What To Do

Briefly, I want to thank Dr. Billy Goldberg and Dr. Christopher McStay, emergency medicine physicians from NYU, for being gracious and entertaining hosts during my Sirius XM interview with them on Doctor Radio the Thursday morning of April 7th.  To their producer, Melanie, a huge kudos for your cool kindness and for seeking me out for this interview.  I am honored by this flattering experience.  You have played a part in making this small town boy's dreams approach his reality...    

It was my birthday.  Because I wasn't home with my wife and kids, eating cake and being silly and opening presents, reminding them over and over again that it was my special day, I was just a little bit sulky while ho-humming it, struggling to make it through my odd 5 pm to 3 am shift in the ER.  This, despite a birthday cake, balloons, several cards, chocolate, and many hugs and birthday wishes from my fellow coworkers, my friends.

I needed an encounter to remind me of my blessings.

As I sat at my computer in the physician station thinking this thought, I felt a sudden light tap on my shoulder.  "Excuse me, Dr. Jim," a nervous voice spoke, slightly quivered and breathy, "would you be able to see one of my patients?"  I turned to find one of our newer hires, a young energetic nurse who had just graduated from nursing school the previous year and was fresh off of her ER orientation, speaking.  I liked her.  I liked her eagerness, her good attitude and her priorities of providing excellent, all-around patient care.  I hadn't been, though, in a serious patient situation to really see her abilities and knowledge tested.

"Hi Chris," I said, "what can I do to help you?"

She spoke quickly as I stood from my chair and we began walking.  It was a woman in her late fifties, Room 22, one of Chris's patient rooms.  She had come in by ambulance and her clinical picture was making Chris nervous.  "Her blood pressure is really low and I can't seem to maintain her oxygen levels.  She looks bad."  She had been sent from her group home to an outpatient clinic appointment because "she didn't look good for a few days."  From the outpatient clinic's alarming find of this patient's condition, she had been sent to us.

"Oh," Chris added, right before we entered the room, "I have to tell you--she has severe MR (mental retardation) and she can't tell you anything.  All of her extremities are contorted, too."

As with most patients in this situation, I expected to find a three-inch information binder, usually maroon, sitting on the counter.  There was no binder.   I also expected an aide, familiar with the patient and her history, to be sitting in the corner chair or, better yet, standing at the patient's bedside.  Again, no aide.

The only people in Room 25, besides the patient, were a tech and another nurse helping Chris settle this patient.  Where was the binder?  Where was the aide?

Uh oh.  "A young woman came with her from the office, but said she had to go move her car and would be right back," Chris said, shaking her head.  "That was ten minutes ago.  She didn't leave us a binder or tell us anything."  Sadly, it would be over an hour before this aide came "right back," and our team was now in a struggle to get any information that we could on this patient.  What was her baseline condition?  We didn't know.  Had she been ill recently?  What was her past medical and surgical history?  Sorry, no information there.  Was her resuscitation status DNR (do not resuscitate) or was she a full code?  Did she have a living will?  Who was her power of attorney?

Don't know.  Don't know.  And don't know.  We were at a loss for any viable information.  At least we had a name, though.  That was a start.

I walked up to this patient's head, slightly forward-flexed at her neck off the pillow.  Her eyes were open, brown and dilated, a little reddened at the sclera, and she appeared to be trying to focus on something.  Anything.  Her skin was pale, ghostly white, dry and wrinkled.  Her hair was wispy gray, brushed straight back over her crown, a little greasy.  She was in a gown, but her pants still needed to be removed.   As Chris had warned, her upper extremities were rigidly flexed at both her  elbow and wrist joints.  Her legs were a little more pliable, resting in a flexed position but easily straightened at the knee.

I brushed some stray hairs from her forehead to her crown, resting my hand on her head. "Maam," I said, bent over and talking into her ear, "my name is Dr. Jim.  We are going to take real good care of you, okay?"  Her eyes found mine but, other than a brief blink, didn't give me any indication of her awareness.

I looked at her concerning blood pressure, 74 systolic over 40 diastolic.  Her heart rate was adequate, 88.  Her respiratory rate was quickened, 24, and her oxygen level was low at 89% on two liters of oxygen via a nasal cannula.  She appeared to be struggling for a deep breath.

"Chris," I said, "open up the fluids and give her two liters of normal saline.  Switch her cannula to a non-rebreather mask at 15 liters of oxygen."  As Chris did this, I did a brief primary exam, followed by a more intensive secondary exam, all the while paying attention to this patient's fragile vitals.

This poor soul, this patient without a history, was dry.  Very.  Her tongue was cracked and fissured.  Her skin was tenting, lacking hydrated elasticity.  Her urine from a foley insertion was scant, darkly-colored, and strongly odiferous.  Her heart was regular, thankfully.  Her lungs, though, had diminished air movement through them, with accompanying sounds of rhonchi and wheezing, suspicious for pneumonia.  Her abdomen was soft.  She didn't appear to grimace with my deep palpations.  Her rectal exam was positive for blood.  A rectal temperature recorded hypothermia at 95 degrees fahrenheit.  Her extremities had faint pulses but their skin coloring was as pale as her core.  Her body was frail and struggling.

This patient was septic, plain and simple, infection threatening to overtake her entire body.  Hypothermia.  Low blood pressure.  Low oxygenation levels.  Suspicion for dehydration.  Suspicion for pneumonia.  Suspicion for a urine infection possibly spread to the blood stream.  An unclear mental status change from an unknown baseline.  And, add to that, a suspicion for a GI bleed.

We ordered our workup.  Blood cultures and blood work.  EKG.  Chest x-ray.  Urine work and cultures.  We continued aggressive IV fluids while covering the patient with a warming "bear-hugger." We started immediate IV antibiotics, gave her breathing treatments, and put her on additional respiratory supportive measures.  With rhythmic purpose, I observed Chris and our ancillary services kick up the care.

Still, we had no information.  No binder.  No aide.  We searched for her group home's number and address.  We had called the outpatient clinic but, since she was a new patient and was so critical, they had not wasted much time delving into this patient's past before sending her to us.

We proceeded as if this patient was a full code.  We had to--it's what you do in these circumstances.  Initially, the patient did okay, responding to our fluids and respiratory interventions.  Her oxygenation picked up to 95%, and her blood pressure increased, 98/62.  But still, she looked fragile.  Pathetic, even, in her misery.  My gut instincts, usually spot-on, told me to be ready for this patient to crump at any moment.

And she did.  Her condition took a turn for the worse at the very moment we succeeded in contacting her power-of-attorney, her concerned brother.  After talking to him, we followed his wishes of doing everything in our power to improve his sister's critical state.  She was a full code.  He sounded quite reasonable and was hurrying to our hospital to be with his sister at her bedside.  Quickly, to stabilize the patient's breathing concerns, we emergently intubated her and connected her to a vent.  Despite sedating and paralyzing her, however, her arms remained quite contracted while her legs and neck relaxed.  We started medicines to elevate her dangerously low blood pressure.  We started central lines and arterial lines to continue giving IV fluids and monitoring vitals.

Then, concerning results began to roll in.  Acute kidney failure.  Severe dehydration.  Significant pneumonia on x-ray.  Low red blood cell counts, probably from a GI bleed, requiring transfusions.  Skewed electrolytes, including a high postassium.  Infected urine.  

She would need an ICU admission, which we pursued and obtained.  She would need emergent dialysis.  She would need critical care from a variety of sub-specialties in attempts to improve her condition.  She would need continued life-saving medications and interventions.  She would need a lot of good energy and a little luck to come back from being so ill.  Hopefully, we started her on the right path.

I sat back in my chair after all the action, exhaling a deep sigh while mentally reviewing this patient's ER course.  Our team had done well and I was proud of them.  I was worried, though, for this patient.  Chris came in and spoke.  "Just so you know, the aide returned."  Chris paused and took a deep breath before continuing.  "I let her know we have called the agency and they will be looking into where she had been for the past hour or so.  Now she is teary-eyed and, frankly, she should be.  Oh, and she has the binder if you need to look at it."  Again Chris paused, before finishing.  "Is that okay," she asked with sincerity, "that I called the agency?"

I looked at Chris, smiling at her.  "Chris," I said, "you did good.  It was the right thing to do."  Simple and direct.  Yeah, I thought, we got ourselves a keeper with this nurse.

I didn't meet the brother, although I heard he was a pleasure to deal with.  Loved his sister.  Had her best interests at heart. Disheartened by her turn of health.  He had been escorted to the medical ICU after his arrival, where they were waiting for him.  I couldn't help but wonder, though, what his life had been like to grow up with a severely-handicapped sister.

After things quieted down, when I was alone again at my station, I looked at the computer screen's lower right-hand corner. Yep, the date said it was still my birthday.  Just a few more hours remained.  Suddenly, though, I didn't feel so old.  Or so ho-hum.  Or so out-of-sorts from not being home celebrating with my family.

Instead, I felt appreciation.  For being healthy in my mid-forties.  For being surrounded by cool people in my life.  For knowing I had family at home waiting for me, ready to enjoy my upcoming time-off with me.  For having a sound mind.  For having flexible joints and limbs.  It wasn't lost on me that, by the luck of the draw, this patient's life could have been any one of ours.

Happy Birthday to me.

As always, big thanks for reading.  A big thanks for the numerous birthday wishes, too.  Several key facts have been changed to maintain patient confidentiality within this story, but the essence of the encounter remains true and thought-provoking.  See you in a few days...