Monday, March 31, 2008

Great postcard

Where I work there is one nurse who is a real outdoor-adventure lover. He's done all kinds of wilderness activities, ocean activities, you name it. Someone brought in a postcard for him that just cracked us all up. The photo on the postcard shows a forest scene with a pickup truck in the middle. In the bed of the pickup is a hospital bed with an IV hung on a stand near the head. There's a guy propped up on pillows in the hospital bed; a nurse, in starched white uniform dress and cap, stands beside him, fingers on his pulse and eyes on her watch. He's holding a rifle or shotgun across his knees. The caption is something like, "This could be the last season I get to go out hunting." Hospice IS a philosophy not a place, no?

Cool people

One reason for loving my job is that I get to meet absolutely terrific people I wouldn't have met otherwise. I got to see a favorite recently--he is the widowed husband of a woman who died some time ago after a short illness. I was the hospice chaplain with her and the family when she died and I quite lost my heart to the family. Her husband is now in his eighties, and he's not in the best health himself, and he has some dementia. But he has one of the biggest hearts I've ever encountered, and he's utterly emotionally open and utterly delightful as well. When I was meeting with the family to plan his wife's memorial service, I remember sitting with him -- he was utterly shattered by this loss as they'd been married for a long time and very close, and had been a terrific match for one another. Husband was ex-military and had seen combat in two wars, and I remember he told me that losing his wife was a pain worse than anything he had experienced in his life, worse even than combat in wartime. While we were planning, and I was marvelling at the family and their grace in the face of ravaging grief, a group of tree trimmers was working at the house next door. Suddenly there came a crash that made the whole house shake, as a giant limb fell to the ground. Husband looked at me. "Well," he said. "That was your car." Best deadpan I have EVER seen. How could anyone fail to adore such a man? As it turned out he was in the hospital over the weekend with a touch of pneumonia. I got to go visit him and hold his hand and hear how profoundly the loss of his wife had affected him. And I got to tell him that I think he is an incredible man and that I wish there were more like him in the world. He went home today before I could visit again, but I am praying hard for him. He's lost 30-some pounds since his wife died, and I don't know if the pneumonia is a passing thing or the beginning of the end. I do know that his kids are crazy about him and have rearranged their own lives to keep him safe in his home for as long as humanly possible. I wish them time to keep sharing their love with one another, and I wish for the goodness and love that is embodied in that family to continue to spread out into the world. And I am thankful beyond words to have met them.

Thursday, March 27, 2008

Idle ramblings

So, one night I was working in the inpatient hospice and a patient was dying, and he'd only been there an hour or so and I didn't know a thing about him. (That's not all that uncommon; I think sometimes when patients come over from one of the nearby hospitals they get to our floor and it is so QUIET that they can finally hear themselves think, and mobilize themselves to get on with dying instead of wondering what that latest overhead page means.) I did learn that he was a real adventurer, piloted planes, I can't remember what all else. Eventually it was time to call the mortuary and my favorite wild driver showed up, and oh, yes, it was snowing to beat the band. I met him at the ambulance entrance and asked if he had his GPS up and operational. OH yes, he said, with a twinkle in his eye. Good, I said, because this one? I think he'd like a little ride. YOU GOT IT, said the driver, and it made me feel happy to think that our late patient was getting his last ride from someone he'd probably have really liked knowing.

One night I was working a shift in the hospital and got called to the emergency department to offer support to the mother of a toddler who had accidentally ingested something toxic in the home. Poor mother--she was there by herself because she has another child who has long-term health problems and had just had surgery and was requiring round-the-clock care at home, and so her husband was home taking care of that child, and mom had run out the door with no socks, shoes, coat, or hat to get to the hospital with the sick toddler, who had to be intubated and hooked up to IVs and monitors and so forth until the toxic stuff worked its way out of the system. Poor mother--best she could figure, the ingestion happened while she was in the middle of some procedure the other kid needs and this toddler just grabbed something--YIKES, little kids grab things so fast--and now the mom was feeling terrified, guilty, lonely, lost, terrified, sick, exhausted, terrified, you can just imagine. And more or less in shock because all this happened so fast and there was the toddler on a ventilator heavily sedated.

Kind nurses had found warm no-skid socks for mom's feet and gotten a chair right outside the trauma bay and water for her, and the staff chaplain just going off shift had been there for her. She worried me because she would alternately sob, desperately and convulsively, and stare ahead with no expression at all. As she began to talk a bit and told me her story, of the other kid who has had so many challenges, of her good and faithful husband who felt so torn but knew a parent needed to be with each child, of their lives, so focused on kids right now that they haven't even had a chance to build a friendship network since moving to this state to be near the best care for the other kid, of her terror that the toddler wouldn't pull through, I began to see how much she and her husband had fought for these children of theirs, how devastating this day's incident was, how truly she believed herself to be an awful mother. She began to shake, then told me she was moving into a panic attack, "I can't stand that I can't do ANYTHING." "I know," I said, "That has to be the worst for a mother--right now you can't go in there and take care of your little one and make it better." "I can't do ANYTHING," she wept, shaking. "Well," I said, "We can pray." I began to talk, very softly, about how we could ask God, the great physician and healer, to touch the toddler, take the toddler into God's hands, and work with the strength and resilience of the child's body, of how we could ask God to be present with just the strength that child needed in the moment, of how we could trust in a loving God to be completely present and completely concerned with the well being of the toddler, of how we could ask God to guide the hands and hearts and minds of the doctors who were involved, and of how we could ask God to enfold the mother as well in warmth and tender care, and grant her as well the necessary strength...I kept trying to use very concrete, even tactile images so that mom could "see" and "feel" with her body, hoping that would ground her to fight the panic. She kept reaching out of her panic to nod along with my soft voice and eventually drew a deep, shuddering breath and said, "Better now."

Shortly the doctor came out with an update. He said the toddler "should make it through this." I asked him to repeat what he'd said and checked to verify that she had heard those words. We got mom into the trauma bay to see the child for a few minutes, and I know that helped, probably helped both. The respiratory therapist especially was very kind, telling mom the good signs she was seeing. Eventually the toddler had to be transferred to a specialty children's hospital, because when a little kid needs to be in ICU, your best bet is to have critical care specialists who are trained to focus on kids. Mom talked to the dad a couple of times and asked me to talk to him once, because I was calmer. I stayed with mom until the transport team was ready to take both of them. We gave the little one a sign of the cross on the forehead and a last word of blessing before they took off. The little kid looked even littler on the pram, with all the monitors and the tube for the vent. The mother was still terrified but now calmer (we'd also gotten her a blanket and orange juice since she hadn't eaten), and ready for the next steps. You *know* you are tired when you can't wait to get to the new hospital because you know they have comfy chairs next to the kids' beds in ICU and maybe you can get some sleep at last.

Puts lots of things into perspective.

Wednesday, March 12, 2008

Evidence Based Medicine--when it fails

Warning--some ranting
Disclaimer--this story has nothing to do with any facility I have ever worked for

OK, so, I have two friends--a woman about my age, we'll call her A, and her mother, who is, let's say, a bit older than we are, like about 90, and we'll call her B. B is roughly the size of a sparrow. They live in a city not far from me, about an hour's drive. B had a bad fall in January, owing to an unfortunate combination of ice and wind. A, being proactive, took B to the nearby hospital's emergency room to get checked out, make sure she hadn't broken anything, etc. B's O2 sats were low (oxygen level in her blood), and while it seemed she hadn't broken anything, tests revealed that she had a pulmonary embolism (blood clot in her lung). Things to note: She has a history of heart disease and is on a couple medicines for that, a beta blocker and something else, and also she had some really deep, painful bruises from her fall.

The hospital where she was seen has, like most hospitals I suspect, a protocol for treating pulmonary embolism. According to this protocol, she was admitted under the care of the hospitalist team, put on oxygen via nasal cannula (she only needed it for a day or so), and started on oral coumadin (a blood thinner, via pills, which takes a few days to build up to a level where it's working well) and intravenous heparin (another blood thinner, yes, the one that has recently been in the news for lack of quality control but that's yet another story) that was supposed to work while the coumadin built up. The plan was for these drugs to keep any more clots from forming and start dissolving the one that was in her lung, and for her to go home as soon as the coumadin had reached a good level in her blood. Blood thinners, we are told, are dosed by patient's body weight. There is no factor for age. Also, don't forget the fall and bruises.

I went to see her in a day or so. She was being switched from the IV heparin to a different drug that she could inject for several days at home, so she wouldn't have to stay in the hospital all week (she hates hospitals and was happy to give herself shots in aid of going home). Physical therapy wanted to get her up walking before agreeing to the release, but she was having pain and as I watched her gait it was abnormally tilted to one side. I didn't like this, and A had reported it to nurses, but the discharge planning process was moving along. Someone from pharmacy came to give her a mandatory "teaching" about her blood thinner. It was all verbal, and took about 15 minutes. Her eyes (and mine and her daughter's) glazed over after five minutes. As part of the training, the pharmacist described the symptoms of abnormal bleeding that occasionally occurs for patients on blood thinners. Huge bruises or growing bruises were two indicators.

The next morning we heard that she was not in fact going home, because her blood pressure kept dropping. Apparently there is a protocol for treating that, too, because she was put on IV fluids. Also, she was really sleepy. At some point of that day, it was decided that her existing heart meds (which had taken MONTHS to tune) must be responsible for her blood pressure drop, so these were discontinued. The blood thinners were continued. The fluids were continued. A reported that B had huge bruises blossoming from her fall. The following morning (24 hours after the blood pressure started dropping), it occurred to someone to take a look at her hemoglobin and hematocrit (blood tests that assess, indirectly, how many red cells you have and how good a job your blood is doing carrying oxygen to your body). The blood tests were not ordered "stat" (draw immediately), so sometime in mid-afternoon the lab tech showed up to draw the blood, and by late afternoon, the results were back. Both numbers were HALF what they should have been. This suggested bleeding somewhere in her body. Perhaps in her ABDOMEN, where she kept reporting pain.

It occurred to someone that perhaps a CT scan of her abdomen would be informative. The CT was ordered and showed internal bleeding in three locations. (Remember the DEEP BRUISES? Do you know what bruises are?? They are areas of bleeding from an injury, and you want the bleeding to, oh, I don't know, CLOT at some point. Blood thinners do not help this process. To put it mildly.) At this point the proverbial brown matter hit the proverbial fan. Blood products were ordered stat, blood thinners were discontinued, and emergency surgery scheduled. I was never able to find out exactly what was done in surgery that night but a part was the installation of a "basket" in one branch of the vena cava to prevent clots that might break off elsewhere from further damaging lungs and heart. She came back from surgery about the time her poor daughter, A, who had been staying with her about round the clock, developed a virulent GI bug. A had to go home. Her best friend and I agreed to split shifts and stay with B the following day.

Poor B had a rocky night. She kept reporting pain and increasing feeling of tightness in her abdomen, and for whatever reason the night staff decided she was having heartburn (that is, when they were not offering tylenol). She was vomiting the heartburn meds and the tylenol. Finally, in the early morning, two things happened: someone checked her blood pressure and it was high. She told that someone that she gets elevated BP readings when she is in PAIN. Also, another someone decided that really tylenol is NOT sufficient for relief of pain due to INTERNAL BLEEDING and put her on a morphine PCA (patient controlled analgesia, pain pump, whatever, which requires the patient to be alert, oriented, able to remember instructions, etc., in order to get pain relief. B is 90, had been very, very sick now for 4 days. She had no clue how to work the PCA.) I arrived just as B's nurse came in to bolus her with an IV dose of Lasix for her high blood pressure. She'd had one dose of morphine which had provided effective pain relief (this, by the way, does suggest the pain was organ pain from bleeding, not heartburn). But she was looking weary and painful. I asked if she had pain, she said yes, I reinstructed her on the PCA, and she gave herself another dose. I was hoping she could rest, although not optimistic because the Lasix, had she been hypervolemic as suspected, should have made her need the bathroom pretty quickly.

20 minutes after the Lasix, it was CNA rounds time, and her CNA came in and took her BP. It was 90/40 (for the record, that is not high. It is LOW. As if, say, a person were bleeding.) I asked the CNA to re-take the BP and expressed my concern about the Lasix bolus in light of the reading. The CNA did a manual BP, no change, and tried to tell me the Lasix was a grand vasodilator and 90/40 wasn't really all that bad. I asked the CNA to report the reading to the nurse. The CNA rolled his eyes at me. Meanwhile, I kept trying to settle B to rest. Her room was right outside the nurse's station because she was a fall risk (true; 90 and disoriented from LACK OF OXYGEN and pain will buy you that, I agree). It was really noisy. I kept closing the door. Every person who came into the room left it OPEN on departure. And there were lots of them. She did get a little sleep before lunch. Which, when it arrived, contained enough food for an army. What tiny appetite she had disappeared, overwhelmed by the sight of so much food.

Right after lunch, A's best friend arrived to change shifts. B's forehead started furrowing again and she agreed, when asked, that she was having pain. I instructed both her and her new "sitter" on how to use the PCA, and she gave herself another dose of pain medicine. Shortly thereafter the nurse came in and announced that the PCA pump would be discontinued because she was using so little medicine she didn't need it and henceforth she could just call the nurse when she needed medicine. In vain did we protest that, without someone sitting with her, she could not manage to use the pump and we doubted she'd be competent to call the nurse, and she did not need to be in pain. He rolled his eyes at us. Shortly thereafter the transport team came to take her for a repeat CT. They unplugged the PCA and wheeled her out in a wheelchair. She was back 20 minutes later. They put her back in bed and left the PCA, unplugged, by her bedside. I'd had about enough so went out to ask the nurse to plug in the PCA. (I didn't remember where it was plugged in, and all the plugs were color coded, who knew where it should go??) He rolled his eyes at me, and said, "It HAS a backup battery, you know" (how would I have known THAT?) but did come in and plug it back in.

A little while later, I had to leave for work. A's best friend stayed at the bedside. B got two more units of blood product (packed red cells). I called later to see if the results of the CT scan were back. They were. It was "unremarkable." What on earth did that mean, I asked A's friend? She had no clue. Did it mean, unremarkable for a patient actively bleeding? Unremarkable compared to normal? Unremarkable as in, no changes from the day before? We had no idea at all. At least B was feeling some better from the morphine, A's friend was there to watch her and make sure that nurses knew if she was having pain, etc.

The next day it was decided that the morphine was causing B's blood pressure to drop too low. She was given a different medicine. Thankfully, it worked. At some point, staff reported to A that B's bleeding did appear to have stopped. And apparently they decided that blood thinners were not a good choice for B.

B made it out of the hospital alive. Luckily her heart failure did not get worse in the days without her heart meds. She did contract A's gastrointestinal virus and was so sick that her (own) doc wanted her back in the hospital but she refused to go and got better on her own. Luckily, also, she has not shown any signs of adverse reactions to her four transfusions. Her pain has been slow to resolve but she is definitely feeling better.

In the eyes of the hospital, this was probably a success. She was given a standard treatment, she had some complications, and these were addressed. New protocols were started when needed. However, in my eyes her stay left a lot to be desired. For starters: the protocol for pulmonary embolism was apparently not designed for someone with trauma/injury, but this was not addressed. B was not seen by the same team on successive days (what with the hospitalists' rotation schedules, and nurse staffing, don't let me go there). There did not seem to be any one person who was responsible, not for the protocol checklist, but for taking care of this patient. When B's blood pressure dropped, logic would demand that someone say, what has changed for this patient? Oh, we started her on blood thinners, wonder if that's responsible? rather than deciding that the heart meds, on which she had maintained normal pressure for, say, MONTHS, must have been the culprit and discontinuing those. The "training" B received re: the blood thinners included watching for pain and increasing sizes of bruises. Although she had these, and they were reported by B's daughter A, apparently no one understood them as signs until they'd been going on for 24 hours. When someone did begin to ask questions, the bloodwork was ordered with normal priority. So the bleeding kept on for way longer than it needed to. The morning after surgery, B stated clearly that pain causes her to have elevated BP readings. No one re-took her blood pressure after the pain relief was started--they just gave Lasix, which turned out to be unnecessary if not contra-indicated. And, the choice of a PCA for an elder who is woozy is not appropriate. Scheduled pain meds, please, and followup with the patient.

But, hey, there are protocols. And they work wonderfully and, I am sure, in a cost-effective manner, for patients who are young, alert, have no pre-existing health conditions, and able to advocate for themselves.

Here's the scariest thing yet: I was telling this story to a friend whose mother had a number of medical crises before her eventual death. I mentioned the pulmonary embolism and the protocol, and she said to me, "Don't even bother with the rest. She got too much coumadin and had internal bleeding and almost didn't make it, right?" So--this protocol has a known problem. Her mother's experience was years ago. Has there been any change? Guess not. I suspect it works enough of the time to be cost effective.

I intend to modify my advance directives to note that if I am ever found responsive near B's hospital I should be left where I am. Don't take me there, leave me in the road or wherever. The outcome will be the same and it will cost a lot less money.

Here's the thing--we somehow must not see our vulnerables, our elders and the sick among us, as deserving of attentive care, if we simply subject them to treatments that appear to have been developed from working with younger, healthier patients, those who present with only the problem being treated and who can advocate for themselves. To me as a chaplain, this is an enormous problem on many levels, including perhaps at core the spiritual. Efficiency and cost control replaces care of persons, and it works well for those in the most powerful class/age group, the decision-making class/age group. Those on the margins are those most likely to have complications. Not OK, not in the justice tradition of Judaism or the tradition of Christianity, despite the fact that "Christian values" are supposed to be important in this country. Let's think about that once in awhile.

Friday, March 07, 2008


Occasionally I get to work shifts overnight in a nearby hospital. COR-0 is the overhead paging code in the hospital that indicates a patient is not breathing and has no heartbeat. The team that responds includes the chaplain. These calls, in my experience, have been heartbreakers. I've responded to a couple where the patient is someone younger than I am, who has not survived despite massive resuscitation efforts. (I have seen ER techs standing on chairs to get a better purchase for CPR, and when the patient comes in by ambulance the team is waiting with medications, defibrillator, etc., at the ready.) There is one benefit to working primarily in hospice, and that is that I am used to dead people and I know what dead people look like. Thus, at the last COR-0 I attended, as the ambulance crew brought the patient in, doing CPR as they raced into the trauma bay, the back of my mind said: I know what that is, that is a DEAD PERSON. And it did help, because it let me get the deep breath and the mental preparation so that when the doctor came out to the family, I knew what the outcome was. And because I was not surprised by the word, I could be more ready to attend to the family. One of the ER docs that night told me that it always takes him awhile to get back to an even keel after a sudden death, especially when the patient was by all accounts a wonderful person. "That's good," I said to him. I should have explained--this doc was immensely compassionate to the family, and I think the fact that he lets the deaths affect him allows that compassion to come through.

A weird thing happened though one night. The page to a COR-0 in a particular room in the emergency department, but as I arrived the staff was cancelling the page. "Just a mistake," they said. I wondered: how do you make a mistake determining if someone is breathing and has a heartbeat? "Oops, never mind, I had the stethoscope backwards?" or did the patient, previously unresponsive, sit up and ask for a Diet Coke? I dunno.

Chaplains also respond to "cardiac alerts." A cardiac alert in this particular hospital is the code that means there is reason to believe that a patient is having a heart attack. When the patient is already in the hospital, a team descends upon the patient's room; when the patient is being brought in, the team awaits in the emergency department. It is awkward being the chaplain at these. I always wonder, while waiting with the cluster of doctors, nurses, lab, portable X-ray, EKG, registration, etc., what on earth I am supposed to do. The unholy part of me, which is the major part of me, has been tempted to say, "Welcome to the hospital. Would you like coffee, tea, or an angioplasty??" Cardiac alerts get cancelled if the cardiologist turns up, looks at the EKG tracing, and determines the heart is OK. That's a good news/bad news thing for the patient. The good news is, not a heart attack. The bad news is, "We don't have a clue what's wrong with you at this moment."

If the patient is having a heart attack, the team rushes her/him for an angiogram to see if there is one or more blocked arteries. In the best case, these can be fixed then and there. My job is to get the family to the appropriate waiting room, help with any calls, offer support and even prayer if they want, and wait with them for the doctor if they want company. Some of the docs kind of ignore the chaplain, while others involve us more, like the one who said to me (I'd stepped out for the doctor's report and the cardiologist caught me on the way back in to the patient), "We're doing a HIGH RISK (meaningful glance) angioplasty for this patient." I did not leave the one relative present until the procedure was over and the patient had survived.