Dying 

 I remember a patient who was admitted to ICU during my critical care rotation . I was an intern then. He had no legs and one arm( can’t remember for sure if he had one or two arms but he lost both eventually).

He came in shock from a nursing home. Further investigations revealed that he had been in a vegetative state for several months . No family , a state appointed guardian and of course the physician assigned to him. The patient was a full code, meaning an attempt for cardiopulmonary resuscitation had to be made regardless of clinical scenario . 

The man was pretty much dead when we saw him . 

In three days he was coded three times. We, the ICU team wanted to make him DNR since we could not figure out why we were saving him again and again.

He lost his last remaining limb because of repeated lack of pulse and underlying diabetes and peripheral vascular disease.

It was an open ICU , meaning the primary doctor was still in charge .

His primary Doctor simply stated that according to his (the doctor’s ) religious belief life had to be saved at all cost. When we called the guardian She decided to let the primary doctor make that desicion. 

We saw the patient everyday of course  . Tubes stuck in every orifice. Mucous and phlegm being suctiond every 10 minute or so. The ICU  doc repeatedly attempted to change the patients code status but could not without the guardian or the primary doc’s approval.

The patient developed some intrabdomianl catastrophe . Needed to have surgery. We asked cardiologist for cardiac clearance . I still remember the expression on the cardiologist face when he came to see the patient. He looked at the patient , sat down ,shock and disgust showing on his face , deep in thoughts and said ” yeah, do the surgery , we haven’t stopped yet , why should we stop now”

‘Is he cleared for surgery’

The cardiologist stared at us with a grim face 

“You really want me to do an angiogram to clear him?” 

The worst thing was that we were not sure if  the patients was ‘locked in’ or in persistent vegetative state . If ‘ locked in’ He probably still could feel , see and hear everything but was unable to communicate .

It is much harder then people realize to determine if somebody is locked in or in a vegetative state. For example you ask them to blink their eyes and they do ,you make the diagnosis of locked in and feel you have achieved something. Now come back in 10 minutes and ask them again ,they don’t blink their eyes and suddenly your diagnosis is uncertain . Do it about twenty times and you remain with three possibilities . 

1 either the patient is locked in because he blinked his eyes initially

2 he is in peristent vegetative state because he is not blinking now and the earlier response may have been automatism or reflex.

3 he is mad at you for bothering him repeatedly.
My rotation ended . I found out later that the patient did develop some further complications a few weeks later and was finally unable to be  resuscitated.

Each month the patient lived the doctor and the guardian received a check . Not a fat one but nonetheless a check .  I wonder if that had anything to do with anything.

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Ovarian cyst

An er doctor called me , a female doctor no less and wanted me to admit a young female because she had an ovarian cyst

I’m  like ” aren’t they common and usually of no concern ”

” well she came with abdominal pain and thats the only thing I can find”

“But that doesn’t mean it is the cause of the pain”

“Her ct is normal otherwise ”

“Is the cyst ruptured or something abnormal with the cyst ”

“No but I’m not a gynecologist!, that’s why I want to admit . We don’t have gynecologist until morning”

I looked at the ct scan while on the phone

“It looks like a simple cyst” I said

“So” she said 

“How about simple gastroenteritis . Does she have nause , diarrhea any vital signs ?”

“Well yeah ”

“So then why are you worried about the ovarian cyst if it is not ruptured and there is no torsion”

“I believe she needs admission to have all this sorted out, if you don’t want to admit I will call somebody else”

I admitted the patient and then discharged her In a few hours with a diagnosis of gastroenteritis . Er dicks should know that ovarian cyst are ubiquitous in young females and are of no concern unless they develop complication . Most of the time they go away by themselves.

I suspect that they do know all this but because they are so busy , because they would rather please a patient who wants to be admitted then talk to her in detail , because they have the fear of lawsuits on their head and because now Hospitalist are available  all the time they would rather admit the patient then spend more time and energy on solving a problem. 

Er

Dr Cranky: I don’t think this patient needs admission to the hospital . 

ER Doc: I have done catscan of head , chest, abdomen along with ultrasound of gall bladder , X-rays of all his limbs and MRI of his ears. Plus I have checked all the electrolytes, liver enzymes , blood counts and I have even done a lumbar tap and semen analysis .What I have  found is that he has a viral infection . 

Dr Cranky : yeah it’s called a cold .