Today I transferred a patient to a higher level of care hospital where the physicians are super trained in dealing with rare diseases.
Alfred came to our part of a country around Christmas time to visit his family. He is 65 years old and lived in the mountains. Wild fox comes to his backyard and it snows till late April. He is an avid skier. On arrival to our city, Alfred developed a weird rash and was admitted to the hospital as his muscles were also sore. He was discharged only to come back later in one week.
That admission he couldn’t breathe as the rare disease has attacked his lungs. He was treated with high dose of steroids and discharged. Another two admissions followed one with abdominal pain along with nerve damage in his legs, and now with heart failure. He went from floor to floor. Myriads of physicians saw him from different specialities. Initially an enigma of a medical diagnosis, later he became a challenge. Seeing Alfred every day reminded us all of our incapability to cure him of his disease.
Once the decision was made to transfer to a higher level of care, the interest in Alfred’s medical condition dwindled. He stayed in the bed most of the day. The physicians, nurses went in and did the cursory rounds. There he was, an avid skier lying wasted in the bed. The only person who was still interested was Alfred’s wife who was feeding him a spoonful of soup at a time, waiting for a miracle to happen. She still had the belief.
Today while I work, I saw a very well dressed couple next to the elevator. They are in their 60s. Neatly dresses, the man was wearing black pants with a blue sweater over a white shirt. The woman had well-cut jeans with a nicely cut blouse and an overcoat. The makeup on the woman was perfect – not too much or way little. Just enough to make her look pretty and in command. The couple certainly didn’t go unnoticed.
As the day passed, I forgot about the couple.
I met with my residents and they started to tell me about David. David is 35 years old who had cardiac arrest two months back. He was resuscitated and now has a tracheostomy tube to help him breathe and a feeding tube to provide him with nutrition. He is admitted to my floor as has developed pneumonia while at a rehab facility trying to get stronger. My heart sinks. Seeing a 35-year-old previously healthy person on a ventilator is not what we want to see on any given day.
I go to David’s room. The well-dressed couple is there. David is their baby son. He used to be a film producer. He had woken up two months back with chest pain. He went to the nearest hospital and crashed. It took the doctors over 20 minutes to revive him. And now he is here, my patient, on a breathing machine with a feeding tube. David can answer simple questions but has no short term memory.
After I talk to the parents about David’s medical condition, the mom looks at me teary eyed and said – “we both had just retired from our jobs and were looking forward to a slow pace of life and travel. There goes our retirement!!”
I walk out of the room thinking – how many days I have spent being miserable and saying – Is it time to retire yet!!!
While at work, Jasmine’s phone is continuously buzzing. I’m trying to talk to her, but the emails click on her cell phone are distracting. I tell Jasmine ” you are famous, so many people like you” She picks up her phone to shows it to me. The emails are from all the stores she has subscribed to. Micheals, Lord and Taylor, Barnes and Nobles, Chicos… the list continues. She gets over 200 emails in her mailbox in a day. I ask Jasmine if this doesn’t fatigue her and if her useful emails don’t get lost in these mass emails.
Jasmine tells me about her life. She had moved from India 25 years back. She raised her kids who have all moved to different cities. Her husband works in a tech company, her family is all back in India and these emails are her way to stay connected to the world outside. We talk for a while more and move on to the next patient. The emails that Jasmine gets continue.
And, I wonder, has technology brought us together or has created wide chiasm between people and has created this loneliness in this world.
Soon, I get a text from the psych floor. I have to see Max. Max is a 45-year-old investment banker who tried to kill himself by hanging using a dog leash as he is lonely and his wife recently filed for a divorce. And I wonder, does Max also have a cell phone which continues to chime the whole night with over 200 emails a day?
Today, while at work, at 7:30am, I’m paged by a nurse to hurry up an oncological consult on a new patient who was admitted overnight.
I have barely printed my census for the day, and have just started reviewing the Electronic Medical Care.
I click on Adam’s chart. He is 41 years old who had developed some shortness of breath a week back. He came to the emergency room as his breathing was getting worse and he had excruciating pain on taking a deep breath. Emergent CT scan of his chest was done. And there was the culprit – a golf ball size tumor sitting in his lung and encasing the nearby blood vessels. The tumor is already widespread. I place an emergent call to the oncologist to see when he will be able to see Adam to facilitate the care.
I go to his room. Adam is 6 feet tall, well-built man. He is well groomed, he has life exuberating from him. But, the look in his eyes is something I can’t forget. He is afraid, tears rolling up in his eyes, he is unable to hold a conversation without his wife filling in the gaps.
And I wonder, there comes Adam’s life crashing. Nothing really matters anymore.
Whereas we, everyday people, continue with our life. We are hamsters in a wheel, worrying about small issues. The small fights, the small egos, the clothes, the money – how much does it all really matter in the bigger scheme of life.
Today, while at work, I was asked to admit Ms. Mercier to my service. She has come from a nursing home and has a fever. I see Ms. Mercier and I talk to the husband who is at the bedside.
Ms. Mercier was a fashion designer where she worked for a fashion magazine in NYC in her earlier days. She retired around 30 years back and had been enjoying her retirement. Around six months back, she fell and broke her hip. She had the hip surgery done, and later had a stroke in the hospital leaving her paralyzed on her left side. She was sent to a nursing home for further care.
While at the nursing home, Ms. Mercier had developed a wound on her back which had eroded into her muscles. She was seen by a plastic surgeon who advised a colostomy, a pouch on her stomach, for feces collection as she had developed stool incontinence from the stroke. The colostomy was done and a suction device was placed on her back to help heal the wound.
This time she came to the hospital with fever, most likely from Pneumonia, infection in her lungs.
I see Ms. Mercier in the emergency room. She is lying half covered in a patient gown, her hair are disheveled and she has muscle wasting. The left side of her body is contracted and there are tubes jutting out of her body. She has a catheter to help her urinate, oxygen tubing to help her breathe, and a bag on her abdomen to help her defecate. A few teeth are missing, and she is slumped to a side, unaware of her appearance.
The husband shows me her picture he always carried with him. She is a smart, young woman, with coiffured hair and smooth flawless skin. She is wearing a mink coat which was her treasured possession.
And I wonder looking at her, what happened to Ms. Mercier’s dignity of life!!!
Naila was admitted to the hospital for Pneumonia, infection of the lung. Further examination and questioning revealed she has a muscular degenerative disorder. She has lost the ability to move almost every part of her body. She can think, nod yes and no, but beyond that, she is unable to do much. She has lost her ability to swallow food.
She used to work on Broadway and she spends the whole time listening to music on her iPad while surrounded by her family and caregiver.
Naila has developed an infection in her lungs as when fed by her family the food sometimes goes into her breathing pipe landing in her lungs causing pneumonia. Naila, on this admission, is started on antibiotics. She is seen by swallow therapist, and not surprisingly, she is found to be at high risk for aspirating on her foods.
The ultimate ethical issue arises – should Naila be allowed to eat knowing she is at risk of aspirating, should Naila be treated for infection knowing she and the family knowingly went against expert opinion and hence responsible for pneumonia, or else, ethics consult should be called as the family is harming Naila.
We talked to Naila’s husband and daughter, Naila had adamantly refused to have a feeding tube placed to keep her alive. She knew the risk of eating but wanted to continue with the feeds through the mouth.
What should be done in these circumstances? Does the patient’s autonomy count? And if the patient knowingly takes risks, should they be treated for the consequences?
Yesterday I received a call from surgical PA. They want to transfer a patient to the medical team. The patient is 91 year old and admitted for an elective procedure. Her name is Myra.
Myra has been doing well except for the pain in her leg. She needed bypass surgery on the leg which will increase blood supply to her leg. She had the procedure done but had complications and needed above knee amputation. Course in the hospital has been complicated. My residents present the case to me today that the patient has had various complications from the surgery and family is being difficult. Myra should be seen by the palliative team and transferred to hospice care.
I walk into the room to expect a frail confused patient barely able to breathe on her own or express her desires. Rather I meet a feisty old woman who is demanding that her hair is brushed. On questioning, we figured out Myra was given strong painkillers post surgery. She had an adverse reaction to the medications where she was confused and also had difficulty breathing. Once the medications wore out, Myra was once again her perky self, demanding everything to be done the way she wants.
I ask my residents – would they have reacted the same way if I was admitted to the hospital. Would they call my middle school kids difficult and my family unreasonable if they want to prolong my life?
After a while, does age define relevancy?