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January 27, 2005 Internship Journal
I am recovering from an emotional call night. I went to spinal cord clinic yesterday and saw a few patients. One patient was a 76 year old male whose chart read C6, ASIA C. I. am a C5, ASIA C. Like I have mentioned before, there is a big difference between C6 and C5. C6 gives a person wrist extension, which allows them to have a functional hand. ASIA C. means that in one muscle group below the level of injury, there is some strength. In my case, it is in my left leg. Unfortunately though, it is not functional. I was also told by the nurse that the patients home health agency had called several times because the patient wanted to know if he would walk again. He had been told several times that he was a year and a half out from his injury, and that most of the recovery people get comes in the first six months, but obviously he had not come to terms with this. With these thoughts in my mind, I entered the room.
I instantly recognized the couple from when I saw them in clinic last fall. They had seen me on the Today show, so they were very excited to see me again. As I spoke with him, I watched his hands open and close freely. His recovery left him with good upper extremity strength and two fully functional hands. When I see people get recovery like this, it is always like getting punched in the stomach. I wish that it did not have this effect on me, but it does. I think about how I could work out in the gym, transfer myself, catheterize myself, drive, and everything else that I could do with functional arms and hand's that would give me some independence. I don't spend more than a couple seconds thinking about this though because right now I am this patient's doctor, and therefore I am happy that he had this recovery. After some small talk, I addressed the issue. I told him about the call from the home health agency. He acknowledged that he had been asking them how much recovery he was going to get. He then said that he would like a summary of where he is in his recovery and what could he expect. Before I could answer, he asked what more could he do to help his legs recover. Although I am in the exact same position, it still broke my heart to tell him that there was nothing he could do. I then reiterated that the majority of return that people get after a spinal cord injury comes in the first six months. He said that he understood this; he just needed to hear it again because it had been so difficult for him to accept. I sat there nodding my head, and I told him that understood. I then explained to him that he could however continue to maximize his upper extremity strength, and work towards a goal of transferring himself. He said that he would certainly do that.
After clinic, I headed back to the hospital. The other interns checked out their patients to me and I went to the intermediate unit where most of the oncology patients are. I wanted to work on a discharge summary for one of my patients who has been in the hospital all month, so that the intern coming on in February wouldn't have to try to summarize January. Just as I was finishing up, one of the nurses informed me that one of the patients was having difficulty breathing. I told her I was almost done and I would be right there. When I finished, she told me that the patient was even more uncomfortable. I read the chart before I went to see the patient. She was a 58-year-old with metastatic breast cancer who had been admitted for shortness of breath and weakness. This had been going on for about a week. She also had a known deep venous thrombosis (DVT). This is a blood clot, usually in the lower extremities, that can go to the lungs. When this happens, it is called a pulmonary embolus (PE). These can be fatal. When I was done reading the chart, I went into the patient's room.
She was on 40% oxygen (room air is 21%) and she was obviously uncomfortable. The monitor said that her oxygen saturation was 92%. However, there was a poor waveform (as the person's heart beats, the pulse is detected by the oxygen saturation monitor, and this results in a wavy line on the monitor), so I wasn't sure how accurate this was. I immediately asked the nurse to call a respiratory therapist. When he arrived, he gave the patient a breathing treatment and put her on 100% oxygen.
As he did this, we talked about what could be causing this. A pulmonary embolus was very possible, so I ordered a STAT CT scan to look for this. I also ordered a STAT EKG, and ABG (arterial blood gas). I also asked Louise (for those of you who don't know her, she is a wonderful friend who lives with us and helps me at work when I am on call) to page the senior resident.
When he got there, the patient was still not doing well. I told him what I had done, and he agreed with everything and then we both agreed that she needed a chest x-ray. Shortly after this, we were told that she was allergic to contrast dye, and therefore could not have the CT scan. Since I had ordered the scan, I had learned that her blood was appropriately thinned by a medicine that was given to treat her DVT. She still could have a PE, but it would be unlikely, and there would be nothing more we could do about it, so I canceled the order.
By this time, it was 715. I had been last catheterized at 230. In November and December, I leaked a few times at work. At that time, I was being catheterized every five to six hours. Since then, I have been trying to go no longer than 4 1/2 hours, and, as a result of this, I have not leaked. So while all these things were going on with the patient, I was constantly looking at the clock, worried that I was going to leak. After they did the ABG that EKG, and we were waiting on them to come take the chest x -ray, Louise and I snuck away for a couple of minutes.
We returned to find the patient continuing to not do well. It was becoming apparent that we were going to have to intubate her and put her on a ventilator. The senior resident asked her if this is something that she would want. She said that if it would help her breathe better, she did.
In the meantime, the nurses were trying to get in touch with her family. The number in the chart was disconnected though. Finally, they somehow got in touch with her daughter. The senior resident explained to her that her mom was not doing well, and they needed to come to the hospital. Unfortunately, she was in Virginia and did not have a ride. To make matters even worse, she did not have a way to get in touch with her dad.
While this was going on, her chest x-ray was taken. Her oxygen saturation's were continuing to decline, despite being on 100% oxygen. Intubation was imminent. As a quadriplegic, I would obviously not be doing this. Therefore, I volunteered to go down to radiology and look at the chest x-ray. As I sped down there, I continued to think about what was going on with her.
She did not have a history of heart problems, so heart failure was unlikely. PE was unlikely because she was already anti-coagulated (her blood was thinned with a medicine). She did not have metastasis to her lungs. There were certainly numerous other possibilities, but I knew the answer would come with the chest x-ray and the ABG, so I didn't spend too much time thinking about it.
Her chest x-ray showed a worsening pneumonia. With this knowledge, I went back upstairs. She was already intubated when I arrived. I told them about the chest x-ray, and we seemed to have the answer. The results of her ABG came back shortly after this. It showed a metabolic acidosis. Her oxygen saturation in her blood was actually OK, and she was doing a good job of getting rid of CO2. This meant that something else was going on other than just pneumonia. Her acidosis was most likely caused from the tissues in her body not getting adequate blood supply and therefore they were getting inadequate oxygen.
Unfortunately, intubation did not fix her problem. Soon after she was intubated, her blood pressure began to drop. We gave her all the IV fluids that we could and put her on a medicine to keep her blood pressure up. This was not enough though, and just a few minutes later, CPR was being performed. After about 20 minutes, she was pronounced dead.
The senior resident called back her daughter and gave her the bad news. She was with her fiancÚ and neither of them had a car, so they were unable to come at that time. I think that she said that she would try to get in touch with her dad, but I'm not for sure.
I hung around waiting for her family while the nurses worked on the paperwork. I filled out the death certificate and waited some more. It was a little after nine o'clock, and I still had not eaten dinner, so I went to the lounge to eat.
As soon as I got there, I was paged and told that the patient's husband had arrived. I headed back over to the unit and found him in her room with the nurse. He was crying and the nurse was consoling him. I introduced myself and told him how sorry I was. He asked me why she had died and I did my best to explain it to him. I then asked him if he would like to be alone with her, and he said that he would, so I stepped out. Soon after this, the nurse came out of the room.
She told me that he slipped into the room without anyone noticing. He then came out and frantically said, "She's not breathing!" He had no idea that she and passed away. When the nurses weren't able to reach him, they had contacted the sheriff, who was supposed to go to his house and inform him of the bad news. Obviously, they were unsuccessful in getting in touch with him. I just sat there shaking my head. I could not imagine walking in thinking that I'm going to be checking on my wife, only to find her dead with an intubation tube sticking out of her mouth. A few minutes later, a guy probably in his early twenties came onto the unit.
I could see him looking at all of the rooms. I asked him who he was here to see. He stated the patient's name. Then the nurse asked him if he was family. He stated that he was her son. I then asked him if anybody had spoken to him. He shook his head no. I told him that his mother had passed away about an hour ago. I told him that she had pneumonia and had gotten worse real quickly and that we had done everything we could for her for about an hour. He was so devastated that he had to lean on the nurses' station because he could not stand up. I told him that his dad was inside the room and I led him in there. They immediately embraced and cried together. At least they were there for each other.
Because I am both a son and a husband, I sympathized with them deeply. Obviously, it is terrible to lose a loved one. However, I think it would be much more devastating to find out about it the way that this family did.
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