When your hands are tied…

I sighed when I saw her name on my list again.

A.N. was one of my favourite patients.  She had rheumatoid arthritis–an autoimmune condition, where your immune system attacks your body .  A chronic condition that may need lifelong medications.  Her grandmother had it.  She knew for her grandma it made her hands deformed and caused her a lot of pain.

Not something a 29 year old young woman wanted to hear.

I had just seen A.N. 6 days ago and she was back again in an urgent spot.

“What’s up?”I asked smiling and knowing she’d laugh as I teased her for coming back so soon.

“I can’t really see out of my eye Dr. B.”, she said with a smile that was more of a grimace.

“What? Since when?” I examined her eye as she reviewed her story with me.

Damn, I thought. Of course it was the afternoon before a long weekend. She needed a specialized exam so that appropriate treatment could be provided.  For a person who was on drugs that weakened her immune system, she could have a few things that were urgent so she didn’t lose her sight.

And my hands were tied.   Our only option was for her to go sit in the ER. She needed to see a doctor who had access to a slit-lamp exam (a special way to look at the eyes), and we both knew that meant she was in for a long evening.

I called her a few hours later to see if she had seen anyone–she said a doctor came by, and told her the slit lamp in the ER was broken.  She had an exam that was similar to what I had given her in the office and booked in to see the eye specialist the next day…

Oh. My. God. What if she loses her vision?  The possibilities ran through my head.  What could I do?  Even though I knew how to treat her, without the proper equipment, we couldn’t be sure what to treat her with.

At that moment, I despaired. As I’m sure the ER doctor did that evening. Our hands were tied due to broken equipment.  Our hands were tied due to broken budgets.

 

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I’ve lived a full life…

I met her my second week at my new practice.  A.W. was a few years older than me and had a great smile.  We had instant rapport. She was in to see me for abdominal pain.

Two weeks later, I got a report about her having emergency surgery. Oh no,  I thought as I reviewed the notes, but lucky for her they were able to operate in time …

I didn’t get to say what I had planned.  When she came in to see me a week later, we had the final reports.

“Adenocarcinoma.” Cancer. It was everywhere.

Stage 4, so by definition, not curable.

As the oncologists rushed to figure out the type of cancer and treatment options, our conversations became existential. How can a 35 year old, vegetarian Tibetan woman – who exercised, never smoked, didn’t drink or do drugs, meditated, and did volunteer work around the world for the poor – have stage 4 cancer?   There was no family history of cancer.  Why was this happening to her?

We talked about this over the next couple of years. We laughed, we cried, we shared stories as I walked with her through this journey. She went through multiple surgeries, mostly emergency as her cancer progressed and caused her pain or other problems.

In the end, I would visit her at home as a friend. She had a palliative care doctor to care for her physical needs now.  I once looked at her family photos on her bedside table and asked her “who’s this?” pointing to a beautiful young woman in the center – knowing as the words left my mouth, that of course, it was A.W. before the cancer had ravaged her body.

I may only be 38 years old but I have lived a full life.”

Being A.W.’s family doctor has been one of the greatest privileges of my life.  She taught me that cancer may take her body, but it can never take her spirit.

And in the end, she still smiled.

No free beds…

Another nurse approaches; ‘Doctor, I’m worried about this patient. His ECG (heart monitor) shows concerning changes and he’s sweating and nauseous.’

‘Can you get him into a room?’

The answer again: ‘We don’t have any beds open. We used our last stretcher for the woman with sepsis (blood poisoning).’

I sigh out of frustration when I really just want to scream. The toddler may be vomiting because of bleeding in her head. The man with the nausea and vomiting may be having a heart attack.  And I know, this will go on for hours. This is just how it is in the ER.  The status quo.

No beds mean that they are already full with sick patients from the day before, waiting to be transferred upstairs to a hospital bed.  It’s the 17th day of “No beds”.  All the hospital beds are full. The ER beds are full.  We can’t close the emergency department so what happens?

Sick patients on stretchers lining the hallways and waiting rooms.  Elderly shivering, babies crying.

Nurses run off their feet trying to care for entire hallways of sick patients.

One by one, I see the sickest patient from triage. The others, while sick, are not ‘sick enough’ and have to wait. Hours tick by. A pit grows in my stomach: the toddler can’t wait if she’s bleeding. The man may not make it or will have heart damage if he is having a heart attack.  My hands are tied. I know they need to be seen but I have no beds to see them in.

That means nowhere to examine and monitor them, draw blood, put on a heart monitor, and treat them.

The underfunding of the health care system has meant frozen hospital budgets: no new beds in hospitals, no money for more nursing. The province’s population grows, the elderly are sicker, yet beds remain the same.

As my shift goes on, thankfully, the vomiting toddler settles and hours later, she is discharged home with concussion instructions. The man with the nausea and vomiting is eventually seen.  By then, his ECG changed to show he IS having a heart attack.  I can’t help but think, if I had seen him 4 hours ago, could I have prevented this outcome?

For a decade or more, the onset of winter brings a sense of dread to emergency doctors across the province.  I’m trained to sniff out serious illness and make people better. But I can’t do that if I can’t see or touch the patient for hours

A Little bit of serendipity

She was the daughter of a childhood friend who I hadn’t seen in twenty years.  She bounded into my office, full of energy, laughing as she excitedly told me about her day.  As a 10 year old, she loved the fact that her doctor was mommy’s friend from when SHE was ten.

“What’s up guys?” I asked her mom and my 10 year old charge.

“Oh, I just wanted to check in with you about something.  I’m sure it’s nothing but just thought I’d double check.  Lisa has been having some nose bleeds that take a while to stop and today she seemed to have trouble swimming –she got tired quickly and said she couldn’t really breathe. I’m sure it’s just a cold”

“I feel fine!” protested Lisa, as her mom told me the story

“Sure you are, and stop putting things up your nose!” I said teasingly, as I helped her up on the table.

Of course she just had a cold, or at worst was a little anemic. I knew this kid didn’t exactly have the greatest diet. I asked about other bleeding including from her gums (yes-she doesn’t floss!) and whether she had started her period (NO!).  I quickly did my physical exam, looking for enlarged glands, open sores in her nose, and listened to her chest,  while chatting with her mom about her current pregnancy.

Out of the corner of my eye, just as Lisa was about to hop off the table, I saw them.

Petechiae.

Just a few scattered on her chest.  I lifted up her pant legs and pushed up the sleeves of her arms and there they were-bright red pinpoint spots.  And on her thigh- a large purple bruise.  A few more when I looked at her back.

“Where’s that from?”

“Oh you know Lisa, always bumping into things”, her mom shrugged.

“Well most likely she’s fighting off an infection and it’s viral given what I’m seeing and hearing” but I would like to do some blood tests.

“Mom, no!!!” Lisa whined as her mom took the requisition from me.

Her mom glanced at me with a raised eyebrow, knowing I wouldn’t make her get a needle if I wasn’t a bit worried.

“I’m sure it’s fine, but Lisa, I do need you to do this” I said. Promises of visits to the toy store were made and the tears soon stopped.

I forgot about the blood test as the week went on. Until Friday. And I saw it.

Leukemia


That was 8 years ago and I’ve left that practice and moved provinces. I’ve lost touch with my friend and her daughter but I know through mutual friends that Lisa is doing fine.

I’ve frequently thought about that visit and wondered, what possessed me to order blood tests that day instead of waiting and bringing them back to see if the symptoms resolved?  That’s what I had always done before and normally would do. It would be the standard of care.

I never did blood tests on kids and subject them to unnecessary needles.

How is it that a friend who I had lost touch with, showed up briefly in my life, for me to diagnose and help her daughter with cancer, only to go our separate ways again?

Serendipity. That’s how.

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When you need to speak and can’t say a word…

I arrived at the nursing home at the same time as the paramedics.  I was the on-call doctor this weekend.

“Hi, who are you here to see? ” I asked.

“A lady on the fourth floor, East side”.

Wait a minute.  That’s one of MY patients I thought as I bounded up the stairs behind the paramedics.

I ran into the room to find my favourite nurse already giving the report. “She suddenly collapsed today and we couldn’t find her oxygen level”.

“What do you mean?”

” I mean, it keeps fluctuating between 40-90%”

That’s not a good sign, I thought, watching the paramedics tuck a moaning Mrs. S. onto the stretcher.  She looked frail. She was frail.  My heart wrenched: Mrs. S. had dementia and was nonverbal. She had been so for years since her last stroke.

Off she went, starting the new year in the cold ER of a downtown Toronto hospital.  The nurse called her brother to inform him so that hopefully, he could keep her company and reassure her.  Until then, she would be alone.

I thought of how scary it must be for her, a woman suffering dementia and unable to express her fear and angst.  Alone in the busy ER until a nurse was able to see her, undoubtedly rushing off because she or he would have at least 10-12 other patients that are urgent or emergent to watch over and take care of.

How would l feel if it was me one day? Surrounded by loud noises, people yelling, harsh lights, lying on a gurney with little more than a thin sheet to protect me against a draft. Unable to get myself up, use the toilet, or cover myself.  How terrifying. How lonely.  How indignant.

The next day I was back at the nursing home for rounds.  To my surprise, I saw Mrs. S. was already back from the ER.  I scanned the ER notes.  She was sent home on oral antibiotics for pneumonia.  But, what about her oxygen levels?   I wondered why she had not been admitted for IV antibiotics.  After all, the low oxygen levels suggested her pneumonia was severe enough to impair her lungs from working!  As I read through the note and looked at the labs, a sense of foreboding came over me.

The nurse and I rushed over to see Mrs. S., and sure enough, she was in obvious physical distress:  breathing rapidly, agitated and moaning.  Again, her oxygen levels were low. We looked at each other, overwhelmed.  What can we do? I walked back to the nursing station to  call to her brother.

” I think the bacteria is in her blood and she’s quite possibly dying.  I can make her comfortable here if that’s what you think she’d want and that’s fine.  But if you want to try to keep her alive, then we need to send her back to the ER again.”

He agonized: she was the sister who cared for the family when they were all young.  He felt an enormous sense of obligation to her and wasn’t ready to let her go, especially if her illness was potentially reversible.

So off she went, back to the same ER.  This time, she was admitted to intensive care. She remained in distress.  And by the end of the night, she died.

Mrs. S. didn’t suffer long, but her story still haunts me.  Her visit to the ER alone.  Being sent back to the nursing home the first night.  It probably wouldn’t have changed her outcome if she had stayed but I wondered, why didn’t they keep her there?

There is only one reason–a lack of hospital beds.

I wanted to cry.  I wanted to speak for her, but to whom?  I can tell her story, but I can’t get the words out to say how bad I feel that our system failed her….