Thursday, August 28, 2014


I've decided it's not the heat here in Central Texas that bothers me; it's how long it lasts. I could easily handle a worse summer than we've had here--only a couple of days over 100 degrees!--if it just ended sooner.

Something about the constant bright sunlight and the lows in the 80's really wears me down.

So does work. Work is wearing me the hell down, People.

I almost had to call in the Ethics Peeps this week. Mama is dying of a nasty sort of metastatic cancer that's hit her brain, liver, spine, and various other bits of important equipment. She has a midline incision from her breastbone on down that won't heal, a couple of cracked ribs from a previous code, 3+ edema every-damn-where, she's breathing too fast and her heart's wearing out, and she's seizing constantly and has been for about the last three weeks. Oh, and she has a galloping infection under her scalp, where a bone flap was taken out when some other neuro guys somewhere else resected a tumor in her brain. That's the least of her problems, frankly.

We've spent the last two weeks trying to convince Son that perhaps Mama should, when Jesus calls, actually pick up the phone. She was a full code this entire time. That means, for you non-medical people, that if her heart or breathing had stopped, we would've gone into Super Nurse Grey's Anatomy Mode and tried our best to bring her back. (Well, not really. I would've walked slowly to that particular code.)

The trouble is that, when you're trying to save people who are that sick, you end up torturing them.

Even the best, most well-executed code has only about a three-in-ten chance of bringing the patient back. And by "bringing the patient back," I don't mean they walk out of the hospital. I mean we stabilize them enough to get them into the CCU, where they'll be intubated and sedated and have drugs pumped into them that will keep their blood pressure up while causing their intestines to slough off and their hands and feet to turn black and gangrenous and we'll put 'em on external continuous dialysis and they'll have tubes coming out of every orifice. . . .

It's ugly. In twelve years, I have heard of--not actually seen--one patient leave the hospital under his own power after a code. Part of that has to do with the people we code: not many, because we're big on comfort care and being rational. Part of it has to do with the population we serve: once your brain goes bad, there's not much point in keeping your heart beating, and no real good way to do it.

Anyway. Mama and I had gotten well-acquaint (or as well-acquaint as you can with somebody who twitches and moans) and I was looking forward to the probability that I would be breaking more ribs, causing her belly wound to come apart and her guts spill everywhere, and generally doing something I didn't want to do. We actually had a call in to the ethics committee about Mama, when a doc I had not met before came sailing in like a white knight and saved the fucking day.

The dude is new to the hospitalist program. I met him for the first time after he'd been straightforward and a tiny bit brutal with Son about Mama's chances. I could've hugged him. Instead, I called Ethics back and told 'em to stand down.

Mama is now a DNR. She's not on palliative care yet, but I'm happy just being able to not have to consider coding her.

Sometimes things work out okay, relatively speaking.


bobbie said...

Nothing like 4plussing gorks on vents ~
That was the one aspect of the job I absolutely HATED. Especially when the cause was to keep Granny's pension/retirement/SS money coming in.

Bless Dr. New & No-nonsense!

Comradde PhysioProffe said...

I sure hope when I'm on my last fucking legs, there's a nurse around like you.

Anonymous said...

I always enjoy what you have to say and like Comrade Physio, I hope there's someone like you around when it's my time to go. I linked this one to my Facebook page so more of my American friends with aging parents can read it.

yrsis said...

I am proud to be related to someone who would call Ethics in this situation. I know, I know: "What else could I do?" That just makes me prouder.

messymimi said...

People like the son make me angry, but part of their problem is they've been watching too many TV shows where Granny has all this trouble and walks out of the hospital, just like her old self, by the end of the show.

And sometimes they do know the score and just want to spare themselves having to grieve the loss.

No matter the reason, the patient deserves better.

Chen said...

I love a blunt physician. One who tells it like it is and does not fill the family with false hope. Too many physicians don't want to have the talk and drag on the torture for days to weeks. I am blunt to the point that some newbies think that I am cruel, but all you can do is explain what is happening and hopefully over a little time the family can grow to accept the inevitability of the grave situation.

I remember one neurologist spoke to me and admitted there was zero hope for a patient. A few minutes later told a completely different story to the family. I asked her, "what up with that?" she explained, "I just don't like giving families bad news". Then you are working in the wrong profession.

cowango said...

Praise Jesus for the Dude and others like him. Sometimes I think people's guilt or misdirected sense of love keep them from grasping reality and what is truly humane. Death is not always our worst experience.

gorochan said...

Actually my first code as a new grad walked out of there. But he was only a COPD exacerbation that we over treated, which messed up his lytes and caused vfib. Youngish dude.

None of the others made it to be transferred to critical care.

Janice said...

My 7-year-old son drowned last summer. He was three hours away at his dad's. He was resuscitated for 45 minutes before having a so-so heart rate and respirations. He was air lifted twice before finally ending up in our hometown. The doctors all told me his prognosis was grave. He would never fully recover, if he came out of his coma, he would have severe brain damage and would be in a wheelchair and require round the clock care. This was my ADHD, smart, funny, imaginative, mama's boy son. I told them then not to beat on is body anymore. Support him medically, but do not beat on him anymore. 36 hours into this, it became clear he was not going to pull through. The tubes were disconnected, he was placed in my arms and the breathing tube turned off. That was the hardest and easiest thing I have ever done. Reading your post confirms to me that I made the right decision. My baby is running around in heaven making people crazy with his questions and antics instead of being stuck in limbo in a body that doesn't work anymore.

Jo said...

Janice, oh my God.

I can't imagine, even a little bit, what that must have felt like for you. I am so, so sorry.

You had to be very brave to do what you did. I know you hear that a lot, but I do know, a little, what I'm saying when I say that. You did the right thing. Please don't ever doubt that.

This may be the first time a comment has ever brought tears to my eyes. I wish I could do or say something meaningful. All I can do is thank you on behalf of your son. You loved him *so much*.

Janice said...

Thank you. That means a lot. I have second thoughts daily about what that day. The doctor and the nurses were wonderful though, and made sure I understood everything that was going on. You can read his story here.