Anyone who follows me on Facebook knows that I'm not the type of person who posts every day. This weekend was the exception. After returning home from 2 weeks of traveling in Sapporo, Bali, and Seoul, I was assigned "pit boss" duty, meaning that I take calls from the ED from 6am-12pm and distribute admissions among my partners. It also meant that on Monday morning I had to redivide our ENTIRE weekend census in order to even out everyone's census (since the total number of hospitalists rose from 8 on the weekend to 12 on the weekday). That was my first time "making the list" and it took me a good 2-3 hours (got to the hospital at 4:45 am, didn't finalize the list until after 7 am), but in the end I was satisfied with my work. Some of my partners have done a crappy job of dividing the list (where half of my patients from the previous week went to other people), but most of us who are off for the weekend want our old patients from the previous week back. I, of course, had a brand new census of people whom I'd never met before, but fortunately the average census was 14-15 people. I even took an extra admission on Monday because I had room to spare (my "desired" census is 15 people/day) Stupid me, I thought being the pit boss meant I had to physically be in the hospital by 6 am (not true), and when one of my partners finally told me on a Thursday morning, I thought, "Oh, then on Friday I'll come in at 7:00." Big mistake.
Normally our group has a rule that there has to be ten hospitalists rounding on any given day so as to not overwhelm anybody. On Thursday there were 11 hospitalists; two were "charity" helpers (one was from another hospital, another should be post-night float but chose to work to earn extra money) and deserved to be off. The other, one of the senior partners, gave no notice except for a note on the board: "Off 3/1, back 3/2." Incidentally, the census at the hospital exploded to maximum capacity. So we went from 11 hospitalists to only 8 hospitalists (which is the number that typically works on weekends), and our individual census rose ridiculously high. I had left the hospital on Thursday with 13 patients; on Friday I had 22.
Some of the remaining partners were pissed, and rightfully so; one had only 11 patients left on Thursday, and she'd made a doctor's appointment for the afternoon. Another had just worked 2 straight weekends and was hoping for a easy Friday. Never mind that I was on call at 5 pm. The lowest census anyone had was 22. This was, essentially, a 3-day weekend type of census. It took me until 7 pm to see my inpatients and 1 consult, and then I got 7 admissions from the ED. In my six months here the hospital had never been so busy before, even during Christmas. The ED was holding 12+ admissions in their rooms because there were no more inpatient beds available; there were even stretchers in the halls, which almost never happens. I didn't see my last new admission until 11 pm; by that time I was pooped. Most people try to dictate their H&Ps while they're in the hospital, but I was so tired and sick of work I went home, showered, and then dictated from home. Then did my billing for the day. I didn't go to bed until 2 am. That day I saw 30 patients.
I need at least 4 hrs of sleep to function, so I woke up at 6, drank coffee to stay awake (which was against my better judgement; coffee in the morning makes me ill), and rolled into work around 7 am. Because I was tired, I wasn't able to keep up my usual pace, and by noon I'd only seen 11 of my 27 patients (including one new admission, which fortunately for me was straightforward syncope.) Of course, of those 10 I'd discharged a few, and discharges always slow me down. As expected the coffee gave me an upset stomach, so I was pretty much in misery the entire day. I didn't see my last patients until 7:30-8:00pm, just in time to hear one of my patients complain that he hadn't seen me all day. Total census that day: 28 patients. I discharged 7 and got my census down to 21.
Fortunately the admissions slowed down so that I only got 1 new admission overnight. I felt much more refreshed after getting 6 hours of sleep (rather than 4), so I was a bit faster. By noon I'd seen 13 patients and discharged 4. The call was not bad either; only 3 new patients. The problem was that a lot more patient families were visiting on the weekends, so I had to take time to speak with them (which sidetracked me), so I didn't see my last admission until around 8pm (again). I discharged another 7 patients and got my census down to 18. When I got home, I calculated that in the past 3 days, I'd worked 44 hours, examined 83 patients, and never saw the sun except from inside the hospital. Wow.
Residency nowadays cannot prepare future hospitalists for this kind of work. Not with patient caps of 14-16 and duty hour rules where an intern cannot work longer than 16 hours at a time. Now I understand why my pod leader looked concerned when I told her on my interview day that I never saw more than 14 patients on any given day; she was probably afraid I wouldn't be able to handle the workload here. I think she took quite a leap of faith in deciding to hire me, and I'm glad to say I made sure she didn't regret her decision. I heard her tell another interviewee that she thought I'd have trouble because I was "green" (complete rookie with no real life experience), but that I learned very fast and was doing pretty well. My other partners, too, have told me I'm doing a pretty good job, and one of the cardiologists told me that they missed me while I was on vacation ;). "You're a workhorse," he'd said. Guess that means I contribute to the group =)
Fortunately this month I'm based at a nearby rehabilitation hospital, which promises to be easier. Hope so.
Tuesday, March 5, 2013
Wednesday, January 23, 2013
Crazy people
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.
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.
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.
Wednesday, December 26, 2012
Burnt Out
I just finished working 17 days in a row. It wasn't entirely by choice; I was supposed to have Christmas off and work over New Year's, but when one of my partners quit and left on December 13, that left one person short to cover the hospital during Christmas. That meant 7 doctors for as many as 240 patients. I was supposed to work the night shift over New Year's (which I did not feel ready for), so I volunteered to work over Christmas. That way, with 8 hospitalists, the average census per physician would be 20-25, which was much preferable to 30.
The drawback, of course, was that toward the end of my 17 day stint I felt like I was losing my mind. I was averaging about 5-6 hours of sleep per night, and during the last week I was taking call from 5 to 10 pm every other day. This was a mistake on the scheduler's part; she'd originally put me down for three 5 to 10 pm calls in a row, which is straight-up suicide. There was a time when I worked back-to back 5-10pm calls, and I am never doing that again. Let me tell you, Q2 call is not fun at all, especially when most nights I wasn't physically able to leave the hospital until around midnight. And it was during one of these 5-10pm shifts that I experienced my worst call ever: 10 patients in 5 hours (capped out). Neither my partner or I left the hospital before midnight that day.
Christmas Eve was bad. There were lots of patients anxious to go home before Christmas, and I broke yet another record by discharging 9 people in one day. I couldn't even see all my patients on time because I had to see the imminent discharges first, and by the time I saw them and did all their paperwork, it was already very late. I'd had plans to have Christmas Eve dinner at a family friend's house at 6:00 pm, but I wasn't even able to leave the hospital until 6:30pm (still had 5 pts to see at 5:30pm, but I rounded extra-fast). Fortunately my friends had just started eating when I arrived, and the beef tenderloin, homemade mashed potatoes, red wine mushrooms, pomegranates, and cabernet sauvignon soon made me forget what a horrible day I had.
Christmas Day itself was better; I was still happy and smiling from dinner the night before (it was just the breather I'd needed), and I discharged two patients that were more than ready to go home. But a few bad things happened, too. A woman who had meningitis (I'll have to write a whole post about her in the near future) needed an emergent ventriculostomy for rapidly progressing hydrocephalus (went from AOx4 and talking to fixed pupils in 30 minutes), and another patient developed massive hemoptysis and went into PEA arrest during a bronchoscopy. Needless to say it was the Christmas from hell for the covering pulmonologist (who works every Christmas because he's Jewish); to quote him, this was his fourth massive hemoptysis since he first began practicing in the 1980s, and it put him in a foul mood for the rest of the day. Needless to say the pulmonology director had a lot of apologizing to do for his disgruntled colleague when he returned from vacation today; doctors, nurses, and even patients and their families complained about the other pulmonologist's unprofessional behavior. Thank goodness he's usually at another hospital.
The day after Christmas (today) was another day from hell. I'd barely seen 4 of my 22 patients when they announced "CODE BLUE, ROOM _____" (this hospital never says "Code Blue;" they use another term), and I immediately recognized the room number of one of my patients. He was an 86-year-old man who came to the hospital with a pathologic hip fracture from metastatic prostate cancer, and he'd been doing pretty well post-op. Just yesterday I was telling him that the Christmas cookies his family had brought him looked delicious. As I soon found out, PT had found him pulseless and unresponsive. The poor man had at least 2 shocks and 15 minutes of CPR (plus epi, amio, bicarb, atropine pushed into him), and when we reached the family, they asked us to keep him alive until they got there. Fortunately after the amio and the 2nd shock we got a "strong pulse" and we were able to transfer him to the ICU. There, his pressures were in the 50s-60s. I wanted to start pressors, but one of the nurses (wisely so) told me to talk to the family first. I met with the family and explained the situation, asking how aggressive they wanted to be. Fortunately they were very reasonable and his daughter said she didn't want any aggressive life-saving measures to be done. "We just wanted to see him," she said.
To me, the timing could not have been better. I would never want anyone's last memory of their loved one to be of doctors and nurses pounding away at their chests and shocking them to keep them alive. My patient had regained a pulse long enough so that his wife and children were able to see him lying peacefully in bed. They had enough time to summon a chaplain to the bedside, and they were together when the patient was extubated and eventually died. It was a good, peaceful death, which is what I wanted for him.
Of course, the whole case with this patient took up a good hour of my time, so I spent the rest of the day struggling to see the rest of my patients in a timely manner. And honestly, between the death of my patient and the fact that this was my 17th straight day of work, I was in a pretty foul mood. I told my colleagues that I felt like death, could barely keep my head on my shoulders, and was at the point where I simply did not care anymore. I spent 17 days taking care of other people, but never had time to take care of me. I didn't leave work until 6:45 p.m., and I am pooped.
Thank goodness it's over.
The drawback, of course, was that toward the end of my 17 day stint I felt like I was losing my mind. I was averaging about 5-6 hours of sleep per night, and during the last week I was taking call from 5 to 10 pm every other day. This was a mistake on the scheduler's part; she'd originally put me down for three 5 to 10 pm calls in a row, which is straight-up suicide. There was a time when I worked back-to back 5-10pm calls, and I am never doing that again. Let me tell you, Q2 call is not fun at all, especially when most nights I wasn't physically able to leave the hospital until around midnight. And it was during one of these 5-10pm shifts that I experienced my worst call ever: 10 patients in 5 hours (capped out). Neither my partner or I left the hospital before midnight that day.
Christmas Eve was bad. There were lots of patients anxious to go home before Christmas, and I broke yet another record by discharging 9 people in one day. I couldn't even see all my patients on time because I had to see the imminent discharges first, and by the time I saw them and did all their paperwork, it was already very late. I'd had plans to have Christmas Eve dinner at a family friend's house at 6:00 pm, but I wasn't even able to leave the hospital until 6:30pm (still had 5 pts to see at 5:30pm, but I rounded extra-fast). Fortunately my friends had just started eating when I arrived, and the beef tenderloin, homemade mashed potatoes, red wine mushrooms, pomegranates, and cabernet sauvignon soon made me forget what a horrible day I had.
Christmas Day itself was better; I was still happy and smiling from dinner the night before (it was just the breather I'd needed), and I discharged two patients that were more than ready to go home. But a few bad things happened, too. A woman who had meningitis (I'll have to write a whole post about her in the near future) needed an emergent ventriculostomy for rapidly progressing hydrocephalus (went from AOx4 and talking to fixed pupils in 30 minutes), and another patient developed massive hemoptysis and went into PEA arrest during a bronchoscopy. Needless to say it was the Christmas from hell for the covering pulmonologist (who works every Christmas because he's Jewish); to quote him, this was his fourth massive hemoptysis since he first began practicing in the 1980s, and it put him in a foul mood for the rest of the day. Needless to say the pulmonology director had a lot of apologizing to do for his disgruntled colleague when he returned from vacation today; doctors, nurses, and even patients and their families complained about the other pulmonologist's unprofessional behavior. Thank goodness he's usually at another hospital.
The day after Christmas (today) was another day from hell. I'd barely seen 4 of my 22 patients when they announced "CODE BLUE, ROOM _____" (this hospital never says "Code Blue;" they use another term), and I immediately recognized the room number of one of my patients. He was an 86-year-old man who came to the hospital with a pathologic hip fracture from metastatic prostate cancer, and he'd been doing pretty well post-op. Just yesterday I was telling him that the Christmas cookies his family had brought him looked delicious. As I soon found out, PT had found him pulseless and unresponsive. The poor man had at least 2 shocks and 15 minutes of CPR (plus epi, amio, bicarb, atropine pushed into him), and when we reached the family, they asked us to keep him alive until they got there. Fortunately after the amio and the 2nd shock we got a "strong pulse" and we were able to transfer him to the ICU. There, his pressures were in the 50s-60s. I wanted to start pressors, but one of the nurses (wisely so) told me to talk to the family first. I met with the family and explained the situation, asking how aggressive they wanted to be. Fortunately they were very reasonable and his daughter said she didn't want any aggressive life-saving measures to be done. "We just wanted to see him," she said.
To me, the timing could not have been better. I would never want anyone's last memory of their loved one to be of doctors and nurses pounding away at their chests and shocking them to keep them alive. My patient had regained a pulse long enough so that his wife and children were able to see him lying peacefully in bed. They had enough time to summon a chaplain to the bedside, and they were together when the patient was extubated and eventually died. It was a good, peaceful death, which is what I wanted for him.
Of course, the whole case with this patient took up a good hour of my time, so I spent the rest of the day struggling to see the rest of my patients in a timely manner. And honestly, between the death of my patient and the fact that this was my 17th straight day of work, I was in a pretty foul mood. I told my colleagues that I felt like death, could barely keep my head on my shoulders, and was at the point where I simply did not care anymore. I spent 17 days taking care of other people, but never had time to take care of me. I didn't leave work until 6:45 p.m., and I am pooped.
Thank goodness it's over.
Sunday, December 9, 2012
I Need a Dreamcatcher
It seems like death just can't leave me alone in my dreams. Last night I dreamed that a childhood friend whom I haven't spoke to in years threw himself off a tall building to his death, but not before calling me on the phone and saying, "You ready?" just before the fatal jump. What I remember most vividly from the dream was hearing his voice on the phone, then the horrible silence that told me he'd jumped, me screaming, and then the accusations that followed about who was to blame for his death.
It's strange that I dreamed about this particular person, whom I considered a close friend in our teenage years, but we grew apart after high school when he became a complete rebel. He couldn't seem to stay in school and became a gay porn model (not joking) for some time. Fortunately, from what I read on FB, he's turning his life around and making a name for himself in other ways. But still, maybe it was because of his troubled background that had me dream of him throwing himself off a building. The first thing I did when I woke up was check FB to make sure nothing had happened to him. He was fine.
But seriously...what's with all these dreams involving death? Is something horrible about to happen?
It's strange that I dreamed about this particular person, whom I considered a close friend in our teenage years, but we grew apart after high school when he became a complete rebel. He couldn't seem to stay in school and became a gay porn model (not joking) for some time. Fortunately, from what I read on FB, he's turning his life around and making a name for himself in other ways. But still, maybe it was because of his troubled background that had me dream of him throwing himself off a building. The first thing I did when I woke up was check FB to make sure nothing had happened to him. He was fine.
But seriously...what's with all these dreams involving death? Is something horrible about to happen?
Thursday, December 6, 2012
Mortality Bites
I rarely remember my dreams more than a minute or so after I wake up, but last night's dream (more like a nightmare, actually) was on a whole new level. I think it began with me being in the hospital, knowing I was ill (cancer, maybe?) and with a limited time to live. I remember looking in the mirror and seeing my face appear gaunt, with hollow cheeks (which has never happened; I've always had a round face), and having friends and family take me home, asking me what I wanted for "after I go." I distinctly remember being in a room surrounded by familiar things, looking through them, and telling my next door neighbor (whom I've known since he was a baby) I wanted to be buried with my childhood journals. It was around then that I woke up, a good 30 minutes before my alarm was set to go off, and no matter what I did, I couldn't fall back asleep. I just lay in bed, feeling uneasy.
As a hospitalist, I'm no stranger to death. Fortunately my white cloud has prevailed as I've only had to sign 3 death certificates so far since starting my job in September. Even still, I've been working three weeks straight with only 1 day off in the middle, and in these past three weeks I've seen a lot of depressing things. For example, a patient with metastatic esophageal cancer came to the hospital and decided the following day he wanted hospice. He even knew which hospice facility he wanted, and knew he wanted to be comfortable in the end. His oncologist told me 1 week later that he'd died peacefully after several days in hospice; that same oncologist also said he'd lost several patients in the past 2 weeks to terminal cancer. I had another patient with ESLD who got a TIPS in hopes that it could curb his ascites. It didn't; one week after I sent him to rehab, I ran into him in the hall on the way to IR to get a paracentesis. He'd gained 27 lbs in 1 week. "Doc, I can't do this anymore, I want to die," he'd said, "and I don't want to die at that place (rehab), I want to go home." Because we were in the hall, the only thing I could tell him was to get the paracentesis, then talk things over with his gastroenterologist and sisters.
I don't think my dreams are prophetic, but there have been a few instances in life where I had a twinge of deja vu and thought, "I think I dreamed of this before." A few dreams I recall that (fortunately) did not come true include a childhood friend being wheeled into a hospital with a needle in his arm (ironically, he's now working as a nurse in Seattle) or me being pregnant and not knowing who the father is (which will never happen if I can help it). But this dream with me dying of cancer? It could happen. I've seen young people in their 20s and 30s be diagnosed with leukemias, sarcomas, and everything in between. Some (a 31-year-old woman with ALL, a 32-year-old with metastatic rectal cancer) are most likely dead now. I've been extremely fortunate to be healthy all my life, but who knows? That could change in a blink of an eye.
Death is not something I try to think about. I've watched my parents grow older these past few years, and I dread the day I have to bury them. I hate it when my dad makes comments like, "Oh, I've probably got about 10 good years left," but the truth is he might be right. And who knows how many years I have left? Everyone would like to grow old and die peacefully, but those of us in medicine know all too well that it rarely ever ends like that. Anything can happen. I can only hope it won't be anytime soon.
As a hospitalist, I'm no stranger to death. Fortunately my white cloud has prevailed as I've only had to sign 3 death certificates so far since starting my job in September. Even still, I've been working three weeks straight with only 1 day off in the middle, and in these past three weeks I've seen a lot of depressing things. For example, a patient with metastatic esophageal cancer came to the hospital and decided the following day he wanted hospice. He even knew which hospice facility he wanted, and knew he wanted to be comfortable in the end. His oncologist told me 1 week later that he'd died peacefully after several days in hospice; that same oncologist also said he'd lost several patients in the past 2 weeks to terminal cancer. I had another patient with ESLD who got a TIPS in hopes that it could curb his ascites. It didn't; one week after I sent him to rehab, I ran into him in the hall on the way to IR to get a paracentesis. He'd gained 27 lbs in 1 week. "Doc, I can't do this anymore, I want to die," he'd said, "and I don't want to die at that place (rehab), I want to go home." Because we were in the hall, the only thing I could tell him was to get the paracentesis, then talk things over with his gastroenterologist and sisters.
I don't think my dreams are prophetic, but there have been a few instances in life where I had a twinge of deja vu and thought, "I think I dreamed of this before." A few dreams I recall that (fortunately) did not come true include a childhood friend being wheeled into a hospital with a needle in his arm (ironically, he's now working as a nurse in Seattle) or me being pregnant and not knowing who the father is (which will never happen if I can help it). But this dream with me dying of cancer? It could happen. I've seen young people in their 20s and 30s be diagnosed with leukemias, sarcomas, and everything in between. Some (a 31-year-old woman with ALL, a 32-year-old with metastatic rectal cancer) are most likely dead now. I've been extremely fortunate to be healthy all my life, but who knows? That could change in a blink of an eye.
Death is not something I try to think about. I've watched my parents grow older these past few years, and I dread the day I have to bury them. I hate it when my dad makes comments like, "Oh, I've probably got about 10 good years left," but the truth is he might be right. And who knows how many years I have left? Everyone would like to grow old and die peacefully, but those of us in medicine know all too well that it rarely ever ends like that. Anything can happen. I can only hope it won't be anytime soon.
Tuesday, November 20, 2012
Discharging the Drug Seeker
When I went to discharge my pain-seeking patient yesterday, I picked up her chart and saw a sealed envelope taped to the chart addressed to me. "For Dr. ____ Only" it read. I wasn't sure what to expect, but what I pulled out were four stapled sheets of notebook paper, both front and back filled out, and consisted mainly of a list of grievances that the patient felt had been committed against her since her thoracotomy two weeks ago. Mostly, she was furious that I'd called an "MD" (her name for the pain specialist) who was "disrespectful" and "power hungry" and did nothing to try to help her pain (as she believes a pain specialist's goal is the comfort of the patient). She also described the increased "suffering" she endured from not being able to talk to me over the weekend (it was my weekend off) and accused me of forgetting our "good relationship built on trust." She felt I put my trust in the wrong person (the pain specialist), and in her words, "I suffered since you left me and in my book and most others that is not very thoughtful practice." My mental response when I read that part: What. The. F***.
Maybe she thought that she was speaking to me as one health professional to another (since she used to be a NP, apparently) and used plenty of medical terminology in her letter to emphasize that, but to me this seemed more like the ranting of a crazy person. I don't blame her for writing a letter and putting all her thoughts on feelings on paper; hadn't I done the same throughout junior high, high school, and college when I kept a journal? But this was definitely something else. She also included a list of medications she needed for home, including Valtrex (which she didn't even NEED anymore since she got 10 days of Valtrex in the hospital for shingles) and my favorite, "Dilaudid 2 mg IV q3." She claimed that she had received IV Dilaudid at home in the past, but I find that extremely doubtful. I vented to several of my colleagues about what to do, and they told me not to give her narcs at all and get her out. The problem: I knew this woman, and if I didn't send her home with scripts for narcotics, she'd throw a fit, and that's the last thing I wanted. My number one goal was to get her OUT.
When I went into her room to see her (with the nurse, of course), she initially didn't make eye contact me and said, "Did you read my note?" I said yes, then added that I'm sorry I wasn't there over the weekend and added, "It was my weekend off." She said that she understood that doctors need time off, then went on about how offended she was by the pain specialist when he tried to cut her off IV meds. I made no move to be friendly during her one-sided complaining; I kept my arms crossed like I meant business and I think she read into that. When she asked if I'd be writing her all the medications she requested, I said, "I'll take care of it." She was particularly insistent about getting oral Dilaudid, saying that she needed it for "several weeks" but I wasn't about to do that. I wrote her for a two week supply of pain medications; if she wants more, she'll either have to go to the ER or go to the pain specialist, which I doubt she'll do since she hated his guts. She even asked if she could have an extra dose of IV Dilaudid before she left, but I pretended not to hear her and the nurse quickly removed her IV and said it was time to go. Fortunately, the patient was mentally ready to leave, and she left without a fight.
Today a lot of us in the nurses' station couldn't stop talking about how much better things were now that she's gone. I, for one, am more cheerful and don't dread that particular floor anymore. I did put her note in the chart and it has been scanned and is part of her permanent record. If she ever returns with drug seeking behavior or tries to get me in trouble, I'll gladly show her note to the CEO or whoever else wants to see. Let them read that note and see exactly what state of mind she's in. She's batshit crazy, and I can only hope that I'm never on call whenever she returns. The two weeks she was my patient, I felt like my soul was being sucked out day by day. Now I can get some of my sanity back.
Maybe she thought that she was speaking to me as one health professional to another (since she used to be a NP, apparently) and used plenty of medical terminology in her letter to emphasize that, but to me this seemed more like the ranting of a crazy person. I don't blame her for writing a letter and putting all her thoughts on feelings on paper; hadn't I done the same throughout junior high, high school, and college when I kept a journal? But this was definitely something else. She also included a list of medications she needed for home, including Valtrex (which she didn't even NEED anymore since she got 10 days of Valtrex in the hospital for shingles) and my favorite, "Dilaudid 2 mg IV q3." She claimed that she had received IV Dilaudid at home in the past, but I find that extremely doubtful. I vented to several of my colleagues about what to do, and they told me not to give her narcs at all and get her out. The problem: I knew this woman, and if I didn't send her home with scripts for narcotics, she'd throw a fit, and that's the last thing I wanted. My number one goal was to get her OUT.
When I went into her room to see her (with the nurse, of course), she initially didn't make eye contact me and said, "Did you read my note?" I said yes, then added that I'm sorry I wasn't there over the weekend and added, "It was my weekend off." She said that she understood that doctors need time off, then went on about how offended she was by the pain specialist when he tried to cut her off IV meds. I made no move to be friendly during her one-sided complaining; I kept my arms crossed like I meant business and I think she read into that. When she asked if I'd be writing her all the medications she requested, I said, "I'll take care of it." She was particularly insistent about getting oral Dilaudid, saying that she needed it for "several weeks" but I wasn't about to do that. I wrote her for a two week supply of pain medications; if she wants more, she'll either have to go to the ER or go to the pain specialist, which I doubt she'll do since she hated his guts. She even asked if she could have an extra dose of IV Dilaudid before she left, but I pretended not to hear her and the nurse quickly removed her IV and said it was time to go. Fortunately, the patient was mentally ready to leave, and she left without a fight.
Today a lot of us in the nurses' station couldn't stop talking about how much better things were now that she's gone. I, for one, am more cheerful and don't dread that particular floor anymore. I did put her note in the chart and it has been scanned and is part of her permanent record. If she ever returns with drug seeking behavior or tries to get me in trouble, I'll gladly show her note to the CEO or whoever else wants to see. Let them read that note and see exactly what state of mind she's in. She's batshit crazy, and I can only hope that I'm never on call whenever she returns. The two weeks she was my patient, I felt like my soul was being sucked out day by day. Now I can get some of my sanity back.
Saturday, November 17, 2012
Master Manipulator
One of the biggest challenges I've found with being an attending is learning to deal with drug-seeking patients. I had plenty of those throughout residency, but I was protected because I didn't have a DEA number and therefore couldn't write prescriptions for narcotics. If they needed pain meds, I just said, "Talk to my attending" and left it to the attending to decide whether or not to write for narcs. Now I am the attending, and I have to deal with these narc seekers directly. Sometimes it goes well, other times not.
For the past two weeks I've had to take care of a patient (who, incidentally, used to work as a nurse practitioner before she was injured in the line of duty in Iraq) who was transferred to our hospital for a thoracotomy for a persistent pleural effusion (no CT surg at the other hospital). I'd heard from the EMS reports that the patient was a big-time drug seeker and that the other hospital was glad to be rid of her. That should have been the first indication that the patient would be difficult. She had the VATS and had two chest tubes placed. Most people are simply placed on a PCA Dilaudid until the pain improved, but not her. In addition to the PCA Dilaudid (which she rarely used), she was also getting 1-2 mg Dilaudid IV q3 prn, and then she "begged" the CT surgery team to give her a basal dose on the PCA since she was waking up in pain. There were many times when I tried to wean her off the PCA (at least the bolus), but she'd always cut me off, saying that it was "unethical" for a patient to be in the hospital in so much pain and that she needed to be comfortable so that she can undergo physical therapy and do what she could to get better.
Finally last Monday her chest tubes were pulled, and I can reinitiated plans to wean her off Dilaudid. The plan was to discharge her on Friday. She didn't really make a fuss when I stopped the bolus and then the PCA (she wasn't pressing the button much by then anyhow), but when I tried to stop the q3 Dilaudid, she argued with me, saying that she "needed" the Dilaudid while she was in the hospital. "When you're ready to let me go, I'll be fine with the pills," she said, "but while I'm here, I want to be as comfortable as I can be." Any attempts I had to try to wean her would lead to 30-45 minute conversations/arguments which I don't have time for, so previously I let her have her own way. Then the patient said she didn't want to go home on Friday b/c she didn't feel "safe" being alone especially with the Fortune-1 race in town, and that she was going to go home on Monday instead because "my insurance will cover my stay." That was the last straw. Finally I took a partner's advice and asked a pain specialist to see her. He prescribed her with a Fentanyl patch, discontinued her IV Dilaudid, and cleared her for discharge on Friday. I was told that right after he left her room, she frantically called her nurse asking to speak with me. Fortunately the nurses protected me and told her I was gone for the day, and I did all her discharge paperwork in hopes that one of my partners (who was covering for me since I took Friday off) would be able to discharge her in my absence.
It didn't work. I'd told my partner to write the discharge order and be done with it, but instead she got sucked into another 45 minute debate as my patient listed all the reasons she couldn't go home on Friday, but then agreed to go home on Saturday. See, that was crafty on her part, because Home Health doesn't go to patient's homes on weekends, and the patient needed Home Health. In agreeing to leave the hospital on Saturday, then saying on Saturday that she can't go home until Monday because that's when home health shows up, she essentially bought herself a weekend stay. I was pretty furious when I called her nurse and got this info; I was hoping not to have to deal with her this coming Monday.
But it looks like I will have to deal with her on Monday, but I'll be damned if I let her manipulate me into staying another day longer. It's pathetic to see how a former medical professional like herself became a drug-seeking manipulator, but I'm through with playing her games. She goes Monday, no matter what.
For the past two weeks I've had to take care of a patient (who, incidentally, used to work as a nurse practitioner before she was injured in the line of duty in Iraq) who was transferred to our hospital for a thoracotomy for a persistent pleural effusion (no CT surg at the other hospital). I'd heard from the EMS reports that the patient was a big-time drug seeker and that the other hospital was glad to be rid of her. That should have been the first indication that the patient would be difficult. She had the VATS and had two chest tubes placed. Most people are simply placed on a PCA Dilaudid until the pain improved, but not her. In addition to the PCA Dilaudid (which she rarely used), she was also getting 1-2 mg Dilaudid IV q3 prn, and then she "begged" the CT surgery team to give her a basal dose on the PCA since she was waking up in pain. There were many times when I tried to wean her off the PCA (at least the bolus), but she'd always cut me off, saying that it was "unethical" for a patient to be in the hospital in so much pain and that she needed to be comfortable so that she can undergo physical therapy and do what she could to get better.
Finally last Monday her chest tubes were pulled, and I can reinitiated plans to wean her off Dilaudid. The plan was to discharge her on Friday. She didn't really make a fuss when I stopped the bolus and then the PCA (she wasn't pressing the button much by then anyhow), but when I tried to stop the q3 Dilaudid, she argued with me, saying that she "needed" the Dilaudid while she was in the hospital. "When you're ready to let me go, I'll be fine with the pills," she said, "but while I'm here, I want to be as comfortable as I can be." Any attempts I had to try to wean her would lead to 30-45 minute conversations/arguments which I don't have time for, so previously I let her have her own way. Then the patient said she didn't want to go home on Friday b/c she didn't feel "safe" being alone especially with the Fortune-1 race in town, and that she was going to go home on Monday instead because "my insurance will cover my stay." That was the last straw. Finally I took a partner's advice and asked a pain specialist to see her. He prescribed her with a Fentanyl patch, discontinued her IV Dilaudid, and cleared her for discharge on Friday. I was told that right after he left her room, she frantically called her nurse asking to speak with me. Fortunately the nurses protected me and told her I was gone for the day, and I did all her discharge paperwork in hopes that one of my partners (who was covering for me since I took Friday off) would be able to discharge her in my absence.
It didn't work. I'd told my partner to write the discharge order and be done with it, but instead she got sucked into another 45 minute debate as my patient listed all the reasons she couldn't go home on Friday, but then agreed to go home on Saturday. See, that was crafty on her part, because Home Health doesn't go to patient's homes on weekends, and the patient needed Home Health. In agreeing to leave the hospital on Saturday, then saying on Saturday that she can't go home until Monday because that's when home health shows up, she essentially bought herself a weekend stay. I was pretty furious when I called her nurse and got this info; I was hoping not to have to deal with her this coming Monday.
But it looks like I will have to deal with her on Monday, but I'll be damned if I let her manipulate me into staying another day longer. It's pathetic to see how a former medical professional like herself became a drug-seeking manipulator, but I'm through with playing her games. She goes Monday, no matter what.
Subscribe to:
Posts (Atom)