The apathetic patient with a bad skin ulcer

A middle aged man is brought in by ambulance to the ED with a report of diarrhea, a wound on his butt and low pulse. As soon as he is brought into his room and the nurse sees him, she comes to find me to say, "he doesn't look as bad as his numbers would make you think." And that would be? His blood pressure is 73/4o something. I take a look at him. The nurse takes a look at me, and like any good nurse, reads my mind and orders her assistants to move the patient immediately to our resuscitation bay.

While the crew is busy getting a second IV and attaching a cardiac monitor, I approach the bed an introduce myself. The patient is pale is a ghost and looks like he has been living in a cave. Turns out he had been. Almost.

"Who called the ambulance for you sir?"

"My VNA."

"Why's that?"

"She said I didn't look too well."

"Where have you been living?"

"In a shed behind my parent's home. It abandoned now that they're dead."

I see dried diarrhea down his legs, although strangely he doesn't smell that bad. Not at all like homeless-drunk bad.

"Where have you been going to the bathroom and what have you been eating?"

"I don't have a toilet no where and I've been eating some food my brother has been bringing me."

He is pleasant, and cordial in his answers. Not at all the combative and confused patient you would typically expect judging from his appearance. He is emaciated, poorly kept, long greasy hair. I don't know why, but a picture of an old hick from the backwoods of 19th century Kentucky diseased with hook worm comes to mind.

But what is even more odd is that he has a list of medicines with him. Many of my patients in far better social circumstances don't even know the name of the medications they've been on for years, or have the sense to carry a list in their wallet. And then he says, "but Coumadin is not on there, I'm taking that too." I can only guess how far off his Coumadin level must be. "And the name of my cardiologist is..." I'm floored. I guy living in a shed wallowing in his own crap actually has a cardiologist and can tell me his name????

Turns out he doesn't have any complaints really. But that blood pressure is still in the toilet, even after 2 liters of fluid. He's mentating perfected well. Really? Nothing's bothering you sir?

So then we go to turn him.

And on his tailbone is a dinner-plate size area of black, rotting flesh with a large gaping hole packed with fetid newspaper. "Got to explore the wound," I hesitantly mumble to myself. I glove up. I want two layers of gloves for this one. No, maybe three. I want a face shield, a gown. No, just give me a hazmat suit. I nervously pull out pieces of the newspaper, unsure of what I will find. It's stuffed in there deep. I mean real deep. Down to the bone, an ulcer large enough to stick in a large grapefruit. And then I see a maggot. I stop and look up at the nurse. She is mortified but maintains composure. The smell is beyond description and I nearly vomit all over the bed. I step away and ask for an instrument kit with some forceps and the overhead surgical light to be turned on. By this time word has got around the department and my colleagues are filing in one by one to gawk with morbid curiosity. I return to the matter at hand and what I see is utterly foul. There is a mass of frantically wriggling maggots trying to escape my detection by burrowing themselves into deep recesses of the ulcer. I pluck a few out and rinse the ulcer with water.

No, strangely, this does not hurt he says. He has no clue what is down there. I tell him there are maggots; he seems indifferent. And that's what I just don't get. I would expect this is an alcoholic or addict. But this level of apathy in a sober person I've never seen before. Before I actually do vomit I ask him to roll back and go to call the surgeon.

The full code reversed

Today the skilled nursing facility, or SNF as we say, sent in a 95 year-old with like a million medical conditions. She was lethargic and had low blood pressure. This indeed was true. As I held the face sheet transfer document with meds, vitals, medical conditions from the SNF, I eagerly scan for the "code status."

FULL CODE. 95 years old. Should have died years ago. And now in my ED where I have all kinds of technology, which are either instruments of life support or instruments of torture depending on the patient.

I don't know what's going on. Probably dehydration, but she's ancient and has problems with every organ, so anything could be wrong. Heart failure? Sure. Kidney failure? Sure. Infection? Absolutely. Thyroid issue? Possible. Simple dehydration? Quite possible. Medication over-use? You bet.

She doesn't perk up with simple IV fluids, but she doesn't swirl around the drain either. She's arousable and talks in disoriented, demented sentences.

I call her health care proxy, the son. "She doesn't want any machines," he tells me. But if her heart stops? "Well then I guess we should make an effort to keep it going." We hear this a lot in medicine. "Try." It seems sane. Seems just. Seems humane. I explain that CPR is brutal and painful. I explain that if a 95 year hold has a cardiac arrest there is virtually no chance of CPR working well and even if so, she ain't going to be walking in a field of daisies. It will be life support and a slow miserable, prolonged death. Well I say that in so many words. But I do my best not to mince words and sugar coat. I've seen too many docs do that because it is easier to say it like that. But honestly, I think patients and their families always appreciate the straight and narrow honesty, even if the truth hurts a lot.

So he agreed that cardiac resuscitation was not reasonable and not what she would want. I've played out these conversations over and over again in my head to get it just right. So much hinges on the way things are phrased, tone, timing.

So what this meant is that the patient was admitted to the regular floor, not to the ICU. This kept a very expensive and valuable ICU bed open for someone who will much, much more likely benefit from life support. And it kept her family - and the rest of us since he bill will be nearly 100% from medicare - from paying thousands of dollars of health care that would much, much more benefit another patient.

This is humane. And it is rationing. And it is rational. Most importantly it is respecting HER wishes, rather than playing into the feeling of guilt that many family members feel when letting go. These situations are never easy, but this one was relatively straight-forward. It gets hard when this same patient is 75, or even younger with a worse disease and worse prognosis.

The man who shit himself

A few nights ago I had my most unpleasant patient ever. EVER. This was not the 25 year old with a wrist abrasion and a minor skateboard accident asking for percocet. This was not another 46 year-old woman with chronic generalized abdominal pain and depression. This was not the irritating and hopeless alcoholic, again drunk with a bump on his head. This was not the 5 week old pregnant girl who called the ambulance because she has some mild cramping. This was not the bipolar 66 year old who comes to the ED every week for a variety of complaints then treats the staff like chopped liver and refuses care. This guy was worse, believe it or not.

A 43 year old man with Crohn's disease. He was discharged the day before from the hospital for "mild Crohn's" exacerbation. He had a several thousand dollar work-up while in the hospital, GI consult, CT scans, the works. Today he got kicked out of his shelter, supposedly for shitting in his bed overnight. Sure loose stool from the Crohn's, but this is not uncontrollable cholera-level diarrhea.

The guy is parked in the hallway right by the workstations and will not let a single staff member walk by without asking for something. He refuses having an IV for fluids, although to be honest it was not really necessary. He openly confesses to me that he has never worked a day in his life because he was "spoon" fed by his mother. He's not used to being in a shelter, "if you know what I mean, man." I don't ask him why he's in a shelter. I can make up the story that is probably pretty close to true. I don't ask him because even asking him the simplest question, like "what did you have for breakfast" turns into a 5-minute nonstop ramble about everything except what I want to know. He wants pain medicine. He wants he diarrhea to stop. He wants some food. He is back because he didn't get the "right treatment." Whatever that is. Can please tell me sir?

Then he shits in his bed. In the hallway. All over, disgusting loose stool. Didn't bother attempting to get to the bathroom. Didn't bother to say "Hey guys, I'm feeling like one's going to come loose, can ya' help to the bathroom?"

The nurse takes him to room and calls me in. I find him sitting in his stool. He starts blathering on and on about his "diarrhea." I can't get him to shut up. I ask him to clean himself up. He makes up more stupid reasons why he can't do this. I mean who the hell does this? I tell the nurse to leave him and say I won't talk to him until he cleans up.

So now he's clean, back in the stretcher. The aides did it by the way. I tell him exactly what I think, well almost minus a lot of expletives, that he's like my 2 year-old son who also shits himself but at least wears a diaper. "I can't wear a diaper man, you know what they say to me at the shelter." No, not really, but it's gotta be a whole lot better than having shit everywhere.

After 7 painful hours in the ED I get him out with some antidiarrheal meds. Admission was not an option. He walked out smiling, like he was happy with his care, what a shit-eating grin that was. Discharged at 10 pm. 15 minutes later the triage nurse calls me and says he's back, complaining again that he didn't get the right treatment. I say tough. He's malingering. He has no place to sleep tonight. To bad for him, but he doesn't have medical condition that needs hospital treatment, a doctor, and a nurse right now. What he needs is some sense of responsibility.