Morphine and Hand-Holding… When the word “fix” changes meaning.

Sometimes, we, as humans, are helpless.  Subject to the needs of our biological bodies and in a position where we are doing well simply to breathe.

Babies, despite being tough little cookies are helpless.

And sometimes, when we are critically ill or dying, the same phenomenon can take place.

Life comes and life goes.  That is how we were made.  Our Earthly bodies are finite.

We celebrate birth, but fear death.

Birth and death are not two different states, but they are different aspects of the same state. There is as little reason to deplore the one as there is to be pleased over the other. –Mahatma Gandhi

I have been covering call for the internal medicine floors.

I love internal medicine.  You can help a ton of really sick people with complicated disease get better.  The thing is, lots of sick, complicated people don’t get better.  At least not in the sense that most doctors or other people, for that matter, want to see.

I got called a couple times overnight to see someone.  A new admission.  Who had recently been admitted, but got better and went home.  And was now sick again.  Sicker.  This person had decided after past experiences to refuse intubation or other breathing assistance aside from oxygen.  So, we were treating the underlying disease and hoping for the best.  Otherwise this person would be in ICU on a ventilator.

I went to see this person, curled up and looking tiny in the big hospital bed.  Just breathing.  Breathing with every muscle in their body despite the high percentage of oxygen mask on their face.

I politely ask how the person is doing.  I knew the answer.  It was written all over their tired face.  They couldn’t breathe.  And as the med student behind me said later, we really weren’t doing much about it.  Some oxygen, some steroids, puffers and antibiotics and crossing our fingers.

I don’t know if you have ever not been able to breathe.

I have.

It is a terrible feeling.

So, I can only imagine how terrifying it would be knowing that you may very likely die from this distress.

We listened to her lungs.  Held her hand.  Asked if there was anyone we could call.  The answer was no.

I went back and looked at the orders.

Nothing for anxiety.  Nothing for pain or to ease the struggle with the breathing.  The plan was ICU until very recently.  And other issues until the situation became more grave made the use of anxiolytics and narcotics not the best idea.  But now, as the nurses said, they basically sent her to the floor to die or get better, whichever came first.

On-call residents are not supposed to change the management too much.

But really, sending me a possibly dying patient without palliative orders is unfair.

Not using invasive measures to sustain life does not equate giving up.  It just means that we don’t violate the pulp out of a person for what may be a non-existent benefit.  However, people who do not have CPR or ventilation often still receive other treatments to help their underlying problem by treating infections, diseases or symptoms.

Sometimes we withdraw everything except for comfort measures. But this decision comes with even further discussion with the patient and family and looking at other things in the picture like the stage of the disease and the goals.

At this point, this person was having their disease treated.  They still had a small but reasonable probability of recovery with treatment of the underlying problem, although their chances of coming off of a ventilator were slim.  We were also managing some symptoms, but they were still having significant difficulty.

I wrote an order for Ativan and for Morphine.   I had a good chat with the student about providing comfort care regardless of the prognosis, but especially when people are end-stage.  I showed her how the blood gases showed the patient was tiring out and medically needs intubation.

I looked in on the patient before heading to bed.  Still curled up and puffing away, but asleep.  I whispered a prayer and went to bed.

I was called to that floor a few more times over night.  Never for that person.  But, a few others with more “fixable” problems.  Things that feel miserable like shortness of breath and nausea, but that are often managed easily with some reassurance that the medications we ordered with soon kick in and they will likely feel better.

There is something satisfying about the easy fix problems.  Knowing that they likely will get better.  Knowing the next step if they don’t.  Or that someone else probably does.

Plus, easy fix problems are ones that can be resolved quickly or at least easily and thus we all get more sleep.

Even in people who are at a point where their problem cannot fix, there are easy fixes.  Sometimes, a simple change can resolve the unpleasant symptom, like the feelings of smothering.  Or holding IV fluid overnight in someone who is beginning to go into heart failure because their kidneys have now stopped working.

There is also something satisfying about seeing someone sleep after a night of feeling like they were dying, even if you likely didn’t change anything big.  At least you gave them some peace while you wait to see if the other solutions will work.

But, there are things that aren’t easy fixes.

There are the obvious difficult situations like complex critical illness, people who are so sick you can’t leave their side, those that need monitoring and multiple medications.

Even once people are beyond those things, there are still tough fixes.  Like fear.  Or loneliness.  Or the knowledge that death is imminent and you are scared.

Sometimes staying awake after a simple call and holding someone’s hand while they breathe and sleep is more satisfying than reviewing the second chest pain (that almost always is nothing) of the night.

The patient was still alive when I went home.  Still looking terrible, but less anxious and ever so slightly better on paper.

Things are complicated.  People surprise you.  People you expect to die live and vice versa.

We are all human.  We all deserve good care.  Even if it is the end of life.  We put tons of money and time into babies (and we should).  But, why not our elderly too?

I love internal medicine.

We get to fix people.  Even if it isn’t always in the way we conventionally use the word “fix.”

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