Dialysis 

“Why do you not have an arterivenous fistula , that’s the stands of care . Why do you get dialysis with a catheter ”

I asked the  somewhat attractive 50 some year old woman laying in the bed 

” I don’t plan to stay on dialysis that long” she said without much emotions

“What do you mean ” I asked

Now her eyes teared. 

“I  been sick for 15 years . I don’t want to continue dialysis . I hate it ”

If she hates dialysis that much why start it in the first place.

She read the question in my eyes

“My parents are still alive.  They are in their 90’s. I have to wait”

Now it all made sense . 

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Oncologist 

Saw a patient with bladder cancer who and his wife swears to me that he is cured . He is admitted with acute kidney injury and is being rounded on by oncologist and urologist daily. I reviewed his charts and found not only the cancer is still there but he also has several metastasis in spine .

What’s  going on here?

Has the oncologist not been able to break the news 

Has the urologist not been able to break the news

Is The patient and family in sweet denial.

Unfortunately this is not an uncommon scenario .

Sometimes the Doctors are not able to say words like “death” and “incurable”, especially oncologist . Sometimes the patients and their families tune out such words.

Being an oncologist is tough and being an oncologist who does not mince his words is even tougher . Still ,this patient needs a clear and open statement.

I guess I will have to be the bad guy .

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.