Surprise

Sometimes patients surprise you. Sometimes you really need to talk to them about their expectations, desires, wishes, and hopes. Sometimes their assumptions don’t quite match up with your own. And sometimes this has unexpected consequences. Today the surprise is in the Resus Room. Here, there are five beds, two nurses. It’s where the sickest come, CTAS 1 and 2, and this morning is no different.

Contestant 1 is a 74-year old male, right-sided failure, no blood pressure to speak of, junctional bradycardia, a medical history that’s a tale of woe, full code, and Altzheimer’s, so he calls out and tries to climb out of bed. Contestant 2 is a 54-year old male, in acute renal failure, who’s blown his only good kidney, anuric, taching along at 140, BP in his boots, maxed on Levophed, whacked out chemistry, including a creatinine of 868; he’s pale to the point of waxiness, and diaphoretic. He’s been sick for a long time, and he has the wary eyes of someone who knows the jig is up.

He needs dialysis now, therein being the problem: Acme Regional doesn’t have facilities for dialysis.  Renal patients are supposed to be sent to Superior Hills Health down the road, which is our regional dialysis centre — except getting SHH to accept transfers is at all times problematic. It’s always some damn thing: no beds, no staff, can’t be bothered, whatever.

But there is a light. The patient, JK, has actually been accepted by the hospitalist and the nephrologist at Superior Hills. It’s just a matter of making the arrangements and sending him off. Maria, my partner for the day, flip a coin — I get JK. I do my initial assessment, which confirms my first thought eyeballing the patient from the nurse’s desk: this guy is circling, and what’s worse, knows it. Fear is clearly in his black eyes, peering out from under knots of unkempt hair, but he says little. And there is little I can offer him, except comfort and a fast transfer out.

But he has some imminent problems: he’s third-spacing all the fluid he can’t pee out, his lungs are filling up like a bathtub, and his respirations are starting to get a little laboured. I’m having a psychic vision of an intubation in my near future, which giving this patient’s condition is clearly a bad plan.

I finish charting and start on the usual telephone trek to get this patient transferred. I page both the hospitalist and the nephrologist who accepted the patient. Neither is on-call, and Locating at Superior won’t get them either. I call the floor at Superior Hills where’s he’s supposed to be going. Nope, haven’t heard of him. I call the Patient Flow Management at SHH.  Same answer — and the bed manager there is a little concerned my patient is obviously an ICU patient, and neither the hospitalist nor the nephrologist have ICU admitting privileges. Finally, after an hour of telephone hide-and-seek it becomes apparent that neither accepting doc has bothered to tell anyone at Superior Hills about this patient.

I sigh, and glance over at JK. Let the games begin. This patient, as critically ill as he is, is going nowhere.

I page the internist, and together we plot a two-pronged strategy: I will continue to hound Superior Hills for a renal bed, while he’ll try to Criticall the patient out. The phone calls continue. Vast amounts of time are wasted, as the patient continues to circle, trying to find a bed somewhere, anywhere, that can do dialysis. The internist speaks to docs in hospitals between between Windsor and Ottawa, looking for a bed. A moment of humour: a nasty phone call from the bed manager at Superior Hills. Criticall called her, looking for a bed. She isn’t impressed. Oops. Finally, at last, we manage to contrive a bed at Holy Somolians Hospital downtown, where he will finally get his much needed dialysis.

At 1700, ten hours after start of shift, the ORNGE team finally collects JK and flies off to Holy Somolians. Good luck, I breathe, so long, and have a good life. Despite hours and hours of bullshit and nearly insurmountable institutional and systemic barriers, you’re going to live.

Next morning. I’m exhausted. I can deal with a sick patient, and I can deal with health care stupid, but doing both at once leaves me wiped. Diane’s in charge.  She takes off her funky pink reading glasses and peers at me over the Desk. “That patient of yours, JK, the one transferred downtown? He died.”

“What?”

“He got there and refused dialysis. Said he never wanted it. Then up and died.”

What?

Surprise.

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  1. #1 by she on Monday 30 November 2009 - 1223

    I have had that patient. It is deflating and frustrating to bust ass only to have a patient decide at the last min to refuse care. I am ok with patients deciding they are done, but please decide that before I spend 10 or 11 hours riding herd on a pack of cats while trying to maintain a MAP of 65 and a O2 sat above 89%.

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