I startle in the windowless sleep room. My call phone summons me awake. In the darkness, I reach for and immediately find it. From week to week, the counties, hospitals, and staff all change, but the phone is permanent.
It is always there, it has become an appendage. My brain seems to have proprioceptively grafted the location of the phone onto its neural circuitry. It has become a permanent part of me in this floating life.
A voice on the end relays the message. “Dr. HP, we have an ambulance coming with a Mrs. Z, complaint of altered mental status, possible seizure. She’s been in here three times for the same complaint in the last 2 months.”
“Ok, I’ll be there.” a disoriented groan.
Patient Arrived Altered…
I walk into the trauma bay. Family is crowded about their her. She lays in a crumpled pile on the gurney. Her GCS is 11, so she avoids an intubation. Nonetheless, she is minimally responsive, completely disoriented, unable to provide any meaningful history.
From the family, the story unfolds like a jumbled ballad of confused pain and suffering. I hear the frustration about the repeated hospitalizations, the perceived lack of answers, the desperation to help her, etc.
“She was here three weeks ago with the same thing. She went home for a few days, and then was in the other hospital in county 10 days later, and now she’s back. We don’t get no answers every time we come in.”
“That must be so frustrating and scary.” I reflexively parrot their emotions back to them as I look up and down Mrs. Z’s body.
“They just say it was another bout of seizure activity and increase her meds, but it seems to be gettin’ worse, not better. We just can’t keep doing this…”
“Jane!” I call her name and her eyes pop open. They fix on me in a wild confusion. She looks straight at me, but I get the feeling she registers nothing.
“Where are you?”
“The hospital…” comes the groggy reply. She meets any further questions with drooping eyelids and a nodding head. The nod.
“Squeeze my hands.” I command her. She faintly squeezes.
The verses of the songs are different, yet we all know the melody by heart and the chorus rarely has much variation. Her life and medical care has become a tilt-a-whirl ride gone awry. No one seems to know where to find the exit as she whirls about, up and down, in and out of hospitals.
She is trapped in a swirling confusing mess of tests and medications, no one really sure what they are treating. But by God, they will treat something.
…She was Arousable to Voice…
The old cowboy saying goes something like this: “The first thing to do when you find yourself at the bottom of a hole is to stop digging.”
This is should be the first tenet of treating the chronically ill.
We all know them, the professional patients. The people perpetually entangled in the Hospital-Pharmaceutical Complex.
Invariably, clinicians know these patients better than any others. We’d rather not, though. We cringe when we see their names.
In clinic, we fear looking at our Monday schedule before leaving work for the weekend. Their name in an appointment slot can cast a pall over the whole weekend.
As hospitalists, our hearts never sink as low as when our pager goes off and we’re told, “Mr. T has bounced back, you admitted him last time. Same problem.” Walking into the room, we sit down in the hole.
We hate sitting in their darkness with them. Because, when we sit with them, we can’t see the way out either. Their presence smacks us with our own impotence.
First, stop digging…
…Only Oriented to Place, but Able to Follow Commands…
Our teachers trained us with cute acronyms for developing differential diagnoses of chief complaints. VINDICATE, VITAMIN C. With the chronically ill, the first three letters should be “I.”
In the mnemonics, “I” stands for Idiopathic/Iatrogenic. Idiopathic – we don’t know why. Iatrogenic – we did this. I find this juxtaposition amusing. The implication of iatrogenesis being close to idiopathic is commonly upheld in clinical practice.
Otherwise brilliant physicians seem to struggle to identify when the cause of patient’s problems are the medical system itself. It seems a kind of heresy to admit our church’s complicity in their suffering.
Yet, when you lean in, comb their histories and medication lists, our fingerprints are always there. The half-hearted attempts at treatment. Another medication added to end a depressing clinic visit, another test to “rule out” some strange disorder before discharging from the hospital.
…In reviewing her med list, I found a great number of sedating medications….
She is definitely altered, but nothing about her looks like a seizure. I review her medications and tick off the likely offenders: gabapentin, baclofen, phenytoin, and, of course, hydromorphone.
“The one that starts with a D.”
She is on a total of 50 morphine milli-equivalents with less than perfect kidneys. She is on this for arm and wrist fractures which occurred several months ago. Well past the acute phase of treatment.
We admit her, she is too altered to swallow medications, we start IV fluids and let her rest, withholding all medications. The medications begin to wash out of her system. Initially, she responds slowly. Once we refuse to give her narcotics unless she requests them, she comes back to life within 12 hours.
None of the nurses, nor myself are surprised.
Encephalopathy Secondary to Polypharmacy
The chronically ill, the products of the Hospital-Pharmaceutical Complex need a different approach. The old mnemonics and work ups start with a faulty assumption. They start with the assumption of originality of complaint, of something new, of a previously healthy person.
The chronically ill meet none of these stipulations. The first questions should be, “What have we done to this person?” followed quickly by “What can I undo?”
After she has returned from pharmaceutical zombie state, I go in to discharge her.
“You’ve been scarce around here. I have seen you since I have been in here.” She stares accusingly.
“I am not surprised you don’t remember me, you were pretty out of it for a couple of days.” I don’t get defensive. Those newly returned to consciousness are rarely polite.
I recommend an aggressive reduction in many of her sedating medications, including her narcotics. Strangely, she doesn’t argue, it seems to make a kind of sense to her.
Mrs. Z goes home. I am not sure she will follow my instructions.
Nonetheless, they seem thankful for a more a logical explanation to her problems than a confusing seizure disorder that seems to get worse despite “appropriate” treatment. For a minute, we stopped digging and the light stopped receding.
Sometimes, a pause in the chronic deterioration seems like an improvement.