Living in Denial

They had said all night that they just wanted to go home; that things "just weren't working out" for them in the hospital. Once or twice she said she was afraid.

That's why she refused the treadmill portion of her stress test. She said she thought it would kill her. "That's not the point of the test," I explained, also discussing critical lab values, such as a K+ of 5.5 and a white count of 21.

We just do tests. Actually killing a patient is a service one must purchase from other suppliers. Sopranos.

She could hardly stand up, she thought it was 1964, but admitted to being "a little confused," and desaturating to just the mid-80's on room air. I wasn't impressed by any of these things, but I told the patient that no doctor would ever just send them home with these issues abounding.

A friend came to visit. He wanted us to let the patient go home, too, but with the patient's permission I discussed my concerns with this visiting "friend." Together they were very close to signing the patient out Against Medical Advice. Then the friend asked me if they could have medicine to help the patient, for them to take at home.

"No," I flatly said, and he said "So if she leaves you're just going to cut her loose?" and I simply responded "No, if she leaves AMA she will be cutting herself loose." Sheesh.

There was something deeply wrong with this gal and I just could not place it. She ended up staying, and because of the hypoxemia the attending hospitalist even gave us ICU transfer orders. It seemed like a soft transfer. The nursing supervisor thought so, but the doc held.

When I called report to the ICU nurse they said the same thing, they didn't really see a clinical need for ICU, and all I could say was that something was up with this one; the hypoxia, the hyperkalemia, the white count, the mental goofiness... not good.

The whole thing was a time-consuming pain in the rear, first the patient was signing themselves out and next thing you know she's in the ICU. Three hours of your basic hospital/patient crapola.

Shortly after the patient got to ICU cardiovascular caught up with them and did an echocardiogram and later they bought themselves a pericardial window. That's when we stick a needle into your chest a little below the sternum and sometimes to the left a little, and drain maybe an ounce or so of fluid that has over-accumulated in the sac around your heart.

It's as fun as it sounds.

And when it's over you still know nothing. Like: "why?"

Personally, as she was a bit of a smoker and hard drinker, though a local legal professional of some repute, I'm thinking cancer.

The renal labs sucked, too, with a BUN of 50. Another straw on the back of the camel.

In a day or two they will bounce her back to my unit and maybe we'll get to talk about it.

Everybody said the patient was "in denial" when she was insisting on going home. Well, in order to be in denial you also have to have one more little thing going on: you have to be alive.

You have to be alive. Then the doctor can let you go home.

The next day, on edit:

Up until the ECHO was done the patient was still requesting to go home, adamantly, but the ECHO showed that bunch of crappy fluid around the heart requiring the pericardial window discussed above.

A couple hours later they were back in yet another intensive care unit, breathing only via ventilator and requiring sedation to do so.

Think of that... one minute the patient wants to go home even against medical advice, and a couple hours later they're in Intensive Care hooked up to a machine that breathes for them, along with the requisite Diprivan drip to keep them sedated enough so that they wouldn't pull out their breathing tube and die, and a chest tube to drain the pericardial window and maybe even the thoracic cavity too, for all I knew.

It happens more often than you might think.

On second edit 4 days later:

The patient is still tubed. It turns out that 700ml of bloody drainage resulted from the window. That's an effing boatload of crap around the heart.

They were *finally* able to perform a chest CAT scan which showed a lung mass. No kidding. They'll either bronch her or do a fluoro-guided needle biopsy to see if that's the original site. The pericardial fluid showed malignant cells. Bloody hell.

Now I'm thinking that the patient may never come back to me. They might check out and die first. Maybe that's what they wanted all along: to go home and die, before we could do all this billable stuff to them.

On edit eight days later:

The patient is still intubated and according to the pulmonologist "is not doing well."