Sunday, 13 April 2014

Deaths, difficult families and the worst day yet


The last week was a terrible week. Very busy and a lot of difficult conversations with families when I didn't feel I had the time to give them the attention they wanted. My new rotation is gastrointestinal medicine, and it is very busy. The last week seemed to have someone dying every day. Many of these people were people with end stage cancer or other serious conditions, but this didn't make it any easier for me at all. The last 8 months or so I have been very fortunate and only had a couple of patients die - now it is terrible.

My week started off on call, where among others I clerked in a lovely gent who was in his 60s and had the same birthday as me. He had a pneumonia (I am still pleased with myself when I get a diagnosis, even one as barn door as this - makes me feel like a 'proper' doctor rather than a glorified PA) and his oxygen saturations (the measure of the amount of oxygen your blood is holding) were about 80% instead of the normal 95-100%. Other than this, he seemed pretty well. With pneumonia it is common to use something called the CURB-65 score to estimate how severe it is, and plan your treatment. This man scored 0, but I started him on the treatment plan for 'high risk' pneumonia (normally a score of 3 or more) because of his poor oxygen levels (not included in the CURB-65 score). A CURB-65 score of 0 suggests that this patient should have a 0.6% chance of dying from the pneumonia, but sadly 2 days later he had passed away. After having a good time joking with him about sharing a birthday, I was quite upset by this - especially as it had been so unexpected. I am pleased I had started treating him with intravenous antibiotics (as high risk) rather than oral antibiotics (as you normally would for a CURB 0 patient) as otherwise I would have felt as though I hadn't treated him properly, but I still felt upset over this. 0.6% still gives you that slim chance that someone may die...

Sadly the week got worse from there, cumulating in Friday which was the worst day I have had since I started work last August. It started off like a normal busy day, our ward works with 2 consultants who take it in turns to accept all new patients, and Friday is our day, so there was quite a lot to do. Part way through the ward round (up on the 2nd from top floor of the hospital) we get a bleep from the surgical ward (ground floor) saying one of our medical outliers has some chest pain. This happens a lot (invariably nothing) so I ask for an ECG and break off from the ward round to go down and check it out, expecting to be able to go back and join in a few minutes. I arrived on the ward, to be shown an ECG with good going ST elevation

ST elevation in an ECG from wikipedia 

I was panicked - what to do? ABC! MONA?! or should I be preparing him for PCI? I started treatment and then bleeped the cardiology registrar. No answer - I bleeped the other 3. No answers, so I dragged my registrar down away from the ward round to come and help me out. Fortunately it all went well, we continued ACS treatment (so many TLAs!) and the ECG changes went away, the patient didn't need PCI today (and he is still doing well)

Sadly, because my registrar and I were pulled away from the ward round (which the consultant completed on his own, as he needed to run a clinic in the afternoon) we were not too sure about the jobs that needed to be done. The SHO is in nights, and the registrar had to go to the consultants clinic in the afternoon, leaving me to work out what needed doing.

This is when the real trouble started. One of the patient's on the wards bloods came back with a high potassium, which means that they need certain intravenous medications (like insulin). I prescribed these medications while talking on the phone to one of the F1s from the acute medical unit. They wanted to transfer a sick patient to the ward from there, but needed a medical handover to do this. He explained that this patient was for palliative treatment due to her breast cancer which had spread extensively throughout her body, and she was too sick to be transferred to a hospice. He said she was already on a syringe driver with medications such as morphine to take away any pain or suffering, and just needed some TLC on the ward. I accepted all this and said I was happy for the transfer to happen. 

As I come off of the phone and hand the prescription chart to the nurse in charge of the ward, one of the other patient's relatives want to speak to me. He has end stage liver disease and is too old for a transplant, he currently has a bacterial infection in his abdomen which we are trying to treat with antibiotics, but not very successfully. It turns out that on the ward round in the morning, the consultant had been exploring the idea of going down a more palliative route with this man and his family. The thought being that the infection was only getting worse, and we couldn't give him a new liver to replace the old one that the alcohol had destroyed. It seemed that the way he had done this was leaving the family and patient (who was not well enough to process information) to think about what route they think would be best, as continuing active medical treatment would involve a central line, a nasogastric tube and more invasive treatment. Having thought about this from the morning, the family felt quite put out by this and felt that they were being asked to make a decision about whether the patient should 'live or die'. We were always taught at medical school that these sort of decisions should be made clinically, then the decision communicated to the family with their agreement - it isn't fair to leave this decision to the family, so I agreed with why they were so upset. I felt this was a decision a little too advanced for me to have to deal with, and went to pull my consultant out of his clinic to talk to the family, which he wasn't too happy with. It is decided that this patient is for full active treatment, and I need to find the 'IV team' who are the team who can insert central lines and suchlike. As it is a Friday, if I do not get these in today then we will have to wait for Monday, which means no antibiotics or fluid over the weekend, as we cannot get any venous access on this patient, which would not be good.

On getting back to the ward, a nurse told me that no-one had been able to give the treatment to the man with a high potassium, as the man had no cannula in to give intravenous drugs. It is about 5PM now and my official time to end the shift. I went to start setting up the equipment to insert a cannula and my bleep went off. I decide to answer it before putting in the cannula, as leaving it would mean they would keep bleeping me while I was inserting this cannula. It is the radiologist calling through an urgent report on one of my patient's scans. This lady has suspected bowel cancer (but not proven), and had been feeling a bit dizzy and faint so we had done a CT scan of the head. This CT scan had shown a very large mass in her brain which was squashing the brain up and starting to lead to coning within the brain (where the swelling squashes the important parts of the brain that control breathing and can lead to death). This needed urgent neurosurgical input, so I prescribed intravenous dexamethasone (a steroid to reduce the inflammation) and called the neurosurgeons to talk through what they wanted me to do. While on the phone to them, the nurse comes to tell me that they still cannot give my treatment for high potassium or the dexamethasone as no-one is trained in cannulation on the ward. I ask if they could call one of the other nurses from another ward to help out (though the neurosurgeon is not happy to be interrupted)! The neurosurgeons want an urgent MRI scan before deciding what to do.

I go to get the equipment to insert these cannulas when a very angry man storms into the nurses station and starts shouting that he needs to speak to the doctor in charge. I am the only doctor on the ward, so am asked to speak with him. He is visibly distressed and shouting about his mum; the lady with breast cancer who had been transferred to the ward a few hours ago. He is shouting things like  'why are you killing her' and 'What is this sh*thole anyway', and physically threatening staff members. I tell him I will happily talk to him at his mum's bedside, and go to look at the patient's notes to prepare myself for this conversation. By now it is about 7PM and I am left in the ward on my own. It seems that this lady with metastatic breast cancer has been known to the palliative care team for some time, and has accepted her diagnosis and the fact that she is dying. With this knowledge I go to speak to the son, at the patient's bedside. Her husband is also there. Her son is very angry, and stands with his face about an inch away from mine and shouts at me. I think about asking the nurses to get security, but decide that it might escalate the situation. It is understandable that he would be upset given the problem with his mum, and I don't want to make things worse. It seems that before the patient left the acute medical unit it was not explained to her son (who was not there) that she was dying and the decision had been made to make her comfortable, as there was nothing more we could do. In addition to this, she seemed very distressed when I was at the end of the bed - the medications she had been put on before transfer were at too low doses to alleviate all of her symptoms. I am stuck behind the curtains with this man accusing me of killing his mother, the poor lady who is visibly distressed and her husband who is just crying. The nurse pops her head around and reminds me that the two other patients are still awaiting cannulas, and they cannot give the steroid to the lady with the swollen brain, or the man with the high potassium (which gives him a risk of arrhythmias and death). I feel so out of my depth, but there is nothing I can do.

I ask the nurse who has popped in if she can give some more midazolam and morphine to this distressed lady, and continue trying to explain things to the son. He isn't having any of it, though, and has decided that I am too young to work there and he wants to speak to someone 'proper'. He wants to know which consultant made the decision for palliative care, so I tell him the name of the consultant who saw her in the acute medical unit. He storms off to talk to the consultant, and I try and explain things to her husband, but he is too busy crying. 

I put in the two urgent cannulas, and call up radiology who are not interested in performing an urgent MRI as it is now far too late. I have to explain to the lady with the mass in her brain that she probably has metastatic cancer which has spread to her brain, as she keeps asking the nurses why she has been started on dexamethasone - trying my best to not rush but to take my time and explain things gently. The acute medical consultant calls me up, not happy that I sent an irate patient down to bother him when he is busy. I am too tired to protest, or care.

It is now about 9PM, 4 hours after I was meant to leave. I still have most of my jobs from the day to do. The day on call has now changed to the night on call. I call up to let them know about the sick patients on my ward, and then get on with finishing off my day jobs. It would take longer to hand them over and explain the situations behind each patient than just doing them myself.

Before I leave, I check on the patient with metastatic breast cancer to make sure she is more comfortable. She is sleeping soundly. The son had gone home hours ago. The husband is still there, and he gets up, shakes my hand and just says "Thank you so much. For everything." The look in his eyes is all apology, he is so guilty for what his son was doing and saying.

I leave for home, physically and emotionally drained, but that handshake at the end made the world of difference to my week.