Monday, May 10, 2010

I'm Going To Die!

Occasionally, a patient will come into the ER with a profound sense of foreseeing their immediate death. A foreboding that, despite their complaints and physical findings not matching up, death might be knocking on their door.

I'm not talking about how some people think they may die young. Or that they may die a tragic or traumatic untimely death. Haven't we all had that thought at one time or another? Rather, I'm talking about that patient who is lying in their cot, looking somewhat stable, piercing into your eyes with their frantic own. "Please don't let me die," they say, before you can even begin to sort out their history and perform a physical exam.

This kind of talk and behavior, as you can imagine, may be quite unsettling, both for the patient and the providing medical team. In most circumstances, that dramatic foreshadowing deserves some attention.

Recently, an elderly male had been rushed to our emergency department from the radiology department, where he had been undergoing an outpatient, IV contrast-enhanced MRI. After the MRI nurse had pushed his contrast into his IV catheter, the patient began flailing and screaming.

"I can't breathe!" Help me!" "I'm going to die!"

The MRI nurses looked for a rash. They found none. They listened to his heart and lungs. They sounded good. They reviewed his extensive MRI checklist but found no documented allergies of suspicion.

"I'm going to die!" the patient yelled again. His frantic nature became contagious and, within a few minutes, the patient was being wheeled into our department. Room 21.

I remember hearing the concerning page overhead. "We need a doctor in Room 21, stat." As luck would have it, I was just walking out of Room 22, the next-door room, after explaining some results to that patient. I hurried into Room 21 before the page was even finished.

Entering, I found an elderly male, 75 maybe, in a loosely-tied hospital gown, sitting upright in his cot. "Are you the doctor?" he asked, focusing his worrisome eyes on me. As I nodded yes, I glanced up at his cardiac monitor, which was showing a stable cardiac rhythm, good oxygenation on room air, and a slightly elevated respiratory rate. As I was looking, an automatic blood pressure reading had cycled and that, too, was normal.

"Help me, doctor," he exclaimed, his eyes remaining fixed on mine, his voice cracking, "I'm going to die!" To add a dramatic flair, one of the overhead fluorescent bulbs began flickering its last hurrah, casting intermittent shadows on the patient's face. An interrogation room atmosphere.

I quickly introduced myself, shaking this patient's hand, as I listened to a brief overview given by one of the two nurses. As she finished, I still hadn't heard what I wanted to hear--a solid reason for this patient's words and behavior.

It was time to interrogate. "Sir," I said, "has anything like this ever happened to you before?" No, he replied. "Are you having chest pain or calf pain with this shortness of breath?" No. "Have you had any recent cough or cold symptoms?" Again, no. "Any trauma or falls?" Nope. "Have you ever had any allergic reactions that may have caused a similar reaction?" You guessed it, no.

I was told this patient's brother, whom he lived with, was going to be escorted to Room 21 shortly. I looked forward to talking to him. In the meantime, I did a thorough exam on this patient and found nothing remotely concerning. He had no rash. He had no wheezing or stridor. He had normal heart sounds.

"Sir," I asked him point-blank, "do you have a history of anxiety or nervousness?" He shook his head "no." "On any new medicines?" Another nod "no."

Even though we approached this patient as a possible allergic or anxiety reaction, based solely on his MRI-department history, he still warranted a thorough work-up, because of his age and several cardiac risk factors.

We ordered a stat EKG, a portable chest x-ray, blood work, including some screening cardiac enzymes that would elevate if there were any concurring ischemia to the heart, and a d-dimer, a blood marker that, if positive, raises one's suspicion for a blood clot.

The patient's brother still hadn't arrived by the time I reviewed the patient's EKG and chest x-ray, both normal. I had someone go look for him as I reviewed the patient's blood work results, hot off the presses. Surprisingly, normal.

I was in Room 21, explaining all the good results to the patient, when a smiling, elderly man was escorted into the room by one of our techs. If you took away the patient's nervousness and sense of dread, this arriving man would have been what I imagine this patient to look like. Obviously, it was the patient's brother.

Being told that his brother had finished in MRI, this man had gone to the cafeteria to grab a bite while waiting for an official discharge. The brother had not been told of the situation in the MRI suite.

"So Frank," the brother spoke, shaking his disapproving head, exasperated, "you did it again, huh?"

"Did what?" Frank asked, now glancing sideways out of his eyes at me.

"Have another nervous attack," the brother said. "I told you to make sure you told everybody you have anxiety and are on medication for it. You didn't, did you?"

I looked incredulously at Frank, who now fully avoided eye-contact with me. I looked at the brother. "I point-blank asked your brother if he had anxiety or nervousness and he told me 'no.'"

"Of course," the brother said, "he always denies it. But he has about five or so attacks a day. He seems to be more and more preoccupied with dying these days. " He looked at his brother, the patient, before turning back to me and continuing. "Did he tell you he was going to die?"

I shook my head "yes." The nurse shook her head "yes." Frank, even, shook his head "yes." "Well," Frank's brother continued, "I hear that about five times in a day. Frank gets all worked-up, insisting that I will be living alone by the end of the day." The brother hesitated, as if he was going to add a quirky little comment to that last statement, but bit his tongue.

"How does Frank look to you now?" I asked the brother.

"Like he always does," the brother replied. That reply was music to my ears. Frank looked at his brother, piercing eyes and all, and spoke quite dramatically. "That's enough, Elmer."

Elmer wasn't intimidated. "You're right, this is enough." I stepped out of the room only after refereeing the minor argument that ensued. And ordering some Vitamin "V" for Frank.

It turns out that Frank had held his morning medications, including his valium and anti-depressant, in preparation of his MRI. Unfortunate, since some people without anxiety still require an anxiolytic to get through MRI testing. After a social service consult, I called Frank's family doctor with a report of what happened and, more importantly, to get a follow-up appointment for the next day.

The family doctor was surprised that, somehow, Frank's medications and history of anxiety were not conveyed to the MRI staff, which could have preempted an ER visit. It made me think, though, that if you point a finger, four are still pointing back at you. The family doctor had ordered the test and knew this patient better than anyone else. I would have assumed he would have alerted the MRI team to Frank's recent bouts of anxiety.

"May I ask," I questioned, still a little perplexed, "what was the reason for Frank's MRI?"

"Oh, sure," his doctor replied, "it was a brain MRI to rule out any recent or remote stroke activity. He's been getting real forgetful lately."

So, as it turns out, the forgetful patient forgot to share his anxiety issues.

I walked back into Frank's room to explain his follow-up plan, only to find Frank and Elmer both calmed down, watching a baseball game on TV. "So I'm not going to die, Doctor Jim?" Frank asked one last time.

I shook my head no. "Sorry, Frank, not today you aren't."

Not on my shift, anyway...

As always, big thanks for reading...I hope everyone had a great weekend. Next post will be Wednesday, May 12. See you then...


WarmSocks said...

Whew! What a relief! I thought this guy without any apparent problems was going to suddenly die (or almost die but you saved him). It's nice to know that sometimes those premonitions are wrong.

Katie said...

Thanks for the smile before my finals today.
I love the last line, too.
<>< Katie

Amber said...

Great post, as always! Enjoyed reading it.

Kate said...

I do believe that people usually know when they're going to die. But in a panic like that? Not so much.

This book changed pretty much everything I believed about death.

After my fiance died, I was so shocked that it didn't seem possible. But after reading that book three years later? I knew that he had known. And somehow, that finally quited the voices of frustration.

The doctor I work for has been fighting electronic medical records for years now, but it's situations like this that are the exact reason why they are becoming more important!

coulrophobic agnostic said...

Re: Kate

I have a the sort of "gift" I wish I could return - I seem to have a spare sense for when people are going to die. Both in terms of medical issues (someone tells me they're going for testing, probably have this disease, just got diagnosed) and I'm usually right in that "feeling" about how it'll turn out. Unfortunately, the morning my father died, I knew it was coming. it was unexpected in every sense but this sucking feeling in my stomach when I said goodbye. I was sure a cop was going to come to my door later that day saying they'd had an accident, because medically speaking, he was sick but not imminently dying.

I was wrong about the how but not the what - he did die. Cardiac arrhythmia.

Of course, when he first started showing symptoms of his cancer, I kept saying "dad, get it looked at, it's serious." Then when the doctor said "It's probably an infection, but we'll biopsy it to be sure," I said "I'm telling you, it's cancer." Sure 'nuff.

AND YET NOBODY EVER LISTENS TO ME. I feel like Kassandra some days ;)

So, yeah, I think it's more than possible for people to know when their own time is coming. And I'm so sorry about your fiance. I'll definitely keep my eye out for that book!

Diana said...

Have you ever had one of those MRI's with the dye (no pun intended) contrast? I have had them 2-3 times, and each time I DO feel like I am dying. I guess it's the warm sensation that goes through your body, I dunno. I also feel like I have wet myself. I hate that dye!

Leslie said...

Another great post Jim! You are a great storyteller.

So I can't help but link (in my mind) this post with your recent one about how men and women deal with pain. And I am wondering, do you find that gender makes a difference in how people deal with anxiety too? Just curious.

Webster said...

My immediate jump-to-conclusion nature is telling me that these anxiety attacks and increased memory lapses are a DEW point for Alzheimer's disease. What do you think, or, being a man of science, don't you jump to conclusions?

Chrysalis Angel said...

I thought for sure the brother was going to drop dead on you instead. Especially, when it sounded like he could be a twin.

I have friends that are twins, and my girlfriend knew when her twin went into labor.

SeaSpray said...

I thought you were going to say he died because sometimes patients just know and do die.

The other thing I was thinking is he should STOP saying that because there is power in our words and he might bring it on.

But then hearing his anxiety state ..he probably can't stop himself.

I agree the pcp should have alerted the hospital staff in case the patient forgot to take them.

At least it was a happy ending.

ACZ said...

Always a pleasure to read your stories, Dr. J!

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