Who Am I Treating?

Occasionally, as difficult as some patients may be to treat in the ER, for whatever reasons, that difficulty may be nothing compared to the stress and negativity brought to the encounter by their accompanying family members or friends. People who "know the patient more than they know themselves" and don't hesitate to try to dictate the course of therapy for the patient.

Don't get me wrong, I appreciate a family's or friend's input greatly. In fact, I welcome it. Sometimes, even, they can be a greater source of the patient's history than the patient himself.

But...sometimes the support person can be totally and completely obnoxious and abrupt in how they choose to communicate with our staff. "Demanding" is a word I hear often. They just know that the patient needs two pillows. Three warm blankets. A new pair of footies. A turkey sandwich. Some ginger ale, not orange juice. The patient likes to lay on their left side, not their right. They need this and this and this test, but not that one. Oh, and by the way, where do they go to get their parking ticket reimbursed for free parking?

I recognize that sometimes this is simply a vain attempt by the visitor to have some sort of control over an uncontrollable situation, sure. A spouse trying to make her sick husband comfortable. A parent trying to ease their child's pain. A best friend trying to step-up to ensure proper treatment. I fully understand all the reasoning behind these situations. More importantly, though, I respect and applaud their advocacy.

Unfortunately, though, sometimes a visitor's intentions can be detrimental to the patient, if the patient is an adult, is coherent, and can easily verbalize their problems and symptoms by themselves.

I was sitting in my hallway seat, several months ago, when I observed the triage nurse escort two women to Room 27. One woman appeared to be in her sixties, the other in her thirties. The older woman appeared irritated, grumpy almost, while the younger woman was smiling and walking alongside the older woman. Neither appeared in any distress.

Within minutes, the patient's name appeared on our computerized list of waiting patients, so I clicked on it. Surprisingly, it was the younger woman who had checked in as the patient.

I walked into the room to find the younger woman sitting comfortably in the treatment cot, a gown draping her thin frame, a smile still on her face. The older woman, who by now I assumed was the patient's mother, sat in a chair under the corner TV. She was still scowling.

I approached the patient first, my hand extended. "Hello, Ms. Brown, I'm Dr. Jim. Nice to meet you, maam." She extended her hand and we shook. "Hello," she returned, meekly. From the corner of the room I heard the other woman speak. "And I'm her mother." I left the patient's side and walked up to the mother, my hand still extended. The mother eyed my hand for several long uncomfortable seconds before finally extending her own. "Nice to meet you, maam," I added after our handshake.

I went back to the patient's bedside. "Ms. Brown," I started, "what can we do to help you today in the emergency room?"

And before Ms. Brown could even begin to answer, her mother started in. "Kathy has a seizure problem and we are due for our yearly neurology appointment and thought we would come here to get everything done."

"In the ER?" I asked. "Yes," said the mother, continuing. "She needs an EEG, an MRI, and you may as well just call the neurologist down to see Kathy as long as we are here. That way, we won't have to waste a day going to their office."

I turned back to Kathy. "Kathy," I said, "how long have you had a seizure disorder?" From the corner of the room, I heard her mother answer. "Since she was seven." I continued focusing my full attention on Kathy. "And Kathy," I said, "have you been having an increase in seizure activity?" Kathy nodded her her head "no" while, again, from the corner of the room, her mother piped-in. "No, it's just time for her annual check-up." Again, I kept my focus on the patient. "Kathy, has there been any changes recently to your anti-seizure medications?" Again, as Kathy nodded "no," I heard the familiar, interrupting voice. "Eight months ago, the doctors increased her dilantin, but otherwise she has been on the same medicines as always."

I had finally had enough. "Kathy," I asked, holding my index finger up to the mother, requesting her to wait, "are you okay to answer my questions? Or is there a reason your mother keeps answering for you?" Kathy looked at her mother to me. "No," she said, "I guess my mother just always likes to be in charge." From the corner of the room, the mother yelled out, "I do not, Kathy."

I looked at the mother and cocked my eyebrow. "What?" she asked, "I haven't been answering all of your questions." "Yes, maam," I assured her, "you have." Her scowl deepened. "I appreciate you trying to help, maam," I said, continuing, "but this is what we are going to do. I am going to ask Kathy all of my questions and then, when I finish, I will give you a chance to add whatever you want, okay?" She dismissed me with a roll of her eyes and a shrug of her shoulders.

So, I had two problems on my hand. A mother who wanted to interrupt my history-taking with every question addressed to her daughter. And, a mother who wanted an extensive work-up and consult that, unfortunately, wasn't going to happen the way she had hoped for her daughter.

Well, I guess it was just one problem, really. A vocal, demanding mother.

After I finished my interview with Kathy, who did a fine job of telling me about her history, I looked toward her mother. "Do you have anything you'd like to add, maam?" She just "humphed" at me and remained quiet. I proceeded with a physical exam that was completely unremarkable.

The triage team had ordered some baseline blood work and some medication levels on Kathy and, after those results were posted, I went in to speak to the women.

"Well," I said, "I have good news. All of your blood work has returned satisfactory. Including your anti-seizure medication levels."

Kathy gave me a grateful smile as her mother spoke up. "But what about her EEG and MRI and neurology consult? Aren't you going to get those done now?" I explained to the mother that those tests, as well as Kathy's neurology appointment, had already been scheduled and that I wouldn't be able to provide those tests through the ER. Not without an emergency concern. And, trust me, there was no emergency concern.

"But," the mother said again, speaking up, "Kathy hasn't been feeling well recently. I want all of those tests done now. We'll wait for the appointment, if that helps."

I assured the mother, again, that Kathy had a great exam, great blood work results, and would need to move forward as planned by her neurology team. In all honesty, I told her, I wouldn't even be able to get this requested workup for one of my family members, unless it was a new-onset seizure or the patient was in status (a seizure that won't stop).

"Kathy," I asked the patient, "are you okay with everything?" "Of course," she answered, sincerely, "I didn't want to come today. Mom thought we could get everything done early so we wouldn't have to waste a couple days next week."

Out of courtesy, I did call the resident on the neurology team to make them aware of this patient's treatment in the ER. They whole-heartedly agreed with our ER approach, reiterating that this patient would need to keep her outpatient appointments.

I discharged this patient to home, knowing that there was no way I was going to make this mother happy. As they walked out of Kathy's treatment room and down the hallway, I noticed that Kathy still was smiling, while her mother maintained the scowl that prevailed during her time with us.

I had to wonder to myself how Kathy maintained such a happy state. I hope her smile was genuine.

The best I could hope for, I guess, was that Kathy, and not her mother, would get the hospital questionnaire. And that she would get some good results from her non-emergent, outpatient-testing, too.

If only we could just make everyone happy...

As always, big thanks for reading. I hope you all had a great weekend. Although I'm traveling for work the next few days, the next post should be on Wednesday, June 16. See you then...anyone with similar stories to share?

This Father's Daughter

She was 50. Prior to being transported to our ER, her only complaint had been for non-traumatic elbow pain over the past two weeks. She was on no medications and had no significant medical history.

She was at home, preparing to visit her doctor for a scheduled visit, when she collapsed. Because she didn't drive, her elderly father had planned on swinging by to pick her up. He had just called and spoken to her minutes earlier to let her know he would be there shortly.

He arrived at her front door and knocked. No answer. He rang the doorbell. Again, no answer. Panic set in. This was not like his daughter to not greet him when she was expecting him. He knocked again, harder. Nothing. He kept his finger pressed to the doorbell, hoping his daughter would hear its continuous ringing and come to the door. She didn't. He tried turning the doorknob, but it was locked. He banged his aging shoulder against the door. It didn't budge.

He remembered the spare key she had given him months ago. "I'll never need this," he had said, trying to give it back, but his daughter had insisted he put it in his glove compartment. He stepped off the concrete porch pad and ran down the sidewalk, back to his pickup truck to retrieve the key. He found it, hidden under a pile of napkins.

Returning to the door, he struggled to fit the key into the lock. As a father, he knew something was wrong, very wrong. With trembling fingers, he finally succeeded in properly jamming the key into the door's lock. He turned the doorknob, barely breathing now, his mind racing of the possibilities he would encounter.

The door opened. He stepped into the small kitchen and yelled his daughter's name. No response. He listened to hear if the shower was running, but it wasn't. He strained his ears for anything, any sound of activity that would reassure him he was overreacting.

That's when he heard the moan. It was garbled and low, guttural almost. He followed the sound into his daughter's bedroom. That's where he found her, lying on the floor, beside the telephone nightstand.

He tried to rouse her, but he couldn't. Knowing something was terribly wrong, he dialed 911. Waiting for the prehospital team to arrive, he sat down on the floor beside her, caressing her head. Talking quietly to his daughter, he filled her ear with the promises that everything would be okay. It had to be, since they were all each other had.

The ambulance team arrived. After briefly interviewing her father and performing an exam, they prepared the daughter for transport to our emergency department. They were concerned that this patient may have had a stroke. They offered the elderly father a ride in the ambulance, with his daughter, but he decided to follow them in his pickup.

In the ER, the prehospital radio went off. They reported that a 50 year-old woman with a sudden onset of right-sided weakness and garbled speech was being transported to our facility. There had been no signs of trauma. Confirming that the time frame was adequate, a stroke alert was called in preparation of this patient's arrival. She would be a perfect candidate for tPA therapy if she did indeed suffer a stroke that was not hemorrhagic.

I, with the rest of our ER team, waited for this patient's arrival in Room 26. In three short minutes, she was being wheeled through our ambulance bay doors and down our hallway. Quickly, we were able to slide the patient from the prehospital stretcher to our hospital cot, all the while listening to the medical report given by one of the paramedics.

Her vital signs revealed that her blood pressure was quite high. She had no fever, her respirations were slow and erratic, and her pulse was normal. On exam, she had a flaccid right side, was nonverbal except for her occasional moaning, and teetered between some minimal form of consciousness and being unresponsive. It appeared that this patient had suffered some catastrophic brain event.

We emergently intubated this patient, both to protect her airway as well as ensure adequate oxygenation to her ill body. After a repeated exam by the neurology team, the patient was hurried to the CT scanner to determine the extent of her stroke.

While she was out of our department, escorted to CT by our nurse, the respiratory therapist, and a neurology resident, I went to the family room to speak to this patient's father. I was accompanied by our social worker and nursing supervisor.

I knocked on the door, opening it slowly to reveal a gentleman in his mid-seventies, tearful and distraught, running his hands through thin wisps of graying hair as he sat in the corner wing-backed chair. He had the look of a hard-working, honest man, dressed in a pressed flannel shirt and brown Dickie pants. He was alone.

"Sir," I said quietly, after introducing myself and my team, "I'm so sorry about what you are going through. Can you tell me what happened or anything that might help us with your daughter's care?"

With great detail, he told me about their plans to visit her family doctor that morning regarding her elbow. He was not aware that she had any medical problems. "She's a hard worker, that one. Never had time to be sick, really." He shared how he went to pick her up, only to find her collapsed beside her bed prior to his calling the ambulance. I listened intently, watching this father struggle to be stoic in his misery.

After maybe five minutes, a faint knock on the family room door preceded one of our nurses stepping in and interrupting our conversation. "Dr. Jim," she said, "can you come here, please."

I excused myself, leaving the father with our social worker and nursing supervisor. I stepped into the hall. "What is it?" I asked the nurse, herself wearing a worried look on her face.

"The CT scan, it's bad. The radiologist wanted me to get you."

I rushed to our physician work space, pulling up the patient's head CT images on the computer panel while I dialed the radiologist's number. What I saw saddened me. This patient had a significant brain hemorrhage, one that was shifting her brain from its midline and filling her ventricles with blood. The radiologist confirmed what I was looking at--that this patient most likely had a ruptured brain aneurysm. I called neurosurgery and the OR stat, since this patient needed emergent decompression of her brain's swelling and bleeding. Her problems were life-threatening.

I went back to the family room, where I sat down opposite the father. His expectant eyes bore into me. Slowly and deliberately, I explained all of the results to him. He unabashedly cried, his shoulder's shaking. "She's all I have left," he muttered. I was affected by his emotions and, looking at the tearful social worker and nursing supervisor, I knew that I wasn't alone.

We escorted the patient's father back to Room 26, where he was able to sit with his daughter as we awaited the go-ahead from the OR. I hovered in the room with several techs, the patient's primary nurse, and a respiratory therapist, overseeing the quick preparations of getting his daughter ready for surgery. I continued to watch the father, unable to turn away from the deep grief and ache that enveloped him.

This patient was taken to the OR. Thankfully, she made it through her emergent neurosurgery. She remained far from a successful outcome, however, since her following few days after surgery would be fragile and tenuous.

Usually, I follow-up with these types of emergent cases, the types that pull at my heartstrings. But, for this case, I didn't. I couldn't. I thought of this patient and her father frequently, yes, but I couldn't bear to think of this father losing his adult-daughter. I was willing to risk not learning of a possible successful outcome if it meant I also didn't learn of a sad, heartbreaking one.

I recognize what I am doing. I am protecting myself, adding another cement block to that protective shell that surrounds my heart. Building it up. Tearing it down. It is a constant but necessary struggle for each of us in the medical field.

I hope and pray, though, that this patient did well. After all, this father's daughter was all he had left.

As always, big thanks for reading. Next post will be Monday, April 19. I hope you have a great weekend...