When Dr. Kate Simon strolled into the Emergency Department, three security guards were struggling to wrestle a roaring behemoth into leather restraints. They were outnumbered because his four extremities were like sprawling red oak branches and his massive hit of methamphetamine energized him beyond belief. He grunted and growled like an angry grizzly as they grappled him into the bed. Finally two hefty aides jumped into the fray to even the odds. Kate had seen some wild incidents in her first two weeks at Mercy Medical Center, but this fight was spectacular. A whopping man with a potent stimulant brewed a dangerous concoction.
Thanks to reinforcements, the guards restrained the crazed man on his back, one limb at a time. They battled to surround each wrist and ankle with padded leather straps, which they belted to the bed. One of the aides took a right hook to his face and ended up a patient himself with a broken nose. Once they finally laid him spread-eagle, a nurse rushed in, plunged a needle into his shoulder, and injected a sedative. He continued to glare and swear at his adversaries and tug at the belts. His drug-induced panic obscured all sensation of pain. After about 10 minutes, his neck finally relaxed, and his head fell back on the pillow. He was quiet at last.
The emergency room physician, Dr. Tom Garbella, glanced over his spectacles and said, “You’ll be glad to know that gentleman won’t be your patient, Dr. Simon. Yours is in Room 55. He’s an elderly nursing home patient with a fever. Looks like he has a urinary-tract infection. You’d better get to work. They told me his blood pressure was dropping.”
Kate felt relief knowing that another poor intern would get the brawler, but the other patient sounded pretty sick. She hurried down the hall, grabbed his chart, and scanned it to evaluate the lab results. She found the patient, Mr. Randal Jamis, had a high white blood-cell count and bacteria in his urine. Both were indicators of a urinary tract infection that most likely had spread to his blood stream. Next she surveyed his vital signs: heart rate, respirations, temperature, and blood pressure. Over the past two hours, his blood pressure had declined from 148/72 to 94/55, and his heart rate had gone from 92 to 133. He had a fever with a temperature of 101.8. All these signs were bad. Kate’s pulse increased, too.
Without delay, Kate scurried in to see Mr. Jamis. One look and she knew he was sick. He was pale and sweating profusely. His respirations were rapid and shallow. Kate swallowed hard, grabbed her cell phone, and rang her senior resident, Dr. Jerome Jordan—J.J.
Her voice was calm and efficient, “Hey J.J., we’ve got a sick one. Could you come down and give me a hand?”
“What’s up?” J.J. must have been catching a few winks. His voice was hoarse.
“We’ve got a 77-year-old gentleman who looks septic and he might be slipping into shock. His blood pressure’s down to around 90, and his heart rate’s up to 135.”
J.J. perked up after hearing those numbers and asked, “Are you giving him fluids?”
“Fluids are running at about 150cc an hour.”
“C’mon. That’s like pissing in the ocean. He needs fluid, Simon. Start a 1000cc bolus of normal saline and run it wide open. I’ll be right down.” He paused, but before he closed his phone he commanded, “If he hasn’t gotten antibiotics, get them ordered stat.”
Kate understood the gravity of Mr. Jamis’ situation. Overwhelming infections can cause extreme drops in blood pressure, creating septic shock. Blood pressure drops as blood vessels relax and dilate. The heart rate increases to compensate. Mr. Jamis was headed toward septic shock.
She also knew prompt intervention could save his life. Intravenous fluids expand the blood volume and increase blood pressure. Antibiotics fight off the organisms that cause infections. Since Mr. Jamis was a nursing home resident, powerful antibiotics were needed to fight off potentially resistant bacteria that flourish in health care settings. Kate called the hospital pharmacy and had the drugs sent up immediately.
After giving the order for the fluid infusion, Kate returned to the chart for a thorough review. Mr. Jamis was delirious and couldn’t speak, so she had to rely on the chart.
J.J. arrived before the 1000cc of saline was in and marched straight to the bedside. He reviewed the vital signs, surveyed the situation, and asked Kate, “Any other data?”
“He’s been a nursing home resident for the last four months since having a stroke. He can’t walk but still eats; he conversed until he became ill. Today they noticed a decline in his alertness and called the squad.”
“Any other medical history?”
“He has hypertension, prostate cancer, arthritis, besides the stroke I told you about.”
“Okay, Simon. While I look this fellow over, you call the nursing home and see if you can get any more information.”
Kate left the room, and J.J. examined Mr. Jamis from head to toe. He listened carefully to his back and chest and probed meticulously over his abdomen. Mr. Jamis grimaced as J.J. pressed on his lower abdomen. After completing his exam, he left to join Kate at the desk. J.J. studied the lab values and pulled Mr. Jamis’ X-rays up on the computer.
When Kate finished on the phone, he asked, “Any more info?”
“The nurse said he’s been having fevers off and on over the past four weeks. They’ve treated him for recurrent urinary tract infections. She said he develops fevers after he’s been off the antibiotics for a few days. Other than that, the rest of the story’s the same.”
“It still sounds like a urinary tract infection with an organism that’s resistant to the drugs they’ve prescribed.” J.J. paused and added, “Let’s be sure we get blood cultures before we start the antibiotics.”
Kate nodded and with a hint of a smile said, “I got the cultures already.”
“Good work,” J.J. said. “Now examine him thoroughly and we’ll discuss the case.” He looked at the monitor and said, “His blood pressure is improving with the fluid bolus. We’re headed in the right direction.”
As Kate walked back into Mr. Jamis’ room, she was thinking about those fevers, and she began looking for other causes of intermittent fevers. She combed carefully through the exam and stared at his hands and nails. She saw thin, dark discolorations like splinters beneath two nails on his right hand. Her pulse quickened and her eyes widened. She’d read about these and remembered pictures in a textbook, but she’d never seen a splinter hemorrhage before. Immediately she went to the heart exam. She listened carefully and could hear a blowing sound along the right side of the sternum. She could hear the sound radiate into the arteries in his neck.
When Kate walked out, J.J. had his feet propped up on the desk as he talked to another intern. He listened carefully and asked several questions as he guided another green doctor through a treatment decision. Kate started scribbling her note. After J.J. finished, he asked, “What do you think?”
“What’d you think of his murmur?” Kate asked.
J.J. shrugged. “I heard it. It wasn’t very loud. It’s probably just an old, stiff aortic valve.”
“I guess it could be, but did you notice those splinter hemorrhages?” Kate said with measured excitement.
J.J.’s feet dropped like a stone. He jumped up and asked, “Splinter hemorrhages?”
“I think I found two on his right hand.”
J.J. rushed into Room 55 and grabbed Mr. Jamis’ hand. He stared at the nails, then grabbed the other hand. Without dropping the hand, he spun toward Kate. He had a big grin and his eyes twinkled. He practically shouted, “Dr. Simon, this is a great pick up. I missed these. You’re not supposed to show up your senior resident—especially in your first month as an intern.”
J.J. turned back toward Mr. Jamis and looked at the palms. Then he pulled down the lower eyelids and scrutinized every square millimeter. He whipped around, and with excitement growing in his voice, he said, “Look here: more evidence! See those little red spots on the lid? Those are hemorrhages, too, and most likely related to endocarditis. Wow, I haven’t seen one of these cases in a long time!” Kate looked with interest, but she already knew about the conjunctival hemorrhages. That was her next question for J.J.
They finished their evaluation and contacted their attending physician. She had just finished medical school and J.J. was in his third year of post-medical school training. Both were learning Family Medicine. Although J.J. was a fully licensed physician, he still was training, so he called his attending physician, Dr. John Dawson, to review the case. Dr. Dawson agreed with their assessment and plans and would see the patient in a few hours on morning rounds. Mr. Jamis continued to improve with IV fluids and antibiotics—disaster averted, thanks to Kate’s sharp eye.
2
Kate didn’t get a wink of sleep that night. She met three other new patients after midnight. In her spare moments, she combed over medical literature to learn as much as she could about her patients’ conditions.
The team of Kate, J.J., two other residents, and a medical student met their attending physician, Dr. Dawson, in the intensive care unit (ICU). Dr. Dawson was a Professor of Internal Medicine at the local university. His research in infectious diseases led to prominence, but his real love was teaching young doctors and caring for patients. He conducted rounds at his patients’ bedsides, so his charges could witness his interactions with them and their families. Besides the science of medicine, he trained them in its art: something caught not taught.
Mr. Jamis was the first patient on their list, and Kate presented his case. She discussed his history, as well as findings on physical exam and test results. She put the case together artfully and concluded with a cohesive plan of attack.
Before Dr. Dawson could ask a question, J.J. interrupted. He looked at the other residents and the student, and with a sheepish grin said, “Dr. Simon scooped me on this one, guys. I missed the signs of endocarditis.”
Kate smiled and looked down at Mr. Jamis. Dr. Dawson took up the questions next. His questions for Kate spanned the spectrum regarding endocarditis. Kate’s sleepless night of reading and hard work paid off: she was about to cross the finish line with flying colors when the final question came.
“What’s Mr. Jamis’ Code status, Dr. Simon?”
Kate’s mouth went dry. In her excitement over the endocarditis, she forgot to contact the nursing home or family to find out about Mr. Jamis’ Code status. He was not alert enough to discuss the matter.
Their previous Code status discussions flashed through her mind. Their first day, Dr. Dawson discussed Code status. He reminded them that unless designated otherwise, all patients receive full resuscitative efforts if their heart stops. When a patient needs resuscitation, “Code Blue” is announced over the hospital public address system. The Code includes CPR and other potentially life-saving interventions. Some patients decide in advance that they do not want heroic measures. It is the doctor’s responsibility to obtain that information, so people are not resuscitated against their will. In other cases, people need to understand the facts about resuscitation, so they can make informed decisions about Code status. For those who decline resuscitation, physicians write a clear order: Do Not Resuscitate or DNR. Code status represents the patient’s wishes regarding end-of-life care.
“I’m sorry, Dr. Dawson. I didn’t address his Code status.” Kate bit her lip and looked down. Being a perfectionist is risky business. Before Dr. Dawson resumed, Kate stole a glance at J.J., who would not look her way.
Like a great coach correcting his star quarterback, Dr. Dawson said, “Code status is an issue that you can’t forget or neglect!” He continued, “Most people don’t talk about Code status until it’s too late, and then they suffer needlessly. If Mr. Jamis would have arrested, then you would have tried to resuscitate him. We need to know his wishes.
“I’ve had a few cases where people with a DNR Code status were resuscitated because of poor communication. That’s a disaster.”
Kate asked, “What chance would Mr. Jamis have of surviving a resuscitation attempt?”
“Good question. There are many issues to consider in estimating a person’s chance of surviving resuscitation and eventually being released from the hospital or survival to discharge.”
Dr. Dawson continued, “Mr. Jamis has several factors that lower his chances of surviving resuscitation including his age, the infection, and other medical problems, and he’s in the intensive care unit. Research shows survival to discharge from zero percent to around 10 percent at best in this type of situation. I’d estimate his chances of survival to discharge to be around five percent or less.”
Kate blurted, “Are you kidding? I thought people did better than that.”
“It’s a misconception that most people have, including doctors. Only about a third of doctors know accurate survival rates after resuscitation.”
J.J. asked, “Do you think patients understand how grim their chances are of surviving resuscitation?”
“Clearly not. Researchers found that most people over age 70 believe their chances of surviving resuscitation are about 50 percent, not five.
“They found that patients get most of their information about medical issues from TV where resuscitations are successful about 67 percent of the time. People in the real world are making these crucial decisions with an overwhelming level of misinformation.”
Dr. Dawson’s expression hardened, and his tone toughened. “Very few people know the truth about this one simple issue. Every day, people suffer needlessly due to failed resuscitation attempts. I don’t want that to happen on our service.”
They finished rounds, and Kate left Mercy at noon, completing her 30-hour shift. Dr. Dawson returned to the ICU later that day and met with Mr. Jamis’ son, Donald.
After introducing himself, Dr. Dawson said, “I want to update you on your father’s condition and discuss our plans.”
Donald nodded and Dr. Dawson proceeded. “Your father most likely has bacterial endocarditis. It’s an infection on one of his heart valves. Our cardiologist did an echocardiogram this morning that shows a small growth on one of his heart valves. Blood culture results are not back yet, but we expect those tests will confirm the diagnosis. Right now he’s stable.”
Dr. Dawson paused and waited for a response. Donald asked, “What caused this?”
“Your father’s aortic valve, which comes out of the main pumping chamber, has calcium in it, which is common in elderly people. He’s had frequent infections over the past several months, and his abnormal valve became infected.”
“How will you treat it?”
“It depends on what organism we culture, but in any case he will need several weeks of antibiotics through the IV line.”
“Will he have to stay in the hospital for that?”
“No. We can insert a special IV line that can stay in place throughout the course.” Dr. Dawson hesitated and asked, “Would your father want to undergo this type of treatment?”
“I think he would. He’s still able to get around in a wheelchair and enjoy conversations with his friends. He’s not ready to quit.”
“We’re treating the infection and will proceed. Now, sir, have you discussed end-of-life decisions with your father’s physician?”
“Yes, Doctor. Dad doesn’t want any heroic measures if he dies. He’s been real clear on that.” He stopped and asked, “Didn’t that information make its way to you?”
“No sir, it didn’t. I’m sorry about that.”
“How can that get missed?” he asked with more than a hint of irritation.
“It requires communication between the nursing home and the hospital. Apparently they didn’t send the document. Our doctors on-call failed to get the information. They clearly fumbled the ball, and I apologize.”
“How can we prevent this in the future?”
“I’ll complete a form that you can sign, since you are his legal power of attorney for health care. Keep a copy with you and on his chart at the nursing home. We will keep it on record here. His status will be Do Not Resuscitate, but we will continue to provide medical interventions like the IV fluids and antibiotics. Of course, we’ll keep him comfortable.”
“That’s fine, but your system is pitiful. I can see how this could get screwed up all the time.” His irritation was growing.
“Our system is a bad one for sure, but it’s the best we have right now. We need a national database that lists people’s end-of-life decisions. Then hospitals and emergency medical workers could treat them according to their decisions. It’s a horrible mistake to resuscitate someone who asked to be left alone.”
“That’s worse than horrible. Don’t let that happen to my dad.”
Dr. Dawson sighed and said, “We’ll do our best, sir. Do you have any other questions?”
“No, sir.”
Dr. Dawson shook his head as he left the room, considering the distinct possibility that Mr. Jamis could have been coded that morning. He turned to the nurse who had followed him from the room and said, “He’s right. Our system is pitiful. Things need to change.”
