Saturday, July 31, 2010

You can't make this S#$% up.

I don't even know where to start with this next patient.

First of all, he was never supposed to end up in my ICU. He had end-stage scleroderma that had hardened and was failing every organ system in his body. He didn't want to be intubated, but when he dropped a lung during an endoscopy to investigate a bleeding Peg tube (dysphagia had robbed him of the ability to eat on his own by this point), his wife said to "do everything you have to! Yes I want him intubated!"

I had heard that he didn't actually want it, but we didn't have any legal papers and he was completely unable to make legal decisions, or even say previously made ones out loud for that matter. Those kinds of decisions aren't ones we just take on good faith, "Oh, his cousin Cooter said he told him he was ready to die a few weeks ago over some beers? Welp, that settles it for me, let's make him DNR folks!" You can't exactly take it back.

Anyway. He got intubated. What's funny is, when you learn to intubate, you learn on dummies. Stiff dummies. And non-alive ones, in case a few of you smart-asses thought we practiced on the slow learners. It's very hard to recreate human skin, at least on a level that you'd be able to pay for. The guys at MythBusters seem to get ahold of good stuff. When you get to real people they are very much more pliable. Except this guy. Put the blade in his throat and instead of lifting his jaw you lift his whole dang body. Needless to say, it was neither an easy or enjoyable intubation, and required us calling Anesthesia for backup. Unfortunately, during the intubation, he aspirated a frick-ton of gut chunks. Sorry. It was gross for me too. There was really no way to prevent it, he was a very difficult emergency intubation. But it gave him a nasty case of aspiration pneumonitis and pneumonia (one's a chemical burn, one's an infection).

Fast forward one miserable week later, and this guy doesn't look like he's ever going to come off intubation. Not that it makes him reasonable. At first he was heavily sedated, but for a few days he perked up enough to spell "Eucerin cream scrotum" to let the nurses know....well, I pretended I didn't know what Eucerin was to make sure they'd take care of it. Not. My. Job.

The problem with this patient was he had nowhere to go. Every organ system he had was crapping out. And now he had a pacemaker and was on a vent and had a feeding tube, and the way his kidneys were working he'd probably need dialysis eventually. In short, the words "long-term" weren't anything we used with the family because there was no other intervention to do for him. He was just waiting for an infection to get him. Meanwhile he wouldn't be able to get off the ventilator for any kind of meaningful time period. It wasn't a bridge to improved health. It was a last resort to keep his body working. In my opinion, it probably shouldn't have been used, and that apparently was his opinion too. But when push came to shove his wife didn't want to let him go. So he laid in our ICU suffering.

That brings me to the meat of my story: the craziest s#$ goes down in hospitals. The lady I thought was his wife? Not actually his wife, but his live-in-ish girlfriend of 27 years. He'd never wanted to marry her, his family told me. Repeatedly.

I had noticed something was weird with the family a few days into the saga. For one thing, there were tons of them. For another, several family members, especially adult women, got thisclose to his face, repeatedly asking questions and trying to get him to write on a little clipboard. They were so close to his face I thougt they were sharing an endotracheal tube. They just hovered constantly. His "wife"/girlfriend/Creepy McCreeperson was especially attentive, fawning over him, fussing over him, accidentally unhooking monitor wires and IV's as she repositioned him. I actually walked in on her putting makeup on his face one day because, "he doesn't like his spots (vitiligo) to show." "Something is just off" I told my co-intern.

One thing that was indisputable was that every morning I'd look at his vitals and they would be perfect. They were something I could take to my attending and show how I had his BP and heart rate under control. Then by 11:00 nurses would be running to find me and tell me his BP was in the 190's and what was I going to do about it?!?!

I tell you what I did about it. I kicked everyone out of his room. It took some huevos, but after I realized I actually had the authority to do it (still can't remember I'm an for real doctor now), I walked into the room, re-introduced myself emphasizing the doctor part, and said, "I know you all want to be with him now, but my job is his vital signs. And they're going to Hell in an emesis basin." LOL I said the last part more like, "All the extra company and crowding in the room seems to agitate him. His blood pressure is up 30 points from when I first see him in the morning. I can't have this for my patient. We have a 2-visitor policy and we're sticking to it." The women clucked and agreed and kissed his hands 30 more times before I realized that they weren't leaving until I said "NOW." Which I actually did as I physically ushered them out. Later his daughter said, "They would not leave him alone! When you came in there and said you weren't having it in your ICU I was like "Oh good, she's MAD now!"

Things got weirder at night. I started making it a habit to go by the cafeteria and pick up my second breakfast (one to get me out the door, one to keep me from jumping out the window) and sit down to read the night nurses notes. One morning I just about spit out my oatmeal when I read the "wife" and her sister (who I didn't actually know was her sister, but whatever) came out of the patient's room and told the nurse that Terrence had asked her to marry him. Huh? The man is on a VENTILATOR. Have you ever tried to propose with a tube down your throat? Oh, he wrote it out they said. "Note showed to nursing staff did not seem to match patient's handwriting," the nurses' documentation read.

I thought it would be dropped, but nope nope nope. By now we were starting to talk extubation and "comfort care only". Things got a little more urgent. The patient also had a plastic sheet with the alphabet on it, thought being you could spell out simple words, not make life decisions or write legal documents. Wouldn't you know, the patient "spelled out "will you marry me?" on his tablet!" the girlfriend insisted.

The macrabre spectacle started becoming a part of our patient care. "Don't let patient get married." was in my checkout sheet to the night resident. "Wha..?" "I'm serious. Crazy things happen here at night. Don't let that be one of them." She brought in a chaplain one night (I was starting to wonder if the fact that I repeatedly put the kibosh on proposal-writing and man-hounding during the day is what made this a nightly occurance) and had to be told for the 10th time that we did not believe the patient was capable of making complex decisions. No, not just because of the ventilator. The powerful narcotics were also something to consider.

As she grew more insistent, so did we. I started to document in my notes that I specifically did not believe he was capable of making legal decisions. It's not something I said lightly, seeing as he knew he was dying and if he did know what he was saying I'd hate for him to not get the chance to cut that mean-looking sister out of his will. But I also saw myself getting lead down a road to one of those fake weddings you see in a movie where the heroine is bound and gagged and the deaf old minister says, ""LemmegoIdon'twantthissssshhhh? Was that a yes? Ok, very well, I now pronounce you..."

Each night she'd insist they were getting married the next day. I started hearing things like, "she told the nurse something about her name not being on their stuff. He has a car and a camp trailer I think." God knows he couldn't have had much else. The patient's mom told the medical student not to let them get married because she gave him crabs in the 1990's. She started asking what kind of doctor can declare a person legally competent to get married. One time, after clearing the room, it was just me and the medical student with him. "Ok Terrence. It's just you and me. Tell me, do you want to get married?" I asked. "I...want...to...breathe...." he said. "Well, I don't know if that's a metaphor, but I'll check your vent settings and try to keep you single." I replied.

One of his sisters came in with papers folded up in her back pocket that I saw her waving under his face with a pencil. His nurse told me they were papers she wanted him to sign leaving her that damn camper and car. "He promised me this stuff a long time ago" she said. "OUT." I said.

His adult children, who I now realized were the only sane ones in the bunch, told me the patient's sisters and brothers were in the waiting room dividing up his stuff. The daughter was in tears over how her family was cracking and spilling their greedy craziness all over what should have been their time to say goodbye to their dad. This is the daughter that thanked me for kicking everyone out. At the time I honestly didn't know if they'd listen or gang up on me, but I guess it's what she was waiting for so she'd get some alone time with her dad.

We got the Palliative Care team involved. They specialize in helping patients and families make tough decisions and transitions. Their attending asked me to PLEASE make sure I was documenting the patient's condition. But the woman wouldn't leave it alone.

The weird thing was, to look at her, she looked like a sweet middle-aged school teacher with little glasses and curly hair pulled back in a low ponytail. If I only saw her during the day, I would have thought it was sweet. But every other piece of evidence pointed to batshit crazy. Why would you stick with a man for 27 years who, when asked if he wanted to marry you, would have actually answered "Over my dead body" and meant it?

On the day we were going to extubate him, she showed up in all in white. Down to her new tennis shoes. "Craaaappp. This is going to be a fight." I thought. She had already bought herself an engagement ring. She had her chaplain. "I just know Terrence's last wish was to get married," she said. The Palliative attending and I got him alone again. "Do you want to get married today?" She asked. "Msmdhhmimme". He said. "Well I don't know if that was a yes or a no. Do you want to get married?" "It's time." He said. Hmm...again not really a yes or no answer. We tried again. "Yes or no, do you want to get married?" He nodded. "I'll be damned." I thought. "It's time." he said. "Romantic," I thought.

After a little ingenuity, the Palliative Care doc came up with the idea of a "spiritual wedding." One where we very clearly stated the patient would not be signing any legal document or marriage license, but if it meant a lot to the woman, they could have a marriage ceremony in the room. I thought it was freaking brilliant, but after the PC attending said of all the weddings she's held in the ICU (really?) this was the only one that made her want to throw up.

So after the patient talked to the kids and they felt satisifed that he really meant it, a "spiritual wedding" was held. It was bizzare, but it shut the lady up. "Huh, maybe all she wanted was to be married in Jesus' eyes after all," I thought.

What a dope. That night his mother called and said that Abigail had told her she and Terrence were married, they signed papers, and it was all legal.

He died the next day while Abigail was reading to him from Psalms. His kids cried and prayed over him for an hour. His sisters and brothers didn't show up. As for me, I won't be surprised if my documentation doesn't earn me a subpeona when this fight over his trailer goes to probate court.

Sunday, July 18, 2010

Emotions take time...

And I don't have it. I've started two more blog posts, but just don't have the emotional capacity or the hour of consciousness it take to finish them. So I'll pacify you with a little story.

I declared my first death the other day. Lucky for me I had a.) Expected it and b.)Not caused it. The senior residents gave us a little booklet with various how-to's they don't have time to teach you in medical school, such as how to declare a death, so when the nurse asked me to pronounce it I trudged to the room, thumbing through the booklet.

Step one is introduce yourself. These people knew me, because before it was imminent (to me) that the man was going to die, I'd kicked the majority of them out of the ICU for hovering around him asking him which of his possessions they could have. I didn't care who got his boat, I cared that his blood pressure spiked 70 points when they were in the room. How do you ask a man on a ventilator to sign a will? ("because he promised me these things before he was on a ventilator" was the answer)

Next up explain that you have to do a physical, see if they want to leave (they still didn't), and then spend an awkward five minutes assuring the person is dead without upsetting the family. How would YOU make sure a person is dead? No, really dead, not just "Oh, I think he's dead but we should call the authorities." You ARE the authority, and if you say he's dead and he isn't, well, I don't want that skeleton in my closet.

Suffice to say, I check his wrist like I'm feeling for a pulse and squeeze the bejeezus out of a fingernail.

You also have to do things like check the wristband to make sure it's the right patient (wonder what happened to get that rule put in place), say his name out loud, listen for heart sounds for FIVE WHOLE MINUTES, which quite frankly is five whole minutes longer than I care to spend in the company of the deceased, and check for pulses in several places.

There are a few things the guide did not mention.

After I'd done each of the steps, I have to admit I was afraid that being freaked out by touching a corpse so repeatedly for the first time since anatomy had made me possibly miss a heartbeat or pulse. I didn't want to just phone this one in, so for good measure, med student by my side, I put my fingers where his radial pulse should have been one more time.

That's when his arm jerked.

Just poop yourself? Because I practically jumped out of my white coat when it happened. I actually physically jumped back and flung my arm up. The slow-reflexed medical student was still frozen beside me when it dawned on us. "I think that's his pacemaker," his spiritual wife (another story) said. Thank God Thank GOD she was focused so much on his body when he jerked she didn't see me swallow my tongue.

So, moral of the story, if someone is going to die, FOR THE LOVE OF GOD CALL MEDTRONIC AND HAVE THEM TURN OFF HIS PACEMAKER! If I didn't know the patient well enough to remember he had it, I may have tried to shoot him in the head.

I hope you all know that's how you kill zombies.

Wednesday, July 7, 2010

And today was his birthday

We had husbands crying all around the ICU today.

I wish I could find humor in it, but today was so stinking sad that I just can't. Today wasn't about finding humor in life, it was about making hard decisions and offering comfort.

One patient has been in the hospital for months. Before that she lost her legs in previous hospitalization, and before that she was a marathon runner. She's in her late 50's, and I don't need magic glasses to see what she was like, I can just look at her daughter who can barely stand to come by the hospital now.

I have been taking care of her for a week, and every morning I'd go in to see her, and every morning she wouldn't respond. She might open her eyes, she might even follow me around, but she didn't answer questions or even reveal any understanding of what I was saying to her. Her skin is puffy and weeping from edema, her face is encircled and squished by the ventilator straps (yes, you can be conscious and on a ventilator-I was not really aware of that). I couldn't tell if she were in pain or not. As a doctor that seemed like the one thing I could really do for her, but I was really just standing there by her bed stupidly repeating the same questions and wondering if she was screaming at me inside her head. Her husband was broken up over this change in his wife. In a lot of people's minds, you're either going to get better or you die. Three months in and we didn't know. That's very hard to understand.

This morning she nodded. She nodded! "Are you in pain?" I asked. She shook her head. "Are you having trouble breathing?" She shook her head. Can you nod your head for me? She nodded. I was elated. I bounced around telling the nurses and other residents that Peggy had cleared up and answered questions for me. This is what I'd been waiting for! We could extubate her! She would breath on her own and then slowly but surely get better and then go home to her sweet husband who brought bags of chocolate for all the nurses!

Then her CT scan came back. She had both persistent and new areas of abscess in her pancreas. You can't get rid of abscesses with antibiotics. You have to drain them or cut them out. Interventional radiology could reposition or replace the drain, but the attendings knew from their previous visits with her that every other time her drain had been repositioned or replaced, she went septic, getting sicker and taking longer to recover each time.

We had a family meeting with her husband today. He was alone in the room with her, dapper in a cowboy hat and boots with a yellow button down shirt. We explained the CT and what it meant, and asked him what he wanted to do.

He said, "She was fine until all this started. Then she got sick the first time. Then it killed her when she lost her legs (during her septic shock her legs infarcted from too little blood, becoming gangrenous) but she said she wanted to be fitted for her prosthetics. Now each time she goes down she comes back worse. She looks like a corpse. It's tearing the kids up to see her. I don't know if I can get my wife back. I know her face; I know the furrow in her brow. I can't see her in agony all the time like this." At this point her nurse started to cry. It took everything I had not to let the tears leave my own eyes. We asked her what she wanted, but she couldn't talk and couldn't answer complex questions. You could tell she recognized her husband. When we asked if she knew what she wanted she didn't answer. When we asked if she was scared her eyes grew big and a tear dropped down her face.

He asked the attending point blank what he would do. The attending thought and said that if it were his mother, he would consider how it would take months of everything going perfectly to get her to her best possible level. And that we didn't even know if that level was going to be where Peggy would want to live at.

In the end the husband decided to pull her ventilator. She is breathing on her own, and we are still giving her antibiotics, but it's only a matter of time before she gets septic again.

Today was her husbands birthday. I hope she makes it a few more days so he doesn't have to remember every birthday like this.

I don't know how the nurses can handle it. They are with these patients for months, get their hopes up, and then sit with the families when there isn't hope left. One nurse drove two hours home to see her parents after a patient suddenly died this week. I made sure to hug my own sweet husband extra tight when I got home today.

I wish

I wish I had a pair of magic glasses. That way I'd see child hugging his mother, instead of an elderly man leaning over a shell. That way I'd see a little boy holding his mother's hand, instead of a stubborn old fool trying to keep a corpse alive. That way I'd see how they used to play together instead of how he tries to manipulate the system for her. I'd understand how he didn't want to leave her the first day of school, then maybe I'd see why he's willing to put tubes and lines in her 90 year-old body so she won't leave him now. To him it doesn't seem to matter that her memories are gone, her consciousness addeled, her speech stopped. As long as her heart doesn't stop beating he still has a mother.

I hope I remember that when we pull her ventilator tube today. Because right now I feel relief for her and pity for him.