Mrs. Jones looks like a cadaver. Her bony yellow legs stick out of the bottom of the gown. A pack of relatives clutch at each of her claw-like hands and stare confidently at the monitor over the bed.
“She’s doing better, right?” Her blood pressure had been coming up steadily. A great-grandson reads the numbers to the relatives standing in the hall who nod in relief.
“We’re giving her fluid. She was pretty dry when she came in.” I am not nearly as optimistic.
Mrs. Jones came to the Emergency Department from her nursing home. According to EMS a nurse had noticed that she was looking more cadaver-ish than usual and became alarmed when she couldn’t get a blood pressure.
“Her doctor said not to give her fluids.” The daughter is the spokesman for the relatives. “He said it would flood her lungs.”
Mrs. Jones’ medical history reads like a pathology textbook. Her congestive heart failure is the least of her problems at this point as it’s competing with severe hypovolemia, probably from diarrhea over the past several days.
“Her lungs sound pretty clear. We’re waiting for the chest x-ray but I’m pretty sure she can tolerate a lot more fluid than we’ve given her. We can always take some of the fluid off later but her organs need fluid now.”
The daughter holds up her hand.
“We want to speak to a real doctor. Our doctor told us to keep residents away from her.”
“I am a real doctor,” I say pointing to my ID badge. The family looks suspicious.
“The other doctor who was in here said she didn’t need that,” says the daughter pointing to the small bag of levophed dripping into her central line. “He said it will make her lungs fill with fluid.”
That must have been my medical student. Or maybe one of the janitors. They clearly don’t buy my explanation of the role of pressors in shock. The daughter throws me a dark look. I promise to get a real doctor to answer their questions.
Several hours later and Mrs. Jones still looks like a cadaver. According to the monitor Mrs. Jones is doing fine though she clearly has one foot in the next world. Her daughter who has become adept at reading the numbers is annoyed that we have not stopped the pressors and have not removed the endotracheal tube, something she insists we do immediately. I don’t think she’s going to be very receptive to the discussion of code status once her mother gets up to the ICU but the prognosis for her mother is grim, cheerfully normal vitals notwithstanding. Mrs. Jones is fighting myelodyplastic syndrome which has converted to leukemia, something I only discovered when I browsed through her old records.
“Why does she need to go to the ICU?” asks the daughter.
“Because she’s dying. The only things keeping her alive are the fluids and the ventilator. I hate to be blunt but surely you are familiar with her medical history.”
“Her doctor said she still had at least six months. You’re not even a real doctor. What do you know?” Some of the relatives look embarrassed. The alpha-relatives, however, are clearly not impressed with me and mutter darkly about a second opinion.
“Let’s get her up to the ICU and you can talk to her oncologist in the morning.”
Mrs. Smith has fibromyalgia. I have hardly introduced myself before her husband mentions this twice. My attending laughed when I picked up the chart. Mrs. Smith is well known to the department. A quick check of the computer shows fifteen visits in the last year for similar pain. She writhes in agony on the bed.
“How long have you had the pain,” I ask, grimly determined to think the best of her.
“Since last night…I’m paining real bad…All Over.” By this time she has learned not to point to a specific spot as we have a distressing tendency to take people at their word and order all kinds of inconclusive and painful tests and studies.
“She gets like this a lot,” says her husband, clearly distressed, “You guys never do nothing for her.”
Normal physical exam. Mrs. Smith has still not caught on that when I am listening for bowel sounds I am actually palpating her abdomen with my stethoscope. Sometimes you have to distract the patient. Neither is there anything unusual in the review of systems or the history except for pain.
“What do you take for your pain?” Her old charts record a bewildering array of pain medications. “Let me try you on some Motrin.”
“I want to speak to a real Doctor,” she says.
The nurse mentions to me that “pain lady” was sleeping soundly just minutes before I opened the curtain.
Mr. Simon’s mother hold the basin as he heaves and vomits a large quantity of red-colored fluid, spits to clear his mouth, then lays back in the bed and continues to curse at the nurses. I’d ordinarily be alarmed but the paramedics told us that his neighbor thought he was hypoglycemic and force-fed him a bottle of fruit punch. His vitals are stable and he’s not tachycardic. On the other hand alcoholics are susceptible to upper GI bleeds from ulcers, varices, and esophageal tears. We send a sample of his vomit to be tested for blood and I make sure to order a type and screen but I don’t think he is bleeding. His blood counts come back normal a few minutes later and his vomit is negative for blood.
“If you stick me again I’m going to kick your fucking ass,” yells Mr. Simon to the respiratory therapist by way of introduction. Aside from being drunk, diabetic, and high on heroin, Mr. Simon’s immediate medical problem is the inability to maintain his oxygen saturation without supplemental oxygen. When he takes off his mask, his oxygen saturation falls to the high seventies. Mr. Simon is only 29 and a heavy smoker but this is definitely not normal. I want to get an arterial blood gas on him. If he thinks the respiratory therapist is hurting him he’s going to enjoy it even less if I have to stick him.
“Stop cursing at the nurses, Mr. Simon,” I suggest gently, “They’re trying to help you.”
“I’m paying your fucking salary,” screams Mr. Simon. “I don’t need this shit from you.” Mr. Simon is what is optimistically known as “self pay” meaning he wouldn’t pay his medical bills even if he had the money.
According to his mother he went on his current binge after being dropped by his girlfriend. He had stopped taking his insulin a day before and his presenting blood sugar was too high to be read by the glucometer. The complete metabolic panel pegged it at 769 which is pretty high but everything else wasn’t too far out of whack. He also had a normal anion gap which was unexpected as the assumption was that he had diabetic ketoacidosis. His potassium was normal so we started him on a modest insulin drip.
Mr. Simon is a mystery. A rancid, abusive, tattooed enigma. His chest films are normal, his respiratory rate is normal, and his GCS is a solid 15. His ABG confirms both a mixed metabolic and respiratory acidosis and a low oxygen saturation. Pulmonary embolism? His D-dimer is low so he’s not making it easy for us. Aspiration? My senior resident starts him on clindamycin as a precaution but would he really be so hypoxic so quickly? Physical exam pretty normal too except that he feels clammy.
Maybe it’s cardiac but unfortunately is EKG is normal. Maybe the cardiac enzymes will give us a clue. I ask him about chest pain but as Mr. Simon answers some variation of “fuck you” to every question, the review of systems is probably going to be a little sketchy.
“Yeah my chest fucking hurts,” He says.
Surprise, surprise. “What does the pain feel like, Mr. Simon?”
“Have you ever had your heart chewed up and then spit back into your chest? That’s what that bitch did to me.” (He points to a scruffy looking young lady who has crept into the room and now shirks against the wall.)
“Not recently. Listen, is it some kind of metaphorical pain or does your chest really hurt?”
“Fuck you. I need to take a crap.”
He’s stable for now although it’s a struggle to keep his oxygen mask on. He keeps pulling it off and threatening to leave. While this isn’t a prison, he is drunk and high so I could restrain him if necessary. He definitely needs to be admitted and I ask the unit coordinator to break the good news to the medicine intern
Mr. Simon was admitted but bolted a few hours later before the source of his hypoxia could be identified. I imagine he is in some hole shooting up with his insulin money.
Mrs. Jones died in the ICU that day.
Mrs. Smith got six vicodin and left gravely disappointed.