Seven Patients

by Atul Kumar

  “Are you two close?”

  “Look, I don’t know what you are insinuating, but we love our Grandmother. She has one other grandson and a granddaughter. If they don’t come by tonight, they’ll be in tomorrow before work. Her husband passed away about ten years ago and she didn’t want to live in a nursing home, so I bought her the mansion next door so that I’d be close by in case something happened.”

  Just then two other well dressed people stormed into the ER and darted straight towards Ms. Maude.

  “Grandma, are you ok? They aren’t hurting you are they?” The female asked as she glared accusingly in my direction before attending again to Ms. Maude.

  “Abigail?”

  I had to take control, or else this family would drive me nuts. “And who are you two? The ER is closed to visitors, only one family member is allowed by the …”

  “EXCUSE ME? Another outburst like that from you and I’ll call the Board of Directors and have you fired,” she announced loud enough for everybody nearby to hear. Nobody cared. ER personnel are accustomed to people under duress trying to flex their power and position. It’s meaningless and doesn’t change a thing. In fact the more power one overtly flexes actually demonstrates how little power they actually have.

  I sighed, since it was all I could really do at this point. It seems like people always feel more entitled at the hospital. I’ve already noticed those that drop names are frequently the most impotent, without any real power or influence.

  Just then Jason arrived, allowing me to escape the family from hell. Intercepting him before he came too close, I gave him a quick update at the workstation. Luckily while we were conversing, the grandchildren were trying to arouse their comatose corpse of a grandmother.

  “Fuck-an-A man, this is the classic situation in which a family that clearly knows diddly about the last remaining grandparent suddenly feels guilt that she’s in the hospital. They’ll want everything done for her while being able to provide no useful information other than to give us heartburn. Remind me to thank Amy!” Jason sighed, clearly having seen this scenario before. “Raj, watch me handle this, and try to take notes.”

  He entered the small room and instantly got everybody’s attention, “Greetings, I’m Dr. Bates and I’m in charge here.”

  “Finally, a real doctor.” Richard introduced his siblings and demanded an update be given on their grandmother.

  “Well, it appears as though she has come to the ER due to altered mental status. This is something we take very seriously and are going to get started on immediately with the appropriate CT scans and blood tests. I will have more information for you in the morning when we start to get some results back.”

  The granddaughter spoke, trying to appear smart and knowledgeable, “won’t the radiation put her at risk for cancer?” With that question she failed, her ignorance obvious.

  I wanted to slap her silly. She’d be lucky if her grandmother made it through the week as cachectic as she appeared. Hell, a CT scan of the head is only about the same amount of radiation as a trans-Atlantic flight.

  Ignoring her question, Jason turned to me and said, “Dr. Raj, can you kindly go to radiology and personally notify them we need an immediate scan for Ms. Maude here? Tell them she’s a VIP and they better make her comfortable and be quick. Also ask for the special ‘low radiation’ protocol.” His wink was almost imperceptible.

  Taking the hint, I rushed off to the radiology department where they looked at me like I was some confused medical student and told me to be on my way. Later I learned that I was just supposed to disappear, not actually do what he said.

  Returning to the ER five minutes later, I found Jason putting his medical knowledge and training to good use: surfing the web.

  “After you left I was able to kiss up to the family. They decided she was under good care and went home. They especially liked the VIP part,” he winked, obvious this time. “They are all successful attorneys at some law firm their grandfather started ages ago. They have no clue what’s going on with their grandmother. Fortunately the butler should be here soon and will fill us in on everything.”

  “What do we do in the mean time?”

  “What we do for all GOMERs … pan-scan her.”

  In patients who are poor historians the physical exam cannot be focused appropriately (these are the same patients who don’t know why there are in the ER in the first place) and is of limited or no benefit. So instead of wasting a long time on an exam which is likely to be useless, a CT scan from head to toe is performed to look for any abnormalities. The physical exam can take a solid 45 minutes while the CT scanning can be performed in less than 8 minutes with modern scanners. Sounds great in principle; the only problem is cost. A pan-scan from the ER starts at around $15K and quickly rises from there if special dyes/contrast agents are needed or if MRI scanning is required.

  We ordered the pan-scan and waited for Bernard.

  ~~~~

  Bernard was a class act, the epitome of classic hired help. He arrived in a British butler’s uniform, nicer than most tuxedos I’d seen. And more importantly, he had Ms. Maude’s entire medical file for the past 35 years that he’d been working for the family. He reminded me of Alfred, the butler from Batman.

  Thanking Bernard, we let him settle into Ms. Maude’s room while we started to go over the records. Apparently he and Josefine, Maude’s personal nurse, were going to take turns so that somebody was by her bedside at all times.

  “Dude, don’t you think he resembles Alfred?” asked Jason as soon as we were out of earshot. Guess I wasn’t the only one thinking about the caped crusader.

  “That’s what I was going to say! He’s just as organized too; look at these meticulous records.”

  We began to familiarize ourselves with Matilda Margaret Maude. The records were so well organized that their review was only a one man job, thus; Jason decided his time would be better spent speaking with Bernard to get his perspective on what was happening. More medical information was soon to arrive once Josefine brought her even more comprehensive medical records about Maude’s history. While both records were very complete, I later noticed that some minor details were missing from both accounts; while nothing crucial, when taken together they were incredibly comprehensive.

  It was quite amazing she made it to 96 years of age. She’d smoked since she was 17 until just a couple years ago, quitting only because her dementia had advanced to the point that she’d forget how to operate a lighter. She was on medications for dementia and high blood pressure. She’d survived breast cancer, typhoid, malaria, 2 MIs, and was on about four anti-depression and anti-anxiety drugs. She also had a history of heavy alcoholism.

  Matilda used to be quite the socialite, always surrounded by people, until about five years ago when she began to withdraw from just about everything. The decline the past couple years had been dramatic; leaving her essentially non-verbal, incontinent, and visited by her grandchildren about once a month, and that too, begrudgingly. Apparently the commute from next door is pretty difficult.

  “Why do you think Bernard and Josefine are so protective of her?” I asked Jason when he returned.

  “Apparently her husband was a standup guy. He was an excellent lawyer with a reputation of treating everybody with the utmost respect. The combination made him very prominent in the community. I’m sure the fact he was uber rich helped too. Anyhow, Josefine and Bernard loved him like a son, and in his will he requested they honor his memory by taking care of Matilda. So part of why they act the way they do might be out of deference to him. I wonder if the inheritance goes to the two of them or the money hungry grandkids?”

  “How was Matilda, before she went all comatose?”

  “Reading in between the lines, I think she was the quintessential trophy wife and bitch. She came from a background of privilege and never worked a day in her life, just looked pretty on her late husband’s arm. He was happy with that setup because she’d entertain herself, allowing him to wo
rk and build his empire. She was also adept at arranging the appropriate social gatherings for a family of their stature.”

  “I bet her family is just here to show their attorneys that they care. I’m guessing if there is any inheritance dispute in the future, their names appearing in the medical record as proof they were here when grandma was ill will only be to their benefit.”

  “Raj, there’s hope for you yet. Trust me, she’ll be a royal pain in our ass for as long as she’s here.” Again Jason’s pager went off, this time with a text page. “Well, the radiologist reports that all her scans are essentially normal. Just the expected osteoporosis and cerebral atrophy, all consistent with her age.”

  “Remind me again why she’s here?”

  “Her grandson called emergency when he was visiting her claiming she didn’t recognize him and kept moaning something he’d never heard before. But he’s a lawyer, so he used the altered mental status buzzword, and voilà, here she is.”

  After finishing up all her admission orders I ask, “How do we get her out of here?”

  “Good question. Smart to think about disposition/discharge early on. I figure we have two options: number one, we keep her here long enough until she gets a nasty nosocomial infection and ends up in the morgue; number two, through frivolous testing we arrive at some bullshit diagnosis, treat it, cure her, and get the family to agree to allow her back home all fixed up. If it’s the latter, I’m sure the hospital will hit her up for a huge donation and name some stupid hallway after her.”

  “Great.”

  “Yeah, tell me about it. On the plus side, Duane is next door, so at least we don’t have to walk far to check up on him.”

  We entered Duane’s room to find him sleeping peacefully. All was stable. His heart rate had increased by 10 BPM, but thinking nothing of it for now, we headed to the call room for some long awaited shut eye.

  ~~~~

  Sleep came quickly and the four hours it lasted was far from enough. Getting out of bed I made it to the locker room to brush my teeth and wash my face. The nice thing about being on call is you can go from being sound asleep to starting work in about three minutes; the bad part is you wear the same clothes as the day before and sleep on a communal mattress. Showering and breakfast are usually forsaken because the extra ten minutes of sleep are too valuable to squander on such activities.

  The first thing I did was check up on Duane. Still sleeping, I gently nudged his shoulder to wake him up.

  “Oh, hey Doc. Good morning.” He sat up in bed rubbing his eyes. “Wow, you weren’t kidding when you said you’d be by early. Is it even morning yet?”

  Pre-rounding, the process of seeing patients and gathering data before actually rounding with the attending physician frequently started well before 6 a.m., and even earlier on surgical services when one had to be in the OR by 7 a.m.

  Cutting to the chase, I ask, “How was your night? How are you feeling?”

  “I slept like a baby.” He straightened his back and stretched his muscles as if wondering himself how he was doing. Pleased with the results he nodded in approval. “I think I’m a lot better, the pain is about 80% less, and I’m not feeling sick like before. Do you think the infection is gone?”

  “Well, you’re on some very broad spectrum antibiotics, so they’ll likely kill most anything that could be causing your infection. We’ll tailor the therapy further when the culture results are back and we know exactly what we’re up against.”

  “Thanks Doc. My wife and girl are coming in later this morning. Do you think you can meet them? I want to introduce them to the Doc that saved my life.”

  I was flattered by his kindness. “We’re not out of the woods just yet, but I’d be happy to give them an update on your status. Hopefully the cultures will be back by then, and if we’re lucky we’ll know exactly what is causing all this.”

  I shook his hand and went next door to check in on Ms. Maude.

  She appeared frail as ever, nearly every bone visible beneath her tissue paper thin skin. Nobody had dared start an IV on her, thus, interventional radiology placed a subclavian line under fluoroscopy guidance sometime in the middle of the night. It was through that that she received her fluids and had blood drawn for testing. She was so decrepit in appearance I was surprised the IV afforded actual blood and not dust.

  I was about to wake Ms. Maude up when I noticed some movement in my peripheral vision. A petite figure hidden in shadows stood up and headed in my direction, picking up a file from the adjacent table on her way over. “Hi, are you the medical student looking after Matilda?”

  “Yes, you must be Josephine? Bernard mentioned the two of you would be taking turns being with Ms. Maude.”

  “The one and only. I brought a summary of Matilda’s medical history for your review. Her grandchildren aren’t exactly savvy to all that Matilda’s been through. And with her dementia, you can’t really trust what comes out of her mouth.”

  Josephine didn’t look within a decade of her sixty plus years of age. She was extremely well put together, fit, and organized. Even though she had spent the last 30 years being a nurse for only one family, she was more competent than just about any nurse on the floor here. That’s what private practice is like; you get what you pay for.

  I scanned through the records. They were similar to Bernard’s, but more complete.

  Ms. Maude had quite the medical history, over sixty years of heavy smoking, half of that was accompanied with alcoholism, depression, anxiety, bilateral hip and knee replacements, a spinal fusion, breast cancer complete with bilateral mastectomies and reconstructions, half a dozen cosmetic surgeries, malaria, and numerous bouts of pneumonia. A total of five vessels in her heart had been bypassed with three of those receiving secondary stents courtesy of her two MIs. Oh I forgot to mention the two strokes she’d survived and completely recovered from. By all accounts Ms. Maude should have been dead many times over two decades ago.

  “How does Ms. Maude look to you today?” I asked.

  “Well, she seems a bit weak. Usually she can sit up in a chair. She loves playing with her pets, not that she remembers their names. Watching television and petting her dog and cat are her main activities. Bernard and I take her through the gardens at least twice a day. She’s a big fan of the roses when they’re in bloom.”

  “Is she verbal at home?”

  “Oh no, she barely says anything as it is, and almost none of what she does utter makes any coherent sense. I’ve been feeding her for the past four years and changing her diapers for about three years now.” Nodding Josefine added, “Sadly, some consider her current status a significant improvement over how she used to be.” As soon as the words were uttered Josefine went rigid and turned around, clearly regretting having divulged too much information. “I apologize, that was rude of me. She was loved by her husband, and that’s what counts.”

  I figured I’d gotten all the information Josefine would provide me for the time being. I needed to build some rapport before I learned more about Ms. Maude.

  A quick physical exam, which consisted of me looking at the monitors to ensure they were rhythmically beeping, confirmed that she was indeed still alive. The days of performing an actual physical examination are long gone. Nowadays it’s all about interpreting numbers and letting the automated readings tell you what’s going on. And Maude had numbers on the screen, they weren’t zero, thus, my initial interpretation was confirmed; she was alive.

  I ran into Jason in the lounge. He asked, “Hey Raj, how are our peeps doing?”

  “Well, Maude is alive, and Duane says he’s feeling 80% better.”

  “Good.”

  “I met Maude’s live-in nurse, she seems quite competent, says Maude’s energy level is down from baseline but otherwise she’s demented and incontinent as ever.”

  “While you were checking up on them I made some phone calls and did a little bit of sleuthing myself. Got some interesting news for you; we’ve got diagnoses for them both.”

/>   “Sweet, what’s Duane’s bug?”

  “Well, I talked to his wife this morning. Seems like they have a healthy sexual life and she recently had an E. coli urinary tract infection that was sensitive to penicillin. A quick call to the lab confirmed that Duane likely has the same bug. It always comes back to sex or drugs.”

  “I bet his wife’s hot.”

  “I’m not willing to disagree with you on that point.”

  “So we just treat him for a couple more days on IV Zosyn and send him out on something oral?”

  “Yep. Ms. Maude is a little more interesting. Her last hospitalization was due to pneumonia from MRSA. She was in the ICU for almost three weeks followed by another couple weeks on the floor before being sent home only two weeks ago. But when I checked her labs this morning her troponin was elevated. She’s having a silent heart attack.”

  “Damn! I wouldn’t have guessed. How’d you think to get those labs?”

  “After we went to our call rooms I remember thinking that in her age group silent MI’s are common. I reviewed the CT scan in my head and all those stents she had bothered me. So I figured what the hell, and called the lab to add a troponin to the tests we already ordered. Best part is, on rounds, I want you to mention that you did it. You’ll look like a superstar.”

  “I can’t do that, it was all you.”

  “Dude, I don’t give a rusty fuck what people think of me here. This is only my internship, and then I’m off to Dermatology residency and the easy life. You still need your letters of recommendation, and this will help cinch you a good one from Miley.”

  “Thanks man, I owe you. Shouldn’t we get her seen by cardiology?”

  “Already on it, I called them like five minutes ago. They’re going to take her for a cardiac catheterization in about an hour. I heard in some European countries they don’t even allow people to get a cardiac cath after the age of 65 for unhealthy individuals and over 75 you’re out of luck no matter who you are. But here they’re more than happy to spend another 100k to add a few days to Maude’s life so she can go home and do whatever the fuck she does.”