Hi everyone! I'm a 2nd year resident doctor in an inner city hospital. This is a blog to document some of the experiences I encounter as a training doctor, and some of the things that I learn in the process. After all, being a physician means that I'll be learning some fascinating topics for the rest of my career, and seeing how I can use those to help patients.
Let's continue with the experience that I started describing yesterday:
Polly’s clinical condition worsens
Polly continued to get worse while we were awaiting the results of her pleural effusion analysis. Her breathing and pain became worse. The chest tube that was draining the fluids did not appear to drain as much as we would have liked, as the lungs continued to fill up even with the tube in place. We had begun to give her some strong pain medications – they were opiates. Strong indeed, but this was the first time in a month that she had actually felt some measure of comfort.
A little bit earlier, Polly had started to express a wish to go back home. Of course, it was not yet safe for her to go home in her condition, and she was not in the clearest of mental states to make full medical decisions. Her family was living far away and they were not always easy to reach. Thus, we started to try to make decisions with both Polly and her family.
More delays in consult specialists and figuring out goals of care
We had discussed Polly’s condition with the palliative care specialists. Prior to having a complete discussion with Polly and her family, they wanted to see what recommendations the lung specialists and oncologists would make, and these recommendations rested upon the results of the fluid analysis and biopsy.
We tried to reach the lung specialists and oncologists for weeks, and we were able to reach the lung specialists – after about a week, they deferred decisions to the oncologists. We then tried to reach the oncologists for a week… and then another week… and then another week. We could not figure out how to talk to them. We couldn’t reach a working phone number and our pages were not returned. The consultation was simply not being answered.
By the time we started to get results, Polly was becoming more lethargic and less responsive. She was not receiving large amounts of opiates, but enough to cause some sedation. For those who know some effects of opiates, they can also cause decreased respiratory drive. For someone who already has trouble breathing, opiates can make the process of breathing even less effective.
Goals of care were finally decided
Polly eventually had her chest tube removed because it was not effective any longer; the fluid had stopped draining. Her pain control was just adequate enough to keep her out a great deal of pain. Her consciousness was slowly away, and she was less awake in comparison to how she was when I first saw her. She was less feisty and sarcastic than her normal self.
We were still waiting for the oncologists to give their recommendations so we could reach out to the palliative care specialists. We never heard from the oncologists. To my understanding from that time, it’s possible that no oncologist was actually available on call at that time of year. I’m not entirely sure whether or not this was true.
The resident who was supervising me decided to take action herself. With Polly’s family member by her side, she went through a checklist of palliative items and decided what she wanted done and what she did not want done (side note: at the time, I did not know that we could ask all of these questions without a palliative specialist ourselves, and I also didn’t know all of the questions at the time – so this was quite a learning experience). Although we could not safely send her home, that same afternoon, we abided by Polly’s wishes regarding her treatment.
The final outcome
The next morning, it was my last day on shift before my vacation. It was a few days prior to New Year 2022. As I came to my shift, I was alerted by the nurse that Polly had lost her pulse and stopped breathing. She did not want to be resuscitated or intubated, so there was nothing else we could do from a medical perspective. I confirmed her death, closed her eyes, laid my hand on her shoulder and caressed it, and said goodbye.
There was some measure of solace taken in the fact that we were able to give Polly some pain relief and abide by her wishes for a short while. I was struck by the amount of time it took for the goals of care to be clarified, and that, as a result, she suffered for such a long time. It was something that weighed on my mind for a long time thereafter, and I made a vow to ensure that if possible, I would fight to make sure that any patient who requests comfort care would be able to attain it.
Fortunately, since that time, I haven’t seen such gross delays of clarification of goals of care. I have observed some delays caused by indecisive caretakers, which resulted in prolonged suffering for patients. Such decisions are extremely difficult and emotional, yet time-sensitive while illnesses are actively progressing. It’s taught me the importance of deciding such matters in advance, and being open to changes when they occur.
I hope you've enjoyed this little snippet of an experience I had as a resident in an inner city hospital. I'll have many more stories and learning experiences coming in the future, so stay tuned.
Sources:
- https://lakesidemedicalcare.com/history-osteopathic-medicine/
- https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/opioids
- Me 😊
Disclaimer: this blog is for entertainment (and possibly educational) purposes only. This is not medical advice. If you have any questions or concerns about your own health, please contact a healthcare provider.
Here are the previous editions of this blog:
Chronicles of an Inner City Hospital Resident Doctor #5
Chronicles of an Inner City Hospital Resident Doctor #4
Chronicles of an Inner City Hospital Resident Doctor #3
Chronicles of an Inner City Hospital Resident Doctor #2
Chronicles of an Inner City Hospital Resident Doctor #1