I was working in Yellow the other day and triage sent me an 80 year old woman whose family brought her in because she had pressure sores on her bottom. She’s a paraplegic and had bleeding pressure sores on her hind end, because frankly, the family doesn’t turn her enough.
We get her into the bed, and the patient responds only to pain, her blood pressure is 86/42, her HR is 70 and V paced, her RR is 40. I called a medical alert. Less than a minute later, I had a doctor, two staff nurses, a charge nurse, a paramedic, and a technician. I asked the Dr for orders to give a liter of fluid, and it was granted. He told me to give a liter of saline, followed by a liter of ringer’s.
I started two IVs and drew blood cultures, a CBC, a CMP, a lactic acid, and a type and screen.
For my medical readers: Her labs came back with all sorts of critical results. Her hemoglobin was 4.3, lactic acid 3.8, troponin was 202.
By this time, she had almost liter onboard and her blood pressure was 76/48. I got the doctor to order 1 unit of emergent O+ blood, followed by two more units of type appropriate blood. The only problem was I had to discontinue the fluids because she was showing signs of fluid overload and congestive heart failure. Her SpO2 began dropping and I had to start oxygen.
It wasn’t long before she was on Levophed. I tried talking to the family about end of life and signing a DNR, but they insisted that she was “a fighter.” I spent the next 8 hours trying to keep her alive and stabilize her. I had two other patients who had to wait awhile because nearly all of my time was being taken by this patient. When she went to CT, I went with her, and the report came back showing all sorts of gas bubbles in her chest and abdomen from the large amount of sepsis. None of the surgeons would touch her because she was too sick. Simply put, she is dying. I was incredibly happy when the time came to transfer her up to the intensive care unit.
18 Comments
Stefan v. · August 13, 2024 at 6:11 am
May The Lord Jesus Christ have mercy on her, and give you strength and patience, wisdom and comfort.
Dan D. · August 14, 2024 at 3:25 pm
Outstanding!
jimmyPx · August 13, 2024 at 7:40 am
What you describe is one of my HUGE pet peeves. I work in a hospital and see this EVERY day (as do you DM).
One big thing that drives me crazy about our society is the absolute fear of dying which leads to situations like you describe. That woman is 80 years old, septic and dying… it was her time to go and the Grim Reaper was on the way. In other cultures they would accept this, make her comfortable until the end and say goodbye. But here — oh no — “she’s a fighter, she’s going to live to 100” even though she’s crippled and suffering and the way the system is, you HAVE to treat her and waste thousands of dollars in manpower and supplies effectively on a dead woman.
I read somewhere that more than HALF of our healthcare dollars in this country are wasted on terminal patients like this. It’s why we greatly need to expand the number of palliative care doctors who can explain to patients and families that no matter what you do, it’s “game over man…game over”.
I can’t tell you how many times I’ve seen people diagnosed with stage 4 cancer spread throughout their body and they say “I’m gonna beat this” and suffer on chemo and radiation and it doesn’t extend their life a day but makes their final weeks miserable and painful. Sure there are the very rare unicorns who DO beat it but honestly they are probably less than 5%.
The way we sometimes treat our human loved ones medically, a vet would go to jail for animal cruelty if they did that to a dog. People need to understand that death is part of life, will come for all of us and when your time is up… it’s up.
Divemedic · August 13, 2024 at 7:50 am
Of course, that is a conversation that my coworkers and I have had many times. If you are barely hanging on to a viable blood pressure, even with blood and levophed, being a fighter isn’t going to change the outcome. All you are doing is suffering and spending GOBS of money to fight a losing battle. Most of the health care professionals that I know fully support end of life care.
The problem is that, and we all know this will happen, insurance companies will quickly take advantage of such a system and tell the patient “Oooh, we don’t approve this procedure, but here is a pamphlet on euthanasia.” Not because the patient is terminal, but because it is cheaper to do so.
The difference is subtle, but important: In one case, you are withholding treatments that would prolong suffering for no real gain in life and allowing the natural process of dying to proceed while supplying pain relief, in the other case, you are actively ending someone’s life.
jimmyPx · August 13, 2024 at 10:31 am
The question is always what are the patient’s chances if they have this procedure and is it worth it ? If you aren’t careful, insurance companies and government agencies will refuse to pay for procedures that have a high chance of helping the patient to save money.
Canada with their MAID (Medical Assistance in Dying) program is experiencing these very things right now. It started allowing euthanasia for terminal patients but now has expanded to those who aren’t terminal.
It’s a very sensitive subject that needs to be studied and debated thoroughly.
Anonymous · August 13, 2024 at 9:51 am
My mom recently passed away at the age of 87 after a few years of declining health. The goal for her care was always quality of life and comfort which we (my sister and I) openly discussed and communicated to her healthcare providers.
When decisions had to be made the first question was was whether a proposef treatment improved quality of life or just extended life. If it only extended life it was not implemented. This made decisions easy and with no regrets.
Dirty Dingus McGee · August 13, 2024 at 1:20 pm
A living will would be helpful in situations like this. I have one which includes DNR situations for accidents. My healthcare power of attorney for this is a 20+ year friend who is also an EMT for the county, so I trust his judgement.
None of us WANT to die, but it’s gonna happen to us sooner or later. Best off having some say in the matter while you can still make the decisions.
Stealth Spaniel · August 13, 2024 at 1:21 pm
As my mother used to explain to patient families: “There is a small window of time when we, as professionals, can do magic and science and amazing things. When that window closes-only God can open it.” There is a HUGE difference between killing folks and accepting God’s will; we do need more ethics in medicine. In the old days, before we all got so bright and smart and transhuman- we accepted that death and life were one and the same.
I used to be that smart puppy. When my mother was dying, I was all for more “life saving” procedures. As the good mother she was, my mom said no. If I can’t garden and cook and be happy in living, then no. She went to Heaven on her own terms. I can’t be grateful enough for that lesson.
Aesop · August 13, 2024 at 4:27 pm
Sometimes, the best medical treatment would be to horsewhip an entire family.
And if Florence Nightengale were alive, she’d cheerfully tie their hands to the whipping post.
Grumpy57 · August 13, 2024 at 6:49 pm
Let’s make it even MORE obvious.
This past weekend, I responded to a Rapid Response (RRT) in the ICU for an 87M – contractures from a stroke, non-verbal from vascular dementia (2/2 stroke), and metastatic brain cancer, having a feeding tube and having increased respiratory distress.
Code status?? FULL CODE.
Criminal! Once the emergency was handled, I requested the case be sent to ethics committee.
ModernDayJeremiah · August 14, 2024 at 10:29 pm
I know you don’t allow memes on here, but I have one that says:
Family, “We want Mom to be full code”.
Mom (picture of an Egyptian mummy).
This lady was circling the drain. What was appropriate would have been comfort care and let her pass naturally.
Divemedic · August 15, 2024 at 7:18 am
I’m good with memes. Here are the rules, for your convenience.
Jerseygirl Angie · August 14, 2024 at 7:43 am
There’s a huge difference between “euthanasia” and comfort care . This lady didn’t need an ICU bed – she needed a quiet room and a morphine infusion .
Of course, doing the right thing would likely get you sued for “killing Gandma” , who the family loved so dearly that they let her get into this moribund condition in the first place .
Jean · August 14, 2024 at 8:30 am
Mom passed in 2003. As she lay in the hospital bed, with a tube in her nose to suck the rotten food out of her stomach because her intestines had scarred shut again. I found out my brother was not allowing her morphine because he wanted to be able to communicate with her. She had bit down so hard that she broke some of her teeth.
I got the nurses to get her morphine. I explain to my idiot siblings that when they brought the crash cart in, that her ribs would be broken by tryng to resusitate an 85 year old woman with osteoporosis.
I got the sibling bastards to agree to a DNR. I got the tube taken out of her nose. I tried to arrange to get her home to die because that is what she wanted.
She died in the hospital. I failed. It was August 18th. All that matters is that she is not in the terrible pain she was endurring.
I miss her and I am in tears all over again.
Divemedic · August 14, 2024 at 4:12 pm
I’m so sorry for your loss. I know how much that hurts
Jean · August 15, 2024 at 7:08 pm
Thank you for letting me post this and Thank You for your kind condolences. I cannot imagine seeing crap like this as often as you all do.
Just so you know, Mom was a nurses aide in a burn unit during WWII.
In the aftermath of all the terribleness, I lay in bed that night in the emotional agony of loss, second guessing all my decisions, and the horror of what my siblings were willing to let happen to Mom so that nothing would change for them.
As the exhaustion set in and I drifted toward sleep, I thought I heard my mother’s voice say “Thank you”. I don’t know if it was her spirit or a hallucination or grace or ??? . I know what I want to believe and I’m staying with that.
Dan D. · August 14, 2024 at 3:28 pm
The book Being Mortal by Gawande is a “should read” for everyone seeing their elderly parents off. I made many mistakes myself.
Nostalgic – Area Ocho · August 21, 2024 at 4:57 am
[…] took the trouble to look up my patient from the other day. Less than 6 hours after I transferred her to the ICU, she passed away. Although I knew she was […]
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