Saturday, May 26, 2012

my favorite patients

#1) 80 something year old woman with end-stage lung disease, no longer able to live without a BiPAP (seriously, desatted to 70% within seconds of removal). Her whole supportive family was right by her side every minute. She was totally out of it, and the daughters decided they would withdraw care later and go to comfort care. Then... snap! Old lady woke up and started chatting and being totally appropriate! So, I encouraged the daughters to talk with her about HER wishes and if she wanted to proceed with comfort care. (Big change of plans in unconscious to consious patient!) Guess what, she told me she was "ready to go". She made her own decision, and the rest of her family arrived, including guitar-playing great-nephew. They had a champagne toast, cake, sang the fight song of her favorite team, and then she called me in there. She thanked me for her outstanding care and said she'd chosen the best hospital to come to. Then she folded her hands over her stomach, leaned her head back, closed her eyes, and said "ok, I'm ready!"
I started morphine. We turned the BiPAP support down a little bit at a time, until we eventually removed it. She slipped away within an hour, no gasping, struggling, or anything else we typically see. She simply closed her eyes and slipped away.
It was PERFECT. And the reason I do what I do.

#2) My patient yesterday was a touch delirious. He was extubated but re-intubated during the night. I went in to turn him after having been in a staff meeting for 45 minutes, during which he'd been sleeping. This guy had mitts on, because otherwise he would extubate himself. But boy did he HATE those mitts! He even tried to bite me sometimes when I put them on. So I went in there to turn him, and oddly, he was totally unresponsive. Like, only responding to sternal rub, but no longer interactive or looking around per usual. I went and got the resident. We both tried to wake him. We couldn't figure it out... all vitals were the same, labs and gas looked good... did he stroke out??

Jokingly I said to the resident, oh I know how to tell if he's awake or not! "*Patient*, do you want me to put your mitts back on??" Suddenly, *patient* shakes his head emphatically NO! WHAT???? Gasp. He was FAKING it??? The resident burst out laughing. She said, "I think he just doesn't like you!" Not true! I replied. "*Patient*, you like me, don't you?" He shakes his head no. I can't believe it! The resident is laughing more. I said, "*Patient*, you don't mean that, do you??" He shakes his head no.
Aahhhh I love these delirious patients! What a hoot!

#3) Ok not a favorite patient, but a least favorite patient, perhaps. 50-something-year-old male cocaine user, found down by his ex-wife, from whom he stole thousands of dollars that day. He came to me with a positive head CT, minimum reflexes, blown pupils, etc. He was labile, and temp climbing up to 106.9. His parents had the DPOA power since he was divorced, and they made him a DNR, but not a withdraw. Soooo... I slaved away to keep this brain-dead guy alive. Then the ex-wife comes running in, having finally found a sitter for her two small kids (patient was the dad), madder than a hornet, just having found out that she had NO money anymore. Oh she believed he had quit the habit, it all started up again when they lost their house a few years ago, but he PROMISED he wasn't going to use ever again. She has no money, no job, two kids, he's left her with nothing. My scrubs were wet with her tears.

The patient died within hours, after his mom in Denver told us to go ahead and stop treatment, it being obvious from a pH of 7.0 and our total inability to oxygenate him that he wasn't going to last anyway. Not to mention the fact that he was HERNIATING.

But I talked to the ex-wife throughout, and she kept saying how nice I was, how much it meant to her. I'd like to think I did just a little tiny bit of good in her world, that day.

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