the obligatory cheesy entry

It was a good weekend on call. 2 of my patients died and a

further 2 came close - but it's not about the mortality or the

sickness. I guess it was good because I learned loads, got to put

some knowledge (previously classed in my memory as 'obscure')

into practice, with the end result of several grateful relatives

for a change. The challenge, as they say, is to "heal the sick

and comfort the dying" - and not get the two mixed up! Also, some

things are best not mentioned to cheesed off relatives - such as

the real reason I took 2 hours to come and speak to them.

(Because I am the only doctor covering 6 medical wards!)
****
LJ is a 60 year-old lady with terminal lung cancer. I'd first met

her by chance about a week ago, because she had come in for a

neurolytic block (injection of phenol to destroy the nerve

supplying a painful area-normally an outpatient procedure), and

had been so short of breath afterward that she had to stay in

hospital overnight. As the on-call doctor, I was asked to see

her. The anaesthetist who had performed the block had thought of

the possible complications- pneumothorax (a punctured lung) and

paralysis, but a check x-ray showed no pneumothorax, and her

chest expansion was symmetrical. When I listened to her chest,

she was extremely wheezy, but denied having asthma or ever having

been a smoker. I prescribed some nebulisers. She stuck in my mind

because of something quite silly- the nurses hadn't removed her

red nail polish, so the pulse oximeter readings were completely

useless. I guess I would have taken an arterial blood sample

anyway, but I was frustrated that the ward didn't have any nail

polish remover. It took about 4 attempts to get an arterial

sample. She screamed every time the needle went into her wrist,

and kept moaning for "Eddy", the elderly man I assumed was her

husband. Anyhow, her saturations improved with the nebulisers and

oxygen.

I didn't see her again for more than a week, and presumed she had

gone home. Yesterday I was bleeped to say LJ was on a different

ward, and her heart rate was 170/min (nearly 3 times as fast as

normal) and she was drenched in sweat, with a temperature of 38.

I instructed the nurse to take blood for various tests, and to

give her some paracetamol. When I arrived on the ward, she looked

dreadful, slumped over and dribbling from nose, mouth, hair. The

front of her nightdress was covered in vomit and she had wet the

bed. She shook her head when asked if she had pain in her chest

or tummy. Her pulse was thready, even at the femorals. I went for

the biggest cannula I could find (still feeling trigger-happy

from inserting two greys into a lady who nearly bled to death

from a duodenal ulcer the day before - but that is another

story!) and got the nurse to push in a litre of saline as quickly

as it would run. For all that, her pulse dropped to - 120. Not

good. I was convinced at this point that she might die, so I had

the nurse contact her son. I had her cleaned up and sat up, the

oxygen turned up, another bag of saline run. I prescribed some

antibiotics to cover a possible aspiration pneumonia. She now

seemed a bit more stable, so i left the ward as my bleep had gone

off about 8 times, including a call about a man in renal failure

(as he hadn't passed any urine for 18 hours) on the other side of

the hospital.

Her son, *Joe, arrived about 2 hours later. I got him into the

ward's quiet room, and tried to impress upon him the seriousness

of the situation. Although he seemed to understand the terminal

nature of her underlying illness, he still had rather unrealistic

expectations of the outcome. Eventually, I said "if your mother

were to stop breathing and her heart were to stop, would you want

us to do everything to bring her back to life?" At this he became

tearful. He paused. Nodded. "yes, of course," he sobbed. I paused

for a bit, then left to let him gather his thoughts. It felt

cruel, but I'd rather paint a grim picture and have them be

pleased when the outcome is better than expected. (rather than

the converse!)

Called away again. I returned to see him standing by her side,

shaking her. "Mom!" She wasn't opening her eyes. She had

definitely been conscious in the morning, despite being in

extremis. I peeled her eyelids back and sure enough the pupils

were pinpoint. Her dehydration had probably caused a build-up of

oxycodone. I got the nurse to draw up some naloxone. "What's that

stuff?" Joe asked, suspiciously. I explained as best I could, and

started to inject it (see entry below - "a suicide, maybe"). She

came round with a jolt. Joe was visibly relieved, but his face

soon fell when she looked him in the eye and said, "I want them

to stop." "Stop what, mom?" "All this," she said, holding up her

arms, which were covered in lines and monitoring equipment.

Oops, have to go head to the airport soon! to cut a long story

short, she survived to see another day. Also, it turned out that

Eddy and Joe are not on speaking terms as Eddy is his step-dad.

And I am going on holiday so I will never know the outcome - will

Joe and Eddy come to accept that intensive care, CPR etc are not

in LJ's best interest? And so on. Every on-call is a bit like

starting a dozen books and never finishing them.