Too long, too short, too little too much...
We have a service cap, in Medicine. At seven admissions/consults, the resident on call stops taking admissions. Period. At that point it's going to take you the rest of your life to finish writing stupid H&P notes on your patients, anyway, not to mention you'll be rounding on seven patients post-call is horrible, not to mention that this is supposed to be a learning experience, right?
I closed the service at 1730 Thursday. Seven admissions, bangbangbangbang. I'd gone into it with four patients on my panel and a load of social issues that were going to have to be dealt with one way or another, and my medicine chief said to me "Maybe you'll have a day like J. She didn't get any calls at all until after dinner."
I got called at 10:30, just after I'd written the last note on my last existing patient. And then at 11:00, and then at 11:45, and then I knew how it was going to go. There was no chance to talk about going home with the fifty-something man who'd been living in his landlord's houses and refurbishing them until he'd suffered a cocaine-induced stroke - no chance to explain to his family that we were going to have to send him to the homeless shelter if they weren't willing to take him in. There was no chance to meet with the family of the retired firefighter with alcohol-induced dementia who was too weak to go anywhere but a nursing home for rehab, no matter how much they wanted to take him home (oh, and by the way, his insurance is hospital indemnity, you'll be paying for it on your own) and find out if they'd decided on a place for him. There was no time to do more than chat briefly with the man with chronic pancreatitis and splenic vein thrombosis, see if he was still willing to go home the next day (he was) and certainly not enough time to pick up medication assistance program forms for him to fill out so that somehow we could work out his pain control. There was no time to carry out more than the briefest of searches for a Spanish list of Vitamin-K rich foods for the lady who'd been here five days and was beginning to fret about how well her husband was caring for their seven children (twins and triplets from the last two pregnancies, what a surprise) while she languished becoming therapeutic on coumadin. It was one patient to the next, jotting down notes on notecards, hoping I could keep up with the essentials and write everything up later.
Ninety-year-old with known coronary disease, chest pain and weakness. The real struggle with her was establishing code status when I realized I hadn't done so. She has papers, she said, at the clinic. She didn't think about these things. It was after five. We went back and forth. She didn't want drastic measures. I described chest compressions, shocks, and intubation. She agreed, they were all drastic measures. Finally she made a statement I could put my finger on. "I don't want you to do anything to bring me back, if I die. And if there's no hope, I don't want you keeping me alive with machines." I nodded. "The last time you were in the hospital, two months ago, did you look at your papers then?" A nod. "And you made your decision based on those papers?" I think so, she says to me, all maddening vagueness and taking-her-time. "Then do you want us to do the same things you wanted us to do the last time?" It was a sweet accord, at last. Yes, I think that would be right. "Last time, you didn't want us to do chest compressions or shocks or anything of the sort. That doesn't mean we won't use medicines to help with your blood pressure or give you oxygen to help you breathe, it just means the drastic things." Yes, she agreed, no drastic things. No shocks, especially.
Order timed and dated, late at night. Code status: No Code Blue. The same order that had been written last time. It was an awkward discussion, not like the no code I'd written a few days prior. But it was, as far as I could tell, what she wanted.
There is a piece of paper folded in the pocket of my white coat: "The hospice facility called to let you know that Mr. X died this morning. Please call with questions." I'd sent him there only the day before, a skeleton of a man, eighty, blind, partly deaf, bedridden and suffering from esophageal strictures that made him unable to eat. GI dilated the strictures, but he seemed to have given up on living at all; his body so thin that every bone was visible. He'd been at home, on oxygen, unable or unwilling to get out of bed since November when he'd come home from pneumonia. His wife said she heard him praying for death sometimes at night. He panicked if she was far from him; this tiny frail woman washed and fed him, tended him, lived for him. Sixty years of marriage had come to this duality, and she was so tiny herself.
He was well-cared-for, well-tended; not as malnourished as he looked like he was. She'd been trying to feed him despite his refusal to eat. We could do little more in the hospital than she'd done at home. And he was dying, slowly, in that agonizing stretched-out way that cardiac cachexia kills, that takes men who do not wish to live but are too stubborn to give up. He didn't want tubed or shocked or reperfused or anything. He didn't even want to be in the hospital with our meager efforts at saving him. His wife looked at me with dark, hollow eyes. "I don't want to be selfish...I want what's best...but I don't want him to suffer any more. This isn't living." I nodded. Code status: No Code Blue.
I meant to call that day, and to find out if there would be a service or flowers or anything. His wife was desperate - no doctors would pay house calls - I told her I would be his doctor during hospice and she broke down in tears. "You're an angel from Heaven." I'm young and I can't stand the idea of this man dying without someone caring. I meant to call, but then there was the man with seizures who came in and went to ICU. There were more rule-out chest pains. There was the man with antiphospholipid antibody syndrome needing pain control. There was the service closing at five-thirty from my seven admits and then I was writing H&P's most of the night.
At least, I only had two more to go when I got called to evaluate my seventh admit, who was not doing so well on her bipap.
The first time I sent a patient to the ICU kept me there all night. I will tell you about it later; for now I need to prepare for tomorrow. Another busy day - at least I'm not on call. Three patients remaining of the eleven I started with on Friday morning, and clinic in the afternoon. It could be worse.
I closed the service at 1730 Thursday. Seven admissions, bangbangbangbang. I'd gone into it with four patients on my panel and a load of social issues that were going to have to be dealt with one way or another, and my medicine chief said to me "Maybe you'll have a day like J. She didn't get any calls at all until after dinner."
I got called at 10:30, just after I'd written the last note on my last existing patient. And then at 11:00, and then at 11:45, and then I knew how it was going to go. There was no chance to talk about going home with the fifty-something man who'd been living in his landlord's houses and refurbishing them until he'd suffered a cocaine-induced stroke - no chance to explain to his family that we were going to have to send him to the homeless shelter if they weren't willing to take him in. There was no chance to meet with the family of the retired firefighter with alcohol-induced dementia who was too weak to go anywhere but a nursing home for rehab, no matter how much they wanted to take him home (oh, and by the way, his insurance is hospital indemnity, you'll be paying for it on your own) and find out if they'd decided on a place for him. There was no time to do more than chat briefly with the man with chronic pancreatitis and splenic vein thrombosis, see if he was still willing to go home the next day (he was) and certainly not enough time to pick up medication assistance program forms for him to fill out so that somehow we could work out his pain control. There was no time to carry out more than the briefest of searches for a Spanish list of Vitamin-K rich foods for the lady who'd been here five days and was beginning to fret about how well her husband was caring for their seven children (twins and triplets from the last two pregnancies, what a surprise) while she languished becoming therapeutic on coumadin. It was one patient to the next, jotting down notes on notecards, hoping I could keep up with the essentials and write everything up later.
Ninety-year-old with known coronary disease, chest pain and weakness. The real struggle with her was establishing code status when I realized I hadn't done so. She has papers, she said, at the clinic. She didn't think about these things. It was after five. We went back and forth. She didn't want drastic measures. I described chest compressions, shocks, and intubation. She agreed, they were all drastic measures. Finally she made a statement I could put my finger on. "I don't want you to do anything to bring me back, if I die. And if there's no hope, I don't want you keeping me alive with machines." I nodded. "The last time you were in the hospital, two months ago, did you look at your papers then?" A nod. "And you made your decision based on those papers?" I think so, she says to me, all maddening vagueness and taking-her-time. "Then do you want us to do the same things you wanted us to do the last time?" It was a sweet accord, at last. Yes, I think that would be right. "Last time, you didn't want us to do chest compressions or shocks or anything of the sort. That doesn't mean we won't use medicines to help with your blood pressure or give you oxygen to help you breathe, it just means the drastic things." Yes, she agreed, no drastic things. No shocks, especially.
Order timed and dated, late at night. Code status: No Code Blue. The same order that had been written last time. It was an awkward discussion, not like the no code I'd written a few days prior. But it was, as far as I could tell, what she wanted.
There is a piece of paper folded in the pocket of my white coat: "The hospice facility called to let you know that Mr. X died this morning. Please call with questions." I'd sent him there only the day before, a skeleton of a man, eighty, blind, partly deaf, bedridden and suffering from esophageal strictures that made him unable to eat. GI dilated the strictures, but he seemed to have given up on living at all; his body so thin that every bone was visible. He'd been at home, on oxygen, unable or unwilling to get out of bed since November when he'd come home from pneumonia. His wife said she heard him praying for death sometimes at night. He panicked if she was far from him; this tiny frail woman washed and fed him, tended him, lived for him. Sixty years of marriage had come to this duality, and she was so tiny herself.
He was well-cared-for, well-tended; not as malnourished as he looked like he was. She'd been trying to feed him despite his refusal to eat. We could do little more in the hospital than she'd done at home. And he was dying, slowly, in that agonizing stretched-out way that cardiac cachexia kills, that takes men who do not wish to live but are too stubborn to give up. He didn't want tubed or shocked or reperfused or anything. He didn't even want to be in the hospital with our meager efforts at saving him. His wife looked at me with dark, hollow eyes. "I don't want to be selfish...I want what's best...but I don't want him to suffer any more. This isn't living." I nodded. Code status: No Code Blue.
I meant to call that day, and to find out if there would be a service or flowers or anything. His wife was desperate - no doctors would pay house calls - I told her I would be his doctor during hospice and she broke down in tears. "You're an angel from Heaven." I'm young and I can't stand the idea of this man dying without someone caring. I meant to call, but then there was the man with seizures who came in and went to ICU. There were more rule-out chest pains. There was the man with antiphospholipid antibody syndrome needing pain control. There was the service closing at five-thirty from my seven admits and then I was writing H&P's most of the night.
At least, I only had two more to go when I got called to evaluate my seventh admit, who was not doing so well on her bipap.
The first time I sent a patient to the ICU kept me there all night. I will tell you about it later; for now I need to prepare for tomorrow. Another busy day - at least I'm not on call. Three patients remaining of the eleven I started with on Friday morning, and clinic in the afternoon. It could be worse.