.
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