I've been working nights for the past 4 days, and during my 2nd night, the ED was full of drunks and psych patients. One ED doc grumbled that he was tired of people calling him a "f***head;" a lot of people joked that maybe the supermoon was the reason why the ED was so full. Fortunately for me, drunks and psych patients don't need to be admitted unless they're medically unstable, so I only did 5 admissions that night. Even still, I had the feeling that I would pay for it much later.
Last night was my worst night call to date. I got 4 patients in the first 30 minutes, already a bad start, but I was able to triage them and see them in order of sickest to least sick. However, the admits kept coming, and after 3 hours I had 9 admits and was still at least four in the hole. The ED doc even asked to make sure I didn't have any sharp/hard objects in my hand before he gave me another admission. I was hoping there would be a time where I'd be able to catch up on my admissions and not be 2+ in the hole, but it never happened. I was in the hole all night, and as the admits kept coming, I'm sorry to say that I also became angrier and angrier. Usually I'm good at keeping my emotions at bay, but not last night. I was slamming charts on the table, dropping f-bombs when talking to the ED docs as they gave me yet another admission, and slightly rude to the floor RNs who called to say their patient needed a sleeping pill. By the end of my shift, they'd given me 16 admissions, of which I could only complete 15 because I didn't have time to see the 16th. I didn't finish dictating my h&p's until nearly 7 a.m., a whole hour after my shift ended. If I'd seen that 16th patient, who knew when I would have left the hospital. At any rate I was in a completely bitchy mood as I left the hospital, which I'm sure did not go unnoticed by my coworkers.
Went home, slept for 4-5 hours, then treated myself to a 60 minute massage (found a 20% off coupon in my inbox, decided to use it). There were a lot of knots in my lower back and neck (no surprises there; I've been waking up stiff for the past few days), but those got smoothed out by the therapist. It was just what I needed after 4 days of working nights; I feel better now =)
Monday, June 24, 2013
Wednesday, June 19, 2013
Prisoners
I recently had a patient get admitted for a-fib, and I learned that he'd been in a correctional facility (aka prison) for the past five years. I don't know what he did to earn such a sentence (and who knows how many years he has left), but he was one of the nicest patients I'd ever had the pleasure of caring for. A few nurses and I wondered what crime he had committed in the past that landed him in prison, and in a way, I don't want to know. I'd rather keep the memory of him telling me, "God bless you" when I told him he could go home, rather than learning that he did something heinous like assault another person or commit murder. That reminded me of another patient I admitted one night, and the "what-if's" still haunt me once in a while.
Last month when I was working nights, I admitted a 29-year old male with asthma exacerbation. He said that he had become short of breath while walking on the street; I remembered he was pleasant to talk to. The following night I heard a "Code Purple" (code for "Aggressive patient or family member") overhead pointing to his room, and I wondered what could possibly be going on because I remembered him being a nice guy and unlikely to cause trouble. Usually I stay away from Code Purples; security usually deals with all that, and I didn't think much of it later. I found out later that he had gotten into an argument with his ex-wife who had come to visit him.
Later on, I looked the patient up to see how he fared after he was admitted. Then I got a huge surprise: the patient's mother had called the hospital saying that he had told her that he had knives in his room and that he was going to hurt himself and some of the nurses who kept coming into his room and "bothering" him. In fact, he had used a fake ID to get into the hospital; in reality, he was wanted by the police for assault (apparently tried to choke his ex-wife prior to coming to the hospital) and has a strong history of violence. He'd had a bag in the room with him that he'd refused to let the nurses handle; when security searched him at the social worker's insistence, they found a machete and another knife in the bag. He then began making threats and ranting that there was a hitman out to get him. The police was then called to take him to jail.
I was speaking to one of the nurses about this today, and she commented that she and another nurse had "been chatting with him" most of that day, and no one knew that he had a knife in his bag. What if he'd chosen to act on his paranoia? What if he pulled out that machete in the ER while my back was turned and sliced off my head? What if he stabbed the nurses instead and then proceeded to attack other people in the hospital? I imagine something like that would have made national news and brought up the issue of safety in hospitals. How the hell did the patient get a MACHETE into the hospital? I know we don't have metal detectors, but usually personal belongings are well documented prior to the patient leaving the ER. I hate to think about what could have happened if the patient's mother didn't call the hospital, what kind of terror he could have unleashed if he became any more unstable in the mind. We were very lucky.
Last month when I was working nights, I admitted a 29-year old male with asthma exacerbation. He said that he had become short of breath while walking on the street; I remembered he was pleasant to talk to. The following night I heard a "Code Purple" (code for "Aggressive patient or family member") overhead pointing to his room, and I wondered what could possibly be going on because I remembered him being a nice guy and unlikely to cause trouble. Usually I stay away from Code Purples; security usually deals with all that, and I didn't think much of it later. I found out later that he had gotten into an argument with his ex-wife who had come to visit him.
Later on, I looked the patient up to see how he fared after he was admitted. Then I got a huge surprise: the patient's mother had called the hospital saying that he had told her that he had knives in his room and that he was going to hurt himself and some of the nurses who kept coming into his room and "bothering" him. In fact, he had used a fake ID to get into the hospital; in reality, he was wanted by the police for assault (apparently tried to choke his ex-wife prior to coming to the hospital) and has a strong history of violence. He'd had a bag in the room with him that he'd refused to let the nurses handle; when security searched him at the social worker's insistence, they found a machete and another knife in the bag. He then began making threats and ranting that there was a hitman out to get him. The police was then called to take him to jail.
I was speaking to one of the nurses about this today, and she commented that she and another nurse had "been chatting with him" most of that day, and no one knew that he had a knife in his bag. What if he'd chosen to act on his paranoia? What if he pulled out that machete in the ER while my back was turned and sliced off my head? What if he stabbed the nurses instead and then proceeded to attack other people in the hospital? I imagine something like that would have made national news and brought up the issue of safety in hospitals. How the hell did the patient get a MACHETE into the hospital? I know we don't have metal detectors, but usually personal belongings are well documented prior to the patient leaving the ER. I hate to think about what could have happened if the patient's mother didn't call the hospital, what kind of terror he could have unleashed if he became any more unstable in the mind. We were very lucky.
Thursday, May 30, 2013
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.
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.
Tuesday, May 28, 2013
You again?!
Almost 5 years ago when I was doing my sub-I at Brack, I had this borderline, noncompliant diabetic patient who was a total jerk through and through. Although I'd forgotten his name, I remembered him well b/c my resident made me see him everyday. Back then he had kept coming back to the hospital with lower extremity cellulitis because he didn't take his antibiotics. I remembered how he kept refusing the MRI that we ordered for him to rule out osteomyelitis, how he threw things at the wall and cursed at nurses, how angry he was because we put him on a diabetic diet, and how his room reeked whenever we went into his room b/c he wouldn't bathe and sometimes wet the bed intentionally so that he could accuse the nurses of neglect. He was only 29 years old at the time, and I thought it was a shame that he wouldn't take care of himself.
During my rounds today, I spotted him in the hall talking to one of the nurses. He saw me, too, and at that point I was 90% sure it was him. How many young overweight guys with a BKA in a wheelchair are there in Austin? Then I heard his voice, and I was absolutely certain it was him. There was not a single day at Brack where he didn't find something to gripe about, and as he complained to the nurse about his doctor, I recognized his voice for sure. I later looked him up; it seems that in the years since I last saw him, he'd gotten an ostomy from an abdominal wall infection, and currently he wanted to fire his doctor for not giving him Dilaudid. Apparently the plan is to discharge him from the hospital tomorrow; hopefully he goes back to Brack because there's no way in hell I want to take care of him ever again. Hopefully he doesn't remember me; I'm sure he's seen lots of doctors and med students come and go since he probably goes hospital shopping. Sad that some people never change.
During my rounds today, I spotted him in the hall talking to one of the nurses. He saw me, too, and at that point I was 90% sure it was him. How many young overweight guys with a BKA in a wheelchair are there in Austin? Then I heard his voice, and I was absolutely certain it was him. There was not a single day at Brack where he didn't find something to gripe about, and as he complained to the nurse about his doctor, I recognized his voice for sure. I later looked him up; it seems that in the years since I last saw him, he'd gotten an ostomy from an abdominal wall infection, and currently he wanted to fire his doctor for not giving him Dilaudid. Apparently the plan is to discharge him from the hospital tomorrow; hopefully he goes back to Brack because there's no way in hell I want to take care of him ever again. Hopefully he doesn't remember me; I'm sure he's seen lots of doctors and med students come and go since he probably goes hospital shopping. Sad that some people never change.
Saturday, May 25, 2013
Discrimination among doctors
The other day I mentioned to one of my colleagues that a UT student recently emailed me asking me for advice on getting into medical school when her GPA (which she did not reveal) was "not very high." His response: "Apply to DO schools?"
I could not believe he said that, but then again, I don't think he knew I was a DO. Unless we ask each other or volunteer the information, I have no idea where my colleagues went to medical school or residency. And unless someone really looks at my ID or white coat, no one knows I'm a DO and not an MD. In the past 3-4 years I've been a doctor, I've never encountered any discrimination against DOs (or maybe I was just lucky). The hospital where I did my residency was a melting pot of US grads, DOs, and foreign grads; there were about 8 DOs in my class, and some of our attendings were DOs as well. There was no discrimination. We didn't care where we'd trained or what initials were after our names; we were colleagues first and foremost. I think there was one time I asked a friend why he went to med school in the Caribbean. His response: "I can't believe you're even asking me that." Which is true. Why did it matter? At any rate, he's doing an endocrinology fellowship, and my other friends who went to Caribbean schools are currently doing fellowships in nephrology, cardiology, and ID. As for other DOs in my class, they matched into fellowships in cards, heme/onc, nephrology, and GI. Actually I think I'm the only DO who didn't match fellowship in my year, but that doesn't make me more of a failure. I'm making a very good living right now, and I'm well liked and well respected in my hospital by doctors, nurses, and patients alike. To me, that is success.
Later I mentioned the other guy's comment to one of my partners (about 20 years older than me), thinking he'd be a more supportive since the two of us work well together and have a good relationship. His response: "Why did you even apply to DO school?" Apparently back in his day my alma mater was sending letters to prospective med students inviting them to come there to study medicine, which gave him the impression that no one wanted to go there and they were desperate for students. Of course it's different now; our school has a good reputation for primary care and is fairly well known so there's no shortage of applicants. My partner then went on to express his astonishment that one of our favorite cardiologists (the only other DO in the hospital that I know of) matched into cardiology and became successful, as though DOs were only meant to do primary care and nothing else. His attitude reminded me exactly of my dad, who tried to convince me eight years ago to give up my spot at TCOM and reapply for MD schools because he didn't want me to be a DO. He'd heard from a MD neurologist that DOs had no respect in the medical profession and that people would always look down on them, and he didn't want that for me. Apparently when I made my rank list, he didn't think I'd actually match at a DO school so he didn't say a word, and he was very unsupportive when I told him I intended to keep my spot. Nasty words were hurled and we had a huge falling out afterwards; I had to escape to Taiwan for the summer to get away before I could speak to him in a civil manner again. I even recall looking at apartment brochures because there was no way I was going to move back home (even though school was 20 min away), but my mom talked me into it by promising me lots of privacy. Of course, this happened a long time ago and my parents couldn't be more proud of me now, but I can never forget the hell they put me through following Match Day, just because they wanted me to be an MD and not a DO.
The conversation I had with my partner, however, dragged up all those unpleasant memories again, and now I'm pissed and angry at him. Why should I have to justify why I was not an MD? Why was he asking me why I even applied to DO school in the first place, eight years after the fact? Back when I was debating whether to keep my spot or reapply the following year, an adviser at UT asked me this question when I told her my dilemma: "Do you want to be a MD, or do you want to be a physician?" The answer was obvious: I wanted to be a physician. And now that I've become what I set out to be eight years ago, I had hoped that my being a DO would not make a difference in how people saw me. And now it seems my own father was right all along. I just wish my partner would have kept it to himself and not thrown it in my face.
Fortunately, most of the people at work don't seem to care about the initials following my name, and if someone does bring it up, I dare them to say I'm a horrible doctor. Because I know that I'm good at my job, and that's what matters at the end of the day.
I could not believe he said that, but then again, I don't think he knew I was a DO. Unless we ask each other or volunteer the information, I have no idea where my colleagues went to medical school or residency. And unless someone really looks at my ID or white coat, no one knows I'm a DO and not an MD. In the past 3-4 years I've been a doctor, I've never encountered any discrimination against DOs (or maybe I was just lucky). The hospital where I did my residency was a melting pot of US grads, DOs, and foreign grads; there were about 8 DOs in my class, and some of our attendings were DOs as well. There was no discrimination. We didn't care where we'd trained or what initials were after our names; we were colleagues first and foremost. I think there was one time I asked a friend why he went to med school in the Caribbean. His response: "I can't believe you're even asking me that." Which is true. Why did it matter? At any rate, he's doing an endocrinology fellowship, and my other friends who went to Caribbean schools are currently doing fellowships in nephrology, cardiology, and ID. As for other DOs in my class, they matched into fellowships in cards, heme/onc, nephrology, and GI. Actually I think I'm the only DO who didn't match fellowship in my year, but that doesn't make me more of a failure. I'm making a very good living right now, and I'm well liked and well respected in my hospital by doctors, nurses, and patients alike. To me, that is success.
Later I mentioned the other guy's comment to one of my partners (about 20 years older than me), thinking he'd be a more supportive since the two of us work well together and have a good relationship. His response: "Why did you even apply to DO school?" Apparently back in his day my alma mater was sending letters to prospective med students inviting them to come there to study medicine, which gave him the impression that no one wanted to go there and they were desperate for students. Of course it's different now; our school has a good reputation for primary care and is fairly well known so there's no shortage of applicants. My partner then went on to express his astonishment that one of our favorite cardiologists (the only other DO in the hospital that I know of) matched into cardiology and became successful, as though DOs were only meant to do primary care and nothing else. His attitude reminded me exactly of my dad, who tried to convince me eight years ago to give up my spot at TCOM and reapply for MD schools because he didn't want me to be a DO. He'd heard from a MD neurologist that DOs had no respect in the medical profession and that people would always look down on them, and he didn't want that for me. Apparently when I made my rank list, he didn't think I'd actually match at a DO school so he didn't say a word, and he was very unsupportive when I told him I intended to keep my spot. Nasty words were hurled and we had a huge falling out afterwards; I had to escape to Taiwan for the summer to get away before I could speak to him in a civil manner again. I even recall looking at apartment brochures because there was no way I was going to move back home (even though school was 20 min away), but my mom talked me into it by promising me lots of privacy. Of course, this happened a long time ago and my parents couldn't be more proud of me now, but I can never forget the hell they put me through following Match Day, just because they wanted me to be an MD and not a DO.
The conversation I had with my partner, however, dragged up all those unpleasant memories again, and now I'm pissed and angry at him. Why should I have to justify why I was not an MD? Why was he asking me why I even applied to DO school in the first place, eight years after the fact? Back when I was debating whether to keep my spot or reapply the following year, an adviser at UT asked me this question when I told her my dilemma: "Do you want to be a MD, or do you want to be a physician?" The answer was obvious: I wanted to be a physician. And now that I've become what I set out to be eight years ago, I had hoped that my being a DO would not make a difference in how people saw me. And now it seems my own father was right all along. I just wish my partner would have kept it to himself and not thrown it in my face.
Fortunately, most of the people at work don't seem to care about the initials following my name, and if someone does bring it up, I dare them to say I'm a horrible doctor. Because I know that I'm good at my job, and that's what matters at the end of the day.
Thursday, April 18, 2013
Being Prepared
After the bombing at the Boston Marathon on 4/15/13, plus the explosion at West and the ricin envelopes in DC, it's become more obvious than ever that no place is truly safe. At lunch yesterday I asked one of the emergency medicine docs if Austin was prepared for mass casualties (it's no longer far-fetched to think that someone may drop a bomb in the middle of SXSW someday), and he said yes. Apparently they run mass casualty drills once a year, and he recalled that when Hurricane Katrina hit, many patients from coastal hospitals were evacuated to Austin. I forget how many people he was able to triage in ___ hours, but it was done. He also commented that if anyone really wanted to do serious damage to Austin, then the football stadium at UT on any home game day would a prime target. Thousands of defenseless people in one spot, they'd be sitting ducks. Whereas at SXSW, everyone was all spread out. And of course UT is always a target; wasn't there already a shooting there in the 60s?
There are many runners at my hospital (one of my partners ran the Boston marathon years ago), so the bombings have been a hot topic here. I know a guy who is a surgery resident at one of Harvard's teaching hospitals, and he commented that he's been treating some of the victims from the bombing. I don't dare ask for details, but I imagine it must be hard being on the front lines, seeing the damage the bombs caused to these patients, trying to fix them up. What can an internist do in such a situation? I once admitted a patient for chest pain after her house caught on fire and her husband died in the fire (back in Philly), but that seems tame compared to what's going on now.
I certainly hope that I'll never have to encounter an event with mass casualties in my lifetime, but if I do, I would be out there helping others, just as we were taught (and called) to do. It's our duty as physicians.
There are many runners at my hospital (one of my partners ran the Boston marathon years ago), so the bombings have been a hot topic here. I know a guy who is a surgery resident at one of Harvard's teaching hospitals, and he commented that he's been treating some of the victims from the bombing. I don't dare ask for details, but I imagine it must be hard being on the front lines, seeing the damage the bombs caused to these patients, trying to fix them up. What can an internist do in such a situation? I once admitted a patient for chest pain after her house caught on fire and her husband died in the fire (back in Philly), but that seems tame compared to what's going on now.
I certainly hope that I'll never have to encounter an event with mass casualties in my lifetime, but if I do, I would be out there helping others, just as we were taught (and called) to do. It's our duty as physicians.
Tuesday, March 5, 2013
The Weekend From Hell
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.
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.
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.
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