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Part 2 - Nobody wears a white coat any more...
...a tribute to becoming a doctor.
ayradyss
ayradyss
Part 2
So as it turned out, things got a little hairy before Jill walked out of the hospital against my advice. I'm frustrated to the point of starting proceedings to fire this patient from our clinic, and that doesn't happen often. I'll try and keep this understandable for the non-medical folks.

Hold your breath. As long as you can. If you had an oxygen saturation meter on, chances are it would never dip below the mid-90's - I've seen swimmers who can get it down to 90-92% but that's about it. That driving need to breathe, the dizziness and suffocating feeling - those are caused by elevating levels of carbon dioxide (CO2), not by dropping levels of oxygen.

COPD is a chronic lung disease (usually related to smoking or toxin exposure) which results in impaired transmission both of oxygen into the bloodstream and carbon dioxide out of the bloodstream. These folks tend to chronically have elevated blood CO2 levels, which eventually blunts the response of the CO2 receptors which control respiration.
This results in something known as "the hypoxic drive" taking over. Basically, these people become more attuned to changing levels of oxygenation, and they depend on their oxygen saturations dropping to remind their brains to breathe. If you put someone with severe COPD on 100% oxygen, you can actually kill them, as the patient's breathing will slow down to the point where they don't exchange gases any more. Subsequent to slow shallow breathing, CO2 levels elevate to the point where they cause acidosis of the bloodstream, coma, and death. Ain't pretty.

Jill had a blood gas drawn in the ER at 6 PM, which was normal for her. She went to the floor around 8 or so. She was placed on 100% oxygen (as a nursing decision and not what I had ordered, since nursing wasn't comfortable with her 88-92% oxygen saturation) and given her home dose of narcotic pain meds. Narcotics can also cause respiratory depression. By the time she got confused, fell out of bed, and was seen by my partner at 1:30 AM, she was sleeping and not able to be woken.
We reversed the narcotics (not particularly nice to do to a chronic narcotic user, since it puts them into immediate withdrawal) and put her on Bipap, which forces air into the lungs and augments normal respirations. It's not comfortable, but it's the last ditch effort before we intubate and put a patient on a ventilator. After a lot of tweaking and a lot of lab work, she woke up five hours later. An hour after that she had yanked the mask off, thrown it at the respiratory therapist, cussed out three nurses, told me she loved me and thanked me for saving her life, and was demanding her morphine.

I told her no - not after what had happened. I told her no for the next 24 hours. She told me that if I didn't give her morphine that she would go home against medical advice and buy some Vicodin off the street. I told her I wasn't giving her narcotics - I can only surmise that her lungs must have taken some damage from the fireball, because she's tolerated far larger doses and fairly high oxygen concentrations without a whisper of trouble. I offered to work with her with meds that don't depress respirations, and talked to the pain doctors about what kind of cocktails might work. I answered 27 pages while in clinic regarding her pain control and her threats to leave. I started her on an anti-anxiety agent and she slept all night with no complaints.
In the morning, she had her caretaker (who I suspect is also selling narcotics) call me. I expleined the situation to the caretaker just as I'd explained it to Jill. I used the words "almost died" and "almost intubated" several times. I explained that she had not only violated her pain contract by telling me she was going to buy Vicodin on the street, but that I no longer felt safe giving any narcotics. I explained that she had been weaned off in the hospital and that to restart them would be poor medical care, and possibly life-threatening.
For once, her caretaker didn't argue with me. She agreed and thanked me. Thirty minutes later, the nurse called to tell me Jill was leaving, and that she'd verbally abused several more staff members. I talked to her on the phone. I explained it all. She told me that she thought I was a wonderful doctor and that I was probably right, but she was going to go home now because I wouldn't give her what she wanted.

One of the rights you do not have as a patient is the right to abuse my ancillary staff. My nurses are doing their very best to take care of more than one very sick person. They are doing their best to carry out the orders I'm giving, and they are trying to help you help yourself. I get much angrier when my nurses and PCA's and social workers are being berated than when patients are mean to me. After all, I'm the one in charge. They're just trying to do the right thing.

One of the hardest things about medicine is the right of people to make poor decisions. Could she go home and buy Vicodin and take it and die? Yes. Would I feel guilty? No. I'd be sorry. I'd feel bad. But I can't help this woman any more than I've done, because she won't allow herself to be helped.

And after all that, my tax dollars aren't footing her bill. Instead, she'll be billed directly since Medicaid doesn't pay for AMA visits. She'll never pay it, because there's no penalty for not paying. So ultimately, we'll write it off, which impacts hospital profits, which comes directly back to my paycheck.
Can't win.

In other news, my Miricups had her second febrile seizure today.  She's doing well, trying to sleep in her swing, but my poor baby...

now feeling:: annoyed annoyed

7 whispers echo . o O ( ... ) O o . whisper a word
Comments
clipdude From: clipdude Date: July 3rd, 2008 04:30 pm (UTC) (etched in stone)
Wow. It's horrible what drug addicts will do.

I hope your daughter gets better.
cuneiforms From: cuneiforms Date: July 3rd, 2008 05:58 pm (UTC) (etched in stone)
Poor Miricups. :(
coanteen From: coanteen Date: July 3rd, 2008 06:18 pm (UTC) (etched in stone)
*hug* for Miricups.

One of my staff advised giving yourself a "gift" on your B-day or Xmas or some other special occasion by firing a particularly troublesome patient.
From: broken_onewon1 Date: July 3rd, 2008 11:10 pm (UTC) (etched in stone)
sorry about Miricups. *hugs*
leon03 From: leon03 Date: July 4th, 2008 10:22 am (UTC) (etched in stone)
Oh dear, I hope this is something temporary for Miriam, and that she'll grow out of it.

And, you can fire patients??
ayradyss From: ayradyss Date: July 4th, 2008 03:02 pm (UTC) (etched in stone)
Febrile seizures should be something you can grow out of.

And yes, you can fire patients. You have to have a good reason (noncompliance, abusive to staff, falsifying records, etc) and you have to give them 30 days of emergency care after you fire them in order to give them time to find a new doctor.
turnberryknkn From: turnberryknkn Date: July 18th, 2008 03:16 am (UTC) (etched in stone)
One hell of a life we've made for ourselves, isn't it?

Wishing you and Miriam strength to endure what we must face, in our road to come.
7 whispers echo . o O ( ... ) O o . whisper a word