OK, long post/rant here. Sorry.
Many times, the EASIEST part of taking care of patients is making the diagnosis and knowing what the treatment is. The part that his harder and requires more creativity and (often) leg or telephone work, it putting the plan into action. “Sealing the deal” is one thing to call it. It’s like when you were in high school, getting to second or third base was usually MUCH easier than closing in on home! Anyway, the other night we had a mess of a situation. An elderly, somewhat demented lady who only spoke Arabic (and who was DNR incidentally) was sent in from the nursing home with vomiting for 6 hours. History was basically unobtainable and after the labs and xray did not show much, and abdominal CT was ordered. She proceeded to vomit up every drop of contrast despite anti-emetics. Finally, after 3 hours, she got her CT scan. It showed something obstructing her GE (gastroesophageal) junction. Holy crap, she had a food bolus impaction that the nursing home did not realised occurred during her breakfast. The patient was not able to verbalise much except that she had pain and was throwing up. Treatment for this – you can try glucagon but honestly if something is stuck there for about 10+ hours, it ain’t coming out without an upper endoscopy. Peace of cake, right?
Wrong. Trying to get people together to do this procedure at midnight is a damn pain in the ass. It requires schmoozing and many phone calls. It requires putting on General Eisenhower’s hat. The whole thing was made a nightmare by the fact the patient’s PMD would not answer his pages. We must have called about 20 times. Honestly, it is not like him to not return calls so I hope he is not unconscious somewhere! We needed him to give us a name for a Gastroenterology consult. The problem is, that NO ONE wants to come in at the that hour and perform a difficult and potentially risky procedure – let alone on a DNR, demented woman who only speaks Arabic! All sorts of consent would be needed by the family – who of course lived far away. The power of attorney would have to rescind the DNR for the procedure since she was likely to have to be intubated for it (to protect her airway) as well as give consent for the endoscopy. See, multiple layers of logistical difficulty. Then there is the problem that no one wants to violate the unwritten rule that if a patient has a PMD at the hospital, the referrals MUST only come at their request, in other words, I just can’t randomly call GI guys. First, they might be worried about stepping on toes, AND they really don’t want to come in in the first place for such a procedure unless the PMD specifically asks for them! Urgh!!!
After flailing for a while without success with the PMD, I had to call the GI guy on call – knowing what his response would be. “Please keep trying to get Dr So and So and find out if he REALLY wants me.” (since the guy on call almost never comes to the hospital and is not well known) I called the nursing home and the family to ask if she had EVER seen a GI guy before – and lo and behold she had – but they did not know the name! Urgh!!! Finally, the nursing home found some old records that had the name of someone – I called his service only to be told that he had just recently suspended his hospital privileges! Double Urgh! Now, 2 hours had passed since I got the CT reading and bit the bullet and called the on-call hospitalist to admit the patient (which by the way, can be VERY tricky since once again, no one wants to step on toes and he runs the risk of being accused of stealing the PMD’s patient! – but the guy wasn’t calling back for two hours so hell with him). The hospitalist finally “officially” called for the GI guy on call to do the consult. After calling him back and telling him that now the hospitalist was admitting the patient AND that the patient’s own GI doc was not on staff, he finally realised the jig was up and agreed to come in. But wait, there’s more…
Because this GI guy almost never comes to our hospital, he had no idea what the procedure was to get all the equipment, the endo nurse, and anaesthesia, and all other crap together to perform the endoscopy! Now, I had to call anaesthesia, the Arabic translator, the family, and the nurse administrator to open up the endoscopy suite to get the machine and scope, schlep it over to the ER, and page the on-call endo nurse . Anesthesia was grumpy because the patient was DNR and demented but what the hell can I do? Deal with it bud. Now three hours had passed and FINALLY everything was arranged for the procedure. Thank God it was not particularly busy at the time and the other patients I saw were quickies or were in holding patterns.
This is the sort of thing you DON’T learn in med school – or in residency for that matter. This is the sort of thing that does not get reimbursed. Honestly, I should be paid more to do this crap since it is much more of a nightmarish pain in the ass than actually practising medicine!!!!
im curious about this condition
I had a farm animal die of a feed impaction as a kid(the feed was a concentrate to be added to a regular grain based feed -it said so on the bag but my dad told me to just feed it alone–>guess who got blamed when our stud animal died?)
So what happens if this goes untreated? Does the person get in trouble because of electolyte imbalance or does the GI degrade from the actual impaction? What kind of time pressure is the actual interval of treatment to occurance of the impaction-have to assume its fairly urgent or you would put off treatment til the specialists can bother to roll out of bed.
I’m certain nothing is black and white in medicine.
Having said that, I thought a DNR overrode everything. Like if she was going to eventually (within a reasonable time period, I don’t know three days?) die from it, you should not intervene.
I thought you could give palliative care (keep her comfortable) but not active care. Where do you draw the line with a DNR?
p.s. Do you always have to contact the family with a DNR in place? If so, what’s the point of having it?
Generally BFG, you want to get something out of the esophagus as soon as possible. It degrades the lining and can eventually cause severe erosions and a perf. However, the short term problem is that obviously no PO can be taken and one gets dehydrated. I don’t think electrolytes are usually an issue for at least the first 24-48 hours. The standard of care is to take these things out within several hours – hence the reason if it is before about 5am, GI should come in during the night and deal with it. Any GI’s out there feel free to comment if you disagree.
Should have called ENT – surgeons understand emergencies.
Great idea Matt but at our hospital, GI has a lock on that area. The only exception is with peds – and then ENT does a rigid scope on them. This is usually for foreign bodies however, not food.
I had to do an emergent LP overnight a few months ago – what a logistical nightmare!!!! As an intern, I’m not signed off and there were few other residents around and no staff (I never thought to grab a staff from the ED – but that’s 20/20 hindsight).
Since it was midnight and the pt was seriously altered and thrashing, we needed conscious sedation:
1. find anesthesia,
2. find someone to open an OR room,
3. find resident (ICU) to staff me.
4. Active lower GI bleed on the floor with hgb 4.5 – had to give him to the ICU, losing me the only resident available that can staff the LP.
5. anesthesia loses interest
6. Wait til GIB more stable and resident can staff
7. re-find anesthesia
8. it’s now 2am –> all for a 15 min procedure….
My hospital’s just not set up for emergent overnight stuff- it might be easier for a surgery resident with more “ins” and who’s taught this side of the logistics puzzle, but it was frustrating for a medicine flea! If it had been in the daytime, it would have taken 10 minutes to put together at the bedside….
“I thought you could give palliative care (keep her comfortable) but not active care. Where do you draw the line with a DNR??”
There has always been confusion over this. DNR, does not mean do not treat. It just means, Do Not Resuscitate. When the heart stops, its over.
This is absolutely the kind of thing that will bring down our health care system sooner or later. It won’t be the uninsured, it won’t be lawyers, it will be the docs themselves and their territorial attitudes. Good for you that you got it worked out, but damn, it should never be so complicated or time consuming.
It’s supposed to be about caring for the patient, not who does what and when. And when the docs are worried about stepping on each others toes or pissing off the insurance company more than what is happening to the patient, there is something horribly wrong.
I had a patient need emergency gynecological surgery at midnight last week. I was surprised at how smoothly everything seemed to go.
[...] Logistical Nightmares [...]
Cardiogirl,
To add to what Cynic wrote, the DNR states that certain procedures will not be done to resuscitate the patient. The intent is that treatment, that is not likely to improve the outcome, is not allowed. The anesthesia and intubation is to allow for a procedure that might not be prohibited. Some DNRs specify “No antibiotics,” or “No surgery,” or “No feeding tube.”
If the family could not be contacted and the patient had a bad outcome from this, the DNR is not going to be what the family will want to hear about. We Monday morning quarterback, so what ever would have led to the best outcome is what almost everyone will believe they would have chosen – if they had been asked. They will believe it. They can convince a lawyer of it. They can convince a jury of it. This is a normal human response. We see the events we already know about, as predictable. We think the correct choice would have been obvious at the time.
Sometimes it is nice to be low enough on the totem pole, that I do not have to deal with these complications.
[...] complicated problems, and how long it takes to take care of people. Wish it was just that way for esophageal impactions. [...]
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