Not Enough Time/Grass Aspiration

Four days ago I got a new patient, a 58 year old alcoholic who presented to the ED complaining of worsening abdominal swelling, spontaneous bruising, and low urine output. On admission his creatinine was 7.7, BUN > 110, INR 3.3, and bilirubin of 13. He had full blown hepatorenal syndrome (HRS); in the words of the gastroenterologist, he was "sick as $hit." The nephrologist and gastroenterologist both did not think he was a candidate for dialysis due to the extent of his liver failure, which meant he would not survive this hospitalization.

When I asked the patient if he understood how he sick he was, he stated matter-of-factly, "I'm going to die." I spoke to him about hospice, and he asked if I would write the important points down because "I know I'll probably forget soon." Even then, as the ammonia built up in his system, he knew that there would come a time where he would not be able to make decisions for himself, and he told us who he wanted us to contact (a female friend who was caring for his cat) if something happened. He had two brothers, but they were estranged due to his alcoholism and poor life choices. He told me he wanted to go home to get his affairs in order and take care of his cat, and I said I'd ask the hospice people to come speak to him about it later that afternoon.

The hospice people never showed, and when I saw him the next morning (yesterday), he was a completely different person. He had become completely encephalopathic, moaning and restless, unaware of anything around him, no longer in any position to make any decisions for himself. His friend was at his bedside and very tearful, but she took solace in the fact that he had listed her as his go-to person, which spoke of his trust in her. She wanted to make him DNR (rightfully so), which the nephrologist and I both agreed with. The nephrologist estimated that he had less than 24 hours left to live, and she was right. He passed away at 3:00 a.m. this morning.

Later in the day I got a text from one of my partners regarding a new admission: "aspirated on grass." That's one chief complaint that I never heard of before. It was really an interesting story; my patient was on a riding lawn mower clearing brush in a park when a branch suddenly flew through the air and smacked him in the nose and mouth. He had not worn a face mask that day, and afterwards he had persistent cough, shortness of breath, and right chest tightness. His chest X-ray  was negative, but his CT chest showed that debris had completely occluded his right bronchus. The pulmonologist on call was out enjoying a bike ride when he got called to the hospital, but he got very excited when he saw the CT. It would definitely have made a great case study. We'll see how the patient does.