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Emotions get in the way

22 Aug

This was a saved draft that I started during finals, and never finished:

Last week at the hospital was difficult. Not like, “I got to try a new procedure and I am thrilled but tired” but rather more of an energy zap and I couldn’t really put a finger on what it was that felt so hard until later. I was able to follow-up with my patient from the previous week, which I was very grateful for. Last week, we connected and it’s hard for me to let go of connections gracefully since I grew so accustomed to them while working in Assisted Living. However, it also was a reality check for me. People don’t go to the RICU very often when they are “getting better.” It’s nothing like Labor & Delivery, for example. You may be quite literally breathing life into your patients, not usually a long term solution. My patient from last week had rapidly metastasizing cancer in her lungs. I knew she wasn’t getting better, but it doesn’t make it easier to watch a 60-something year old woman face dying when she isn’t ready for it. I spoke with her son last week who told me that she was non-responsive and nearly obtunded. She couldn’t speak anymore. So much changed in merely a week. The RICU might be her last stop.

My patient for the current week didn’t improve my outlook. She was alert and oriented to person/place/time when we began our care in the morning, although she was also very old and sickly. She had taken a big fall and broken an arm as well as hitting her chin on something hard which caused a lot of swelling and ecchymosis. She was in the RICU for her breathing which was labored and required supplemental oxygen. Just days before, she had been living independently, but the fall had taken a huge toll. Here we were, doing a head-to-toe bed bath, trying to elicit responses and receiving far fewer than we liked. We watched the nurses take blood tests from her delicate veins, covered by a dry and papery-thin layer of skin. They were trying to figure out if her reduced mental status was due to an undiagnosed infection. By the end of the morning, she had gone from awake and alert to lethargic and somnolent. It was hard for me to watch this progression. When we presented on our case in the afternoon, it seemed clear to us as well as to our preceptor that our patient’s prognosis did not look good. I left that day feeling a little bit heavier. I am starting to realize that you don’t always get to help your patients “get better.” As rewarding and obviously satisfying as that might be, it’s only one facet of the job.

Update: The following week, when I went back to the hospital, the aforementioned patient was much better! She had made almost a complete 180. She was awake and alert. She said that she remembered us from the previous week even though it hadn’t seemed like she was at all “with it” to be aware of us. Her bruised chin was less swollen, she was breathing entirely on her own, her skin was cool to the touch and best of all, she could communicate with us. I know this won’t always be the case. Not every patient gets better. But in some cases, the patients that seem the least likely to make a full turnaround, do. You provide the same level of care to everyone and sometimes you get a great outcome. It’s important not to decide for your patient whether they will get better or not, but just adjust your care to the changing conditions, with monitoring mental status being one of the most important indicators. It was so gratifying to see a patient on the road to recovery.

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One response to “Emotions get in the way

  1. genie

    August 25, 2010 at 11:00 am

    A key factor is what the patient want…some may want to continue living..others find continue to live in decreased capacity objectionable. They should be given an honest estimate of what their life is likely to be after discharge and be able to consider the options.

    Another factor is whether the patient still has a spouse..then the spouse benefits from the patient surviving.

     

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