The Home

It happens most nights in the ER. One of the many nursing homes, that channel their residents to my hospital, calls about a pending transfer. GGB (geriatric go boom)? Difficulty breathing, fever, chest pain, vomiting and or diarrhea, altered mental status are all possible reasons. The first thing the ER staff wants to know is the patient's code status. DNI, DNR, DNH. It is not unusual to get a patient that the NH says is a full code who is actually a do not resuscitate. If the patient recently arrived in the NH and the DNI/DNR forms haven't been signed by the NH doctor, the patient, despite the patient and family's wishes is sent to me as a full code. DNH patients are essentially on hospice care. They are not to be transferred to a hospital without the consent of the health care proxy. Surprise, the NH staff sends the patient without calling the family.

Many NH patients have multiple medical problems and frequently have some degree of diminished mental functioning if not diagnosed dementia. This makes it difficult for the ER staff to get any history as to the presenting complaint's onset, progress or associated symptoms. For a patient with dementia, the trauma of being taken from their bed, loaded into an ambulance and transported to the hospital is frightening and disorienting. The patient's agitation may make the patient violent towards the ER personnel.

EKG's, IV's, rectal temps, catheter placements, examinations, hard stretchers, lights, and noise all add to the stress on the NH patient. This is usually occurring in the middle of the night. The disturbance of the patient's normal sleep schedule is an additional factor in their discomfort.

For me, it is now personal. My elderly, somewhat demented mother resides in a NH. The facility is clean, well staffed and offers stimulating programs for the residents. My siblings and extended family visit my mother frequently. She is still able to use a telephone to call family and friends. As with most patients with dementia, my mother's demeanor can change rather suddenly. Her lack of short term memory leads to her attempting to make sense of changes in her environment. She can become angry and lash out verbally at her children and the NH staff. Other times she is her usual sweet and loving self.

I admit that I do not see my mother as often as I should. Distance and my own health issues limit my visits to at most a once a week schedule. Being a physician, I cannot help but observe the physical condition of the the other residents of my mother's NH. Her tablemate for meals is a fairly young person who has both physical and mental limitations. Traumatic brain injury, post encephalitis, and multiple sclerosis are all possible etiologies. This patient is also delightful. Smiling, laughing and singing are this person's usual responses. My mother's roommate is sadly not very lively. This patient has had what appears to be a dominant hemisphere stroke and is aphasic and hemiplegic (nonverbal and paralyzed on one side).

Other residents are limited by arthritis, minor residual stroke symptoms, severe lung disease or congestive heart failure. One young person is clearly the victim of a traumatic brain injury, brain tumor or hemorrhagic event. I can see the evidence of a craniotomy on this patient's scalp. A few residents defy my powers of observation as to why they reside in a skilled NH facility. Chronic mental health issues may be the issue that led to them being patients in this NH.

As complicated, challenging, and frustating as these patients can be, they are still human. The care given by the ER techs and nurses is amazing. I think we all see our own elderly family members and even our future selves in these patients. My mother, in a very lucid state during yesterday's visit, told me something that may be a common desire in NH patients. She said that the staff was very good, even the food was OK, but that this was no life for her. Her wish and prayer is that at age 91, she wants to go to sleep and not awaken.

Stopping by woods

Sitting and drinking coffee watching the snow fall. Did my 30 minutes on the rowing ergometer. Abs and obliques have been tuned. The old hound and I walked in the snow and he did his business (I scooped and dumped). Waiting for the snow to stop so I can shovel out. I am trying to remember why I never bought a snow blower.

The ER has been busy despite the frequent snow storms. Nothing keeps my patient from their ER visits. A disturbing trend has been an uptick in the number of overdoses both intentional and accidental. The quality of injectable opiates varies greatly. Just a slight increase in the purity of the heroin leads to a bump in OD's. The cynical and jaded would say that this is social Darwinism at work. I try to keep the thought in my mind that every junkie is someone's friend, son, daughter, parent, etc.

Straight opiate overdoses from oxycodone, hydrocodone, heroin, methadone and others respond rapidly to Narcan. This antidote may be injected into a vein or a muscle and rapidly reverses the sedating effect of the opiate. It has the deleterious side effect of inducing immediate opiate withdrawal. A gown, mask and shoe covers are recommended for the ER team as the addict often vomits like an open fire hydrant.

Cocaine is toxic in any dose. Snorted, shot or smoked the effects are immediate and protean. Chest pains, arrythmias, strokes, nose bleeds, lung damage are all possible presenting complaints for the cocaine user. The major weapon in the ER doc's bag of tricks is lorazepam. Sedation and lots of it is the standard of care. A high degree of vigilance is needed to assure a safe outcome for the patient and the ER staff.

The real challenge is an overdose involving medications and household or industrial chemicals. In my younger days, the assessment, decontamination and treatment of such ingestions or exposures was hit or miss. The concept of a centralized source of information for treating toxic ingestions or exposures began in Colorado with Dr Barry Rumack. The info was stored on microfiches. For the Google generation, a microfiche was a sheet of clear plastic that contained very small printing and was read with a special reader. Regional Poison Control centers are still available by phone 24/7. The internet is also a great source of info for ER staff.

Toxidromes are groups of symptoms associated with specific classes of medications. Every med student, PA and resident has learned the acronyms for these toxidromes. An example is MUDPILES. Many toxins and diseases can present with metabolic acidosis with a high anion gap. The pH of human blood is normally 7.4. When the pH goes lower that is acidosis. I will spare my nonmedical readers a boring dissertation on the Henderson-Hasselbalch equation. The acronym is an aid to remember the causes of this toxidrome and aid in a search for the agent or disease process and guide the treatment.

Acetaminophen (Tylenol and other brands), aspirin, ibuprofen (Advil, etc.), nonprescription sleep meds, cold meds, rubbing alcohol all can be dangerous and even lethal in high enough doses. Many young people take an overdose as a cry for help and/or attention. They are unaware of the toxicity of the common nonprescription medications they ingest.

Acetaminophen interferes with a metabolic process in the liver. As few as thirty 500 mg Tylenol tablets can lead to liver damage and death. The toxic dose is weight related and the time after ingestion guides the treatment. An effective treatment is available and effective if given before permanent liver damage has occurred. N-acetylcysteine is the antidote. There is an IV form of the chemical that makes treatment easy and rapid. The oral form of the chemical was noxious to the patient and the health care workers as it smells like rotten eggs. Thank goodness for progress.

Antihistamines (eg Benadryl) are found in sleep aids, cold and flu formulations and allergy medications. Although they are safe and effective when used in recommended doses, they can be very dangerous in large amounts. The mnemonic that I learned back in the dark ages was: mad as a hatter, hot as a hen, red as a beet, dry as a bone. The symptoms of anticholinergic poisoning include hallucinations, fever, flushing, and dry skin thus the mnemonic. Tachycardia, seizures and coma are also seen in OD's of antihistamines. Jimson weed (Datura stramonium) is smoked and made into a tea as a mild hallucinogen. Too much can cause anticholingeric toxic symptoms.

For parents of small children (or adventurous/suicidal adolescents and teens) the recommendation for home treatment has changed. Giving Ipecac to induce vomiting is no longer the treatment of choice. Activated charcoal is the best option. It binds most medications and therefore limits the amount of the drug that can be absorbed from the GI tract. Check your medicine cabinets. Safely dispose of any medication that you are not currently using. Use child-proof containers. Consider locks on medicine cabinets. As little a single pill of some prescription medications may be a fatal overdose in a toddler.

The snow is still coming down but it should end soon. Let the shovelling begin. I think tonight I will have Hiberian Cure-all, single malt scotch and ibuprofen.

A Day in the Life of Mikhail Jizniovitch

With apologies to the fictional Ivan Denisovitch and his creator Aleksandr Solzhenitsyn

My name is Mikhail Jizniovitch. I am a prisoner in the gulag. The gulags are also known as hospitals. The masters of the gulag have many names: Medicaid, Medicare, Red Cross/Red Shield and others. We, the inmates, toil to do the bidding of our masters. We dole out health care to the proletariat.

Today is Tuesday. The gulag must function 24 hours a day, seven days a week, always we must be of service to the people and our masters. I work every Tuesday night in my capacity as a healer in the Urgent Center of my gulag. Many other prisoners labor in the Urgent Center. My healer assistant is Robina Popova. The nurse comrades and technician comrades have also been sentenced to serve the health care bureaucracy.

I arrive at 2030 hours to relieve my fellow comrade healer of his difficulties. Comrade healer tells me of the illnesses and plans to treat our comrade patients. Scanning my computer screen makes me sigh. There are 8 patients on racks awaiting their care. Many more peasants sit in the holding area seeking help for their pain and suffering.

Before I can see a single patient, the Emergency Medico Serfdom (EMS) rolls to the door with an unfortunate who is vomiting into a blue bag and groans in pain. The nurse commandant and her minions struggle to make room for this arriving sufferer. My list of patients must be amended to place the new patient in the order of prioritized illnesses.

The patients electronic dossiers are read. Examinations performed and histories obtained, I order tests and medications. My dear coworkers struggle to meet the demands of the patients and their families. Monitors send off alarms, patient call buttons emit piercing klaxons; chaos is our ever present companion.

In the local region of our province we are the gulag for the victims of violence. Members of the rank and file, who have been injured by automobile collisions, knives, guns, predation of parental, sexual and criminal types, arrive walking, limping, or carried by EMS. We also minister to children and expectant mothers of the region. Those who suffer from diseases of the mind or the ravages of old age are preferentially depositing in this gulag's Urgent Center.

Chest pain, abdominal pain, headaches, weakness, depression, delusions, fever, coughs, bumps, twists, deformities, wounds; blood and/or drainage from noses, genitals, mouths, rectums; boils, sores, rashes, imbibers of vodka and other intoxicants; shortness of breath, lethargy, confusion; births and deaths.

I have served 30 years of a life sentence. My needs for shelter, food and even the pleasures of my life are met by the rewards bestowed by the masters of the gulags. My actions are closely scrutinized. I may be summoned before the politburo at any time. I am tired in body and spirit. The true payment is in the camaraderie of my fellow inmates and the gratitude of the masses who turn to the gulag's Urgent Center for relief.

Auld Lang Syne

DNR. DNI. DNH. These are abbreviations for advanced directives(do not resuscitate, intubate or hospitalize, respectively). Patients, family members, health care proxies, and guardians may decide in advance the level of medical care the patient wishes during a health emergency. The ER staff is often faced with issues related to these choices. A patient from a nursing home or assisted living facility should have a copy of the patient's advance directives (AD) available on arrival in the ER. I stress the should, because there have been many instances in which erroneous information led to unwanted and futile resuscitation efforts.

This past week I went in to examine a septuagenarian who was in severe respiratory distress when he arrived from a nursing home. The EMT's told me the patient was a full code. Thanks to the hospital's EMR (electronic medical record) system I knew that the patient had chronic pulmonary and cardiac problems and suffered from dementia. A DNR was found in the pile of forms sent with the patient. I treated the patient with medications and when his family arrived they confirmed his DNI/DNR status and were grateful that we had given him some relief without compromising his AD.

Many years ago when the ER was not as busy as now, I went into to see an elderly man who was near death. There was no AD. His daughter arrived and I explained that even with intubation and ventilator support, her father's prognosis was poor. She asked me what I would choose if this was my father. My father died at home under hospice care with metastatic renal cell carcinoma. He died peacefully and in accord with his wish to die at home. I shared my experience with this woman. Together, we decided to let the natural course of the father's disease go untreated except for some mild sedation. She held one hand of her father and I held the other. He died peacefully in less than 15 minutes. She and I shared some tears and honored our fathers.

This past week I experienced the reverse of this outcome. An elderly man arrived in distress. His health care proxy and guardian was a cousin near to my age. There was no AD. When I explained the problem and offered care and comfort, she opted for full resuscitation. Respecting the family's wishes, I intubated the patient, put him on a ventilator and admitted him to the ICU. Primum non nocere. "First do no harm" is part of the Hippocratic Oath. I felt that instead of relieving this gentleman's suffering, I had prolonged his existence but not his life. I believe that family's request were given in good faith and in the belief that the patient should be given every chance of continued life.

A recent controversy, in reimbursement for primary care doctors, is whether the physician should be compensated for the time needed to help families making end of life care choices. It is frustrating for ER docs that during a crisis, my colleagues and I must ascertain from a distraught family as to how aggressively we should treat the patient. The time for an individual to make decisions about end of life care is when they are healthy. A trusted family doctor can be of great help to a person and his or her family in making informed AD.

My 91 year old mother resides in a nursing home. Three years ago it had become apparent to my siblings and me that she was not safe living alone. A clean, attractive and well managed assisted care facility was found and my mother moved into her "apartment". Several months later, Ma fell and broke her hip. She was trying to get a good seat at the movie being shown and had neglected to use her walker. One month later after successful surgery and rehab, she was back in her apartment. In early November 2010, she fell again and fractured her "good" leg. Do to advancing age, increasing dementia, and physical problems she was not able to return to assisted living and will need care in a nursing home.

My mother had made it clear to her children, after my father's death, that she did not wish to receive any resuscitation if she suffered a cardiac arrest. She was of sound mind and body, 77, and still working when she made this choice. When she was in preop this past November for the repair of her second hip fracture, I was by her side. The hospital and physicians had her DNR/DNI documents. I signed her operative and anesthesia consents. I told the anesthesiologist that no cardiac compressions should be given, even if she had a cardiac arrest under sedation. He protested and said that the anesthesiology department's practice was to perform CPR, even in patients who were DNR/DNI, if the cardiac event occurred during the surgical procedure. I was grateful that this physician promised to respect my mother's wishes and that my mother's surgery went well.

We are born and we die. All religions include some variation of life after death. Resurrection, reincarnation, or nirvana are all comforting to mortals. When I get home in the early morning after a ten hour night shift, my wife (if she hasn't left for work) asks me how the night went. I usually give a simple answer, "no one died". There are those patients who die under my care, and I can say "he/she had a good death".