Mr. Jones was sick. You could tell from across the room. He was shriveled like a prune and was moaning like a goat. As the paramedics unloaded him onto the gurney, I asked one of them for his vitals and my hunch was confirmed.
“Blood pressures are about 70 over palp, heart rates in the 130s, and we couldn’t really get an oxygen sat he was shivering so bad,” the medic said.
“Ok,” I said, “Then we better get to work.” I started to examine the patient further. “How old is he?” I blurted out loud. Did I mention he looked really old?
“Uh, lets see,” the nurse said flipping through the notes from the nursing home. “Ninety six!”
“Wow,” I muttered under my breath and continued my exam, first listening to his fast but distant heart, and then listening to his shallow breath sounds. “Mr. Jones!” I yelled in his face. More bleating. It was quite like a veterinary exam, since he would not answer me in any consistent fashion.
“Here’s his EKG,” the nurse taking care of the patient said as he handed it to me.
I glanced at it in my usual fashion, and then ordered him and another nurse to place two peripheral IV catheters and to start lots of IV fluids to help bring his dangerously low blood pressure up. This guy was clinically in shock—he either had a really bad blood born infection (septic shock) or was bleeding internally, or was really dehydrated, or had overdosed on his pain pills, or was…”Dr. Nagavi,” the nurse for another patient asked. “Can I give the patient in room 12 some Zofran for his nausea?”
“Uh, 12…lets see, sure,” I replied as I walked back to the computer formulating my plan for the tests I would need for my sick patient. Let’s see, where was I: urinalysis, basic metabolic panel, blood counts, blood culture, and a chest x-ray. What the hell, lets add a CT of his brain, he could be bleeding in his brain; maybe that was the cause of his goat-ification.
After I finished ordering the tests and had seen several other patients, Seth informed me that the urine he had obtained from the patient’s urinary catheter “had a ton of chunks.”
“Bingo,” I thought. “Urosepsis.” I then reminded myself to check his chest x-ray as that might be the source of infection. The study looked to be of poor quality with his bent posture and oxygen mask in the way, but nope, no pneumonia seen. The charge nurse then informed me that the Mr. Jones’ son was in the room with him. I walked into the room stuck my hand out, “I’m Dr. Nagavi, good to meet you, sir.”
“Thank you for taking care of him,” he said, “I’m his son Tom.”
“As you know,” I started, “your dad is very ill. I don’t have all of the tests back yet, but his blood pressure is dangerously low from what appears to be a urinary infection that has gone into his blood.”
“OK.”
And the infection is causing all of the fluids to leak out of his blood vessels into the surrounding tissues.
“OK.”
And so we are going to give him lots of IV fluids and antibiotics, but sometimes that isn’t enough and we have to put a large IV into his heart, and give a powerful blood pressure medicine to elevate his blood pressure.
“Do whatever you have to do, doctor.”
“And sometimes all of these fluids that we would give might back up into his lungs, and we might then be forced to put a breathing tube down into his lungs and put him on the ventilator for the machine to breathe for him.” I waited a while. “These are invasive things.”
“Uh, huh,” the son was thinking. “What did you say about the IV into his heart?”
“It’s called a central line,” I started. “It is a long IV that a ER physician would put into the neck usually, to give several powerful drugs at once. It can be painful and uncomfortable, and it can sometimes damage a lung so that it collapses, and it can also sometimes introduce a new infection.” I waited. “These would require further invasive procedures to correct.”
“OK, do whatever you have to do, doctor,” he said.
“These are all invasive procedures,” I repeated, “And not everyone would wish to have them done to them.”
“Well dad, he—he’s a trooper. He fell from a tree 30 years ago, and they thought he would never make it! But he made a full recovery.”
“Yes, he may have done well then, when he was 60 years old. But he’s NINETY SIX now,” I emphasized.
“I know, doctor, but you really don’t know him. He’s a fighter. He’s been such a good dad to us, I jut want the best for him…”
I had to cut the guy off, “At his age; and with this serious of an infection, his likelihood of surviving the illness and leaving the hospital are very grim.” I had to start getting blunt with this guy.
“I see…but you just don’t know him.”
“We can still give the antibiotics and fluids, and even the blood pressure medicine through the peripheral IVs, and that may be all that he needs to improve, but I think we need to start thinking about how far HE would want us to go,” I said.
“I think we should do EVERYTHING for him, doctor,” he said.
And with that I was obligated to throw common sense out the window. He squashed my twelve years of training and experience under his feet, because he “felt” it was the right thing to do.
I had no recourse, no further ability to advise otherwise. I had offered him the two treatment options: be kind to grandpa, which I knew to be appropriate. He may get better, but he probably wouldn’t. Or go crazy, and let’s not minse words: stick him with a 12 inch long IV catheter into his Jugular vein and into his heart and a massive snorkel in his wind pipe.
Therefore, for the next half-an hour I was busy putting in a central line and breathing tube in this sick old man as he lay sedated on the ventilator, unable to protest. Meanwhile, the ER continued to fill up to the hilts with patients that had emergencysore throats and vaginal discharge.
By the way, the patient improved in the ER after tanking up with equivalent of two 2-liter bottles of Gatorade through the IV, and went to the ICU. There, he died four days later of fulminant septic shock, which I had predicted. Total avoidable ICU cost? Estimated $15k cost in ICU vs $4k general hospital room vs his free comfortable room at home that he could have passed away in.
–DrMedicineMan
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