Art of Medicine

Art of Medicine

On the third day I came on service and found him in bed. The width of the bed from
railing to railing cuddled him and he laid in a strange stillness. His wife was
holding vigil. He was awake. His face visibly was puffy. He had the customary nasal
cannula on flowing oxygen into him. His pillows propped at 45 degrees.

I had read his outpatient chart and the inpatient notes. He was on an unusual
cocktail of medications that to me denoted an attempt to care for a man who had few
options. I recall looking for the partner who claimed him as a patient and being not
surprised. Steve was always one to take care of a person and disregard all the
package inserts and medical legal warnings that let lawyers rest easy.

His back pain was so bad he took narcotics. His lungs so bad he couldn’t take
narcotics. His kidneys so compromised he reluctantly took Motrin. His stomach so raw
he took proton pump inhibitors and misoprostol. This all kind of worked.

Until…

The day of admission he felt woozy and passed out.

So here he was and all medications held abruptly and efforts to revive and
reestablish the delicate balance achieved thoughtfully before the syncope were
undertaken.

Medications transformed into a new unrecognizable list. His wife tried to follow
along. He tried to just roll over or sit up without screaming in pain. Fluids were
given for resuscitation. As I typed in the rate per hour I calculated when I would
reverse order and begin squeezing him dry again.

Over the next three days he had more problems oxygenation. Laying in bed guarding
each breath his lungs collapsed onto each delicate sack to a dense cheese.

His oxygenation upgraded to a high flow cannula.

I left my last recommendations for no fluids and now diuretics and hoped the ground
I gained for the kidneys would hold.

I returned five days later on service and the mission was continuing in jagged steps
forwards and backwards. A placed foley lead to gross bleeding.  He now was on a
diuretic drip and set for a thoracentesis to drain a collection.

His wife asked for the overview.

“Is this progress?”

“Kind of. Let’s see…” I said vaguely implying the looming truth.

Three days later he hit the wall. Swelling gone. Breathing 50% better but still
requiring high flow and with movement pain was improved but not gone. He remained
debilitated and too sedentary to open the sails of expanded lungs and the vigor of
living. Meanwhile the diuretics did their number on the kidneys and the creatinine
shot up. I held the diuretics and we circled the wagons to see if the kidneys would
come back online. I gave him a unit of blood hoping a little human voodoo would help
breathing and kidney failure since he had gotten slowly anemic from the trauma of a
foley placement passed by a large prostate.

The next days we watched the kidneys shut down. On the sixth day since return to
service, the doctors nodded to one another and I volunteered to take the angle and
go in for “the talk”.

“Good morning. How are you feeling?” I asked gloving myself. The first barrier for
physical and now emotional protection.

“I’m ok.” he said laying flat in bed with the rush of high flow oxygen swirling and
the covers pulled up around him. His wife stood up on guard.

I tried to picture him in street clothes. It helps me to keep centered between facts
and tenderness and not care about time and disappointing them.

I began to recap the course, the barriers, the reality of back pain plus heart
failure plus chronic lung disease obesity kidney disease and now the unraveling of
pain control and the issues with being bedridden and kidneys that can’t go the
distance for lungs that get marginal relief from being dried out. I talked to a
staring audience and then off to the right she cried then had to sit.

He pulled the covers up to hide.

I kept my gaze on him and lowered my hand to touch him. The blanket stopped moving.

“You have to hear this. I’m sorry.” I thought to him.

“Here are our options. You don’t need to decide today but tomorrow I will need to
know. We could place you on dialysis and see if that can introduce a possible new
variable that relieves enough to move forward. We could also do no dialysis and
focus on comfort.” I heard myself say. The words echoed into a cold distance now
that split reality.

The wife cried and asked whether he was coming home, whether dialysis was forever if
started.

“Ok. That’s a complicated question. To be home you need to be independent and mobile
and on less oxygen. These are barriers we are and will have still. Despite the pain
control that we can manage because of your breathing you haven’t been able to roll
or sit up without three people helping. Dialysis likely will need to be permanent to
try to keep a balance going. I can’t tell exactly if it will aid significantly as
you are in acute failure but poor maintenance to begin with. I think you may be on
dialysis and in a skilled nursing facility long term.” I spilled.

She continued to cry apologizing for crying. He nodded. His eyes remained deep and
available. He had not glossed over.

A long pause.

“What do you understand about this? What do you see happening here?” I asked just
him. “Do you feel shocked?”

“No. I’m not.”

“I am,” his wife interrupted.

“I know why you are shocked,” I said to her. “Tell me why you are not shocked, sir.
Is it because you have seen how complex this is? Have you realized the conundrum?”

His eyes still alive and focused told me he was registering clearly, fully. “Yes. I
understand,” he said calmly coolly.

The wife cried.

I ended the beating and told them to talk, think and I would be back the next day to
help decide and support the journey.

I motioned the wife to come just to the door. He could still see her and hear us.

“Are you ok?”

“Yes,” she sobbed. “I cry all the time. I’m a crier.” She laughed apologetically.

“I think you should cry.” I said.

“I knew. I just I don’t know…. He told me he didn’t want to be in a nursing home.
I promised I wouldn’t do that,” she began to sob again.

We stood knowing the decision but waited.

“It’s ok. Let’s talk tomorrow. Just be with him today. Talk a little but not all day
about it,” I said staving off the decision more to buy the comforts of time and
avoidance for us all.

“You know, I waited a long time for this man! We were 40 when we married.”

I raced to recall his age having types it a dozen times. 57.

My heart dropped. What words. What pain. My heart audibly broke and I slumped and
mustered something along the lines of, “well he is all yours and seems happy to be!”
I gauged this immediately. Not my best work but all I had.

We parted and I promised to be in early at 6 am.

That night my nurse called asked if he should come in early to do anyone and I said
I would let him know as i had to check on one patient early.

I arrived at 6 am going immediately to a chart and found it paled on the long
patient list. A paled out name meant he had left the hospital or…

I reviewed the chart looking for clues hoping he was home with hospice. I found he
had suddenly deteriorated that night and within and hour died.

It’s unclear why his blood pressure tanked but once that happened he stopped
breathing and died refusing intubation.

At 615 am I called his wife. I told her I would be in contact. I felt I owed her
this. She was of course wide awake.

“I’m sorry.” I said when she picked up.

“It happened so fast,” she sobbed.

“I called because I owed you a call and because I guess after yesterday I owed you a
little insight. Neither you nor your husband could make the decision I was asking of
you. I hope you see this sudden event as not robbery but mercy,” I offered.

“I do. I really do,” she sobbed and sobbed and sobbed. “People say we had more in
our marriage than many after 50 years. I’m happy about that and one day that truth
will be bigger than what I feel now,” she shared.

I felt destroyed. I raised my chin inhaled and told her again I was sorry and that
yesterday she struck me with how much they loved each other. I was happy they had
that.

She laughed a little at that recognition and thanked us all.

I hung up and thought about medicine and what people want to believe it is or who or
how it can be done. I got chills thinking how this was the story told out a million
times by healers and how it will never be distilled to the codes and legislation we
are inundated with daily.

I stopped my pondering briefly to call the dialysis nurse and considerately tell him
he wouldn’t need to come for this patient but another one I had just caught a smell
of would need him sooner than later. Her pH was 7.1 overloaded. Go. Go. Go.

Just doctor. Try to doctor the best you were CALLED to do. Heal. Fix. Comfort.
Affirm. Witness.

People need to be seen, heard, and cared for.

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