Macys Or Mom

I walked towards Room 22 to see my next patient, an elderly woman who was found lying on the kitchen floor of her private home. She lived alone. Because of her advancing dementia, she was unable to provide any history as to how long she had been down or the circumstances that lead to her being on the floor. Unfortunately, due to the strong smell of stale urine and feces that permeated the hallway outside of her room, it was a safe assumption that she had been down for quite a while.

Not yet fully aware of how disheartening this patient's case would be, I opened the room's partially-closed glass door before sliding back the room's privacy curtain. I stepped into this patient's room as this patient stepped into my consciousness.

What I stepped into was sad. No, heartbreaking. The patient, rolled onto her left side by our staff and lying fully exposed on her treatment cot, was being tenderly wiped and cleaned by two of our ER nurses, one standing behind the patient while the other stood in front. Despite the slightly-dimmed room lights, I could appreciate the momentous task these nurses had of cleaning the hardened stool and human waste from this patient's neglected body.

I looked to unflappable Charlene, the nurse standing in front of the patient, who was shaking her head in frustration. "This is bad," she said, "really bad." She went on to explain that the patient was found by her two children, a son and daughter, on the floor of her kitchen, conscious but covered in human waste. Her own. The prehospital team believed she had been down at least several days. According to Charlene, the paramedics, our local experts on witnessing the best and worst of living conditions, said that this patient's home was among the worst conditions they had ever encountered. "There were multiple mounds of strewn garbage, numerous puddles of drying urine, and smeared feces everywhere you looked," Charlene said, repeating their words.

I shook my head. Although I hadn't yet learned the particulars to this patient's social situation, I had seen my share of elderly patients who were brought to our ER for treatment after they had been discovered incapacitated in their home, whether ill from a trip and fall or, worse, a catastrophic medical event like a stroke or heart attack. Unfortunately, they might sometimes lay there for several days, alone and possibly in pain, frightened of never being found.

The thought of a patient suffering in this manner always makes me shudder.

Descriptions of poor living conditions sometimes accompanied these patients, as well, but none to the degree that Charlene described. "Seriously, Dr. Jim, the prehospital team said that feces was even smeared on the kitchen counter." Maybe this patient simply struggled after going down, making a bigger mess of things.

I briefly observed this patient's body--her frailness, her thin, cachectic limbs, her slightly protruding belly, her transparent pale skin, her matted-down silvery hair, her deep facial wrinkles--before walking towards her head and squatting down to her face level, ready to introduce myself. "Maam," I said, caressing the right side of her face as I spoke, "I'm Dr. Jim and I will be taking care of you today." The patient stirred as I continued to stroke her face. And then, quite suddenly, she opened her eyes, searching eyes of hazel brown, that stared back into mine. After sizing me up, she gave me a big, confused, wondrous smile, the familiar smile of a good-natured dementia patient.

"Do you hurt anywhere, maam?" I asked, beginning my exam while the nurses continued to clean her. "No," she said feebly, shaking her head. I looked in her ears, her mouth, her nose. I listened to her heart, her lungs, her abdomen. I palpated every part of her body, rotating and flexing her joints to make sure she had no clinical evidence of fractures.

Outside of the obvious signs of dehydration and her frail body breaking down at her pressure points, I was happy not to find any obvious signs of injury or acute medical illness. Now, we could pursue a thorough heart and brain workup (including a head CT to rule-out a stroke) as well as several clearance x-rays and some additional urine and blood studies. More importantly, social services could be called to pursue further information on this patient's living conditions and social situation.

It was near the end of my physical exam on this patient, though, when I began to see the situation more clearly. As the nurses continued to clean the patient and I stood beside the patient auscultating her abdomen, the room's curtain flew back and a very meticulous, very well-dressed, very put-together woman hurried into the room. She was middle-aged.

"May I help you, maam?" I asked, pulling my stethoscope from my ears as both nurses looked toward the woman, taking her in as I'm sure I had done.

"Yes, I'm her daughter," the woman answered with severe enunciation, taking a corner chair while nodding towards the patient. I waited briefly for her next question, a question that never arrived--"How is my mother doing?"--while taking in her neatly highlighted hair, her pressed wool pants, her polished heels, her matching argyle blazer, the multiple bands of gold that hovered on her neck and wrists, her ring-covered fingers, her painted face. I looked back at the patient, now rolled to her other side, and back at this daughter again.

The dichotomy of the situation was startling.

I leaned against the wall, giving the situation a few minutes to play itself out. The nurses continued their diligent work, occasionally glancing at the daughter, while the daughter continued to sit comfortably in her corner chair. And watch. I didn't expect her to offer her help bathing her mother. And she didn't. I had hoped that she might offer to hold her mother's hand, though, or whisper some encouragement in her ear. But she didn't. No moments of tenderness or love ever came.

Finally, I went up to this daughter and introduced myself and the two nurses. "Can you please tell me what happened with your mother?" I asked, eager to hear what she could contribute to her mother's story.

"Well, we, my brother and I, hadn't heard from Mother for a couple nights, so we called her. When we got no answer, we went over to her house and found her on the kitchen floor."

"Any signs of trauma?" I asked. "No," she answered. "Any blood?" "No." "Was your mother awake when you arrived?" "Yes." "Did she complain initially of any pain or have any difficulty breathing?" "No."

After finishing my questions, none with answers that would change our treatment plan, I asked this daughter about the living conditions the paramedics had described.

"Oh, that," the daughter said, blase, "we think Mother may have tried to get back up several times and failed, creating such a big mess." I nodded my head, hoping this was the extent of it, hoping that there wouldn't be anything more to this story when social services investigated. But, by Charlene's account, the paramedics had said the whole house was in disarray, not just the kitchen. "My brother is over cleaning Mother's house now as we speak," the daughter added.

I continued. "And your mother has dementia but lives alone, I see?" She nodded 'yes.' "Why hadn't anyone seen her for at least a couple days? How often do you check on her? Who cooks and cleans for her?"

The daughter shifted in her chair. "Well, either my brother or I go over every day, but both of us were busy and thought the other had been over. We were wrong. We have a cleaning maid and meals delivered, too, but not on weekends."

Although most of the answers seemed adequate, something still made me uncomfortable about this case. Something I couldn't put my finger on. At this point, though, I saw this daughter's eyes glisten. "Maam," I said, acknowledging her first signs of compassion, "I'm sorry if these questions might upset you, but they must be asked. Your mother's health and care depend on your answers." She nodded her understanding.

After a few more minutes of talking with the daughter, I said goodbye to both her and her mother, but not before thanking the nurses for yet another awesome job of patient care. They are worth far more than what their paycheck reflects. I made a conscious decision to leave the rest of the social questions to our case management team and focus on the patient's medical care.

Unfortunately, the patient's kidneys had begun failing her, both from her moderate dehydration and from being clogged with muscle-wasting metabolites (rhabdomyolysis). She was admitted, obviously, for further medical care before ultimately being placed into a safe nursing home environment. She would never again be left alone at home.

I refuse to sit in judgment of this daughter. And the son I never met. But in my line of work, a healthy dose of suspicion is sometimes what the doctor must order. So I did. I have to trust that our system works.

I have several friends who recently lost their fathers. Just last week, my brother-in-law suddenly lost his mother. My world is filled with people who, regretfully, have lost one or both parents. Who have lost their spiritual guiders. Who would give anything to have just a few more minutes with their deceased parent. Who would do things a bit differently than this patient's family, I'm sure.

I know I would.

As always, big thanks for reading. This post is dedicated to those who give of themselves to benefit an elderly person in their lives. May your kindness and compassion be returned tenfold...see you again in a few days.

Macys Or Mom

I walked towards Room 22 to see my next patient, an elderly woman who was found lying on the kitchen floor of her private home. She lived alone. Because of her advancing dementia, she was unable to provide any history as to how long she had been down or the circumstances that lead to her being on the floor. Unfortunately, due to the strong smell of stale urine and feces that permeated the hallway outside of her room, it was a safe assumption that she had been down for quite a while.

Not yet fully aware of how disheartening this patient's case would be, I opened the room's partially-closed glass door before sliding back the room's privacy curtain. I stepped into this patient's room as this patient stepped into my consciousness.

What I stepped into was sad. No, heartbreaking. The patient, rolled onto her left side by our staff and lying fully exposed on her treatment cot, was being tenderly wiped and cleaned by two of our ER nurses, one standing behind the patient while the other stood in front. Despite the slightly-dimmed room lights, I could appreciate the momentous task these nurses had of cleaning the hardened stool and human waste from this patient's neglected body.

I looked to unflappable Charlene, the nurse standing in front of the patient, who was shaking her head in frustration. "This is bad," she said, "really bad." She went on to explain that the patient was found by her two children, a son and daughter, on the floor of her kitchen, conscious but covered in human waste. Her own. The prehospital team believed she had been down at least several days. According to Charlene, the paramedics, our local experts on witnessing the best and worst of living conditions, said that this patient's home was among the worst conditions they had ever encountered. "There were multiple mounds of strewn garbage, numerous puddles of drying urine, and smeared feces everywhere you looked," Charlene said, repeating their words.

I shook my head. Although I hadn't yet learned the particulars to this patient's social situation, I had seen my share of elderly patients who were brought to our ER for treatment after they had been discovered incapacitated in their home, whether ill from a trip and fall or, worse, a catastrophic medical event like a stroke or heart attack. Unfortunately, they might sometimes lay there for several days, alone and possibly in pain, frightened of never being found.

The thought of a patient suffering in this manner always makes me shudder.

Descriptions of poor living conditions sometimes accompanied these patients, as well, but none to the degree that Charlene described. "Seriously, Dr. Jim, the prehospital team said that feces was even smeared on the kitchen counter." Maybe this patient simply struggled after going down, making a bigger mess of things.

I briefly observed this patient's body--her frailness, her thin, cachectic limbs, her slightly protruding belly, her transparent pale skin, her matted-down silvery hair, her deep facial wrinkles--before walking towards her head and squatting down to her face level, ready to introduce myself. "Maam," I said, caressing the right side of her face as I spoke, "I'm Dr. Jim and I will be taking care of you today." The patient stirred as I continued to stroke her face. And then, quite suddenly, she opened her eyes, searching eyes of hazel brown, that stared back into mine. After sizing me up, she gave me a big, confused, wondrous smile, the familiar smile of a good-natured dementia patient.

"Do you hurt anywhere, maam?" I asked, beginning my exam while the nurses continued to clean her. "No," she said feebly, shaking her head. I looked in her ears, her mouth, her nose. I listened to her heart, her lungs, her abdomen. I palpated every part of her body, rotating and flexing her joints to make sure she had no clinical evidence of fractures.

Outside of the obvious signs of dehydration and her frail body breaking down at her pressure points, I was happy not to find any obvious signs of injury or acute medical illness. Now, we could pursue a thorough heart and brain workup (including a head CT to rule-out a stroke) as well as several clearance x-rays and some additional urine and blood studies. More importantly, social services could be called to pursue further information on this patient's living conditions and social situation.

It was near the end of my physical exam on this patient, though, when I began to see the situation more clearly. As the nurses continued to clean the patient and I stood beside the patient auscultating her abdomen, the room's curtain flew back and a very meticulous, very well-dressed, very put-together woman hurried into the room. She was middle-aged.

"May I help you, maam?" I asked, pulling my stethoscope from my ears as both nurses looked toward the woman, taking her in as I'm sure I had done.

"Yes, I'm her daughter," the woman answered with severe enunciation, taking a corner chair while nodding towards the patient. I waited briefly for her next question, a question that never arrived--"How is my mother doing?"--while taking in her neatly highlighted hair, her pressed wool pants, her polished heels, her matching argyle blazer, the multiple bands of gold that hovered on her neck and wrists, her ring-covered fingers, her painted face. I looked back at the patient, now rolled to her other side, and back at this daughter again.

The dichotomy of the situation was startling.

I leaned against the wall, giving the situation a few minutes to play itself out. The nurses continued their diligent work, occasionally glancing at the daughter, while the daughter continued to sit comfortably in her corner chair. And watch. I didn't expect her to offer her help bathing her mother. And she didn't. I had hoped that she might offer to hold her mother's hand, though, or whisper some encouragement in her ear. But she didn't. No moments of tenderness or love ever came.

Finally, I went up to this daughter and introduced myself and the two nurses. "Can you please tell me what happened with your mother?" I asked, eager to hear what she could contribute to her mother's story.

"Well, we, my brother and I, hadn't heard from Mother for a couple nights, so we called her. When we got no answer, we went over to her house and found her on the kitchen floor."

"Any signs of trauma?" I asked. "No," she answered. "Any blood?" "No." "Was your mother awake when you arrived?" "Yes." "Did she complain initially of any pain or have any difficulty breathing?" "No."

After finishing my questions, none with answers that would change our treatment plan, I asked this daughter about the living conditions the paramedics had described.

"Oh, that," the daughter said, blase, "we think Mother may have tried to get back up several times and failed, creating such a big mess." I nodded my head, hoping this was the extent of it, hoping that there wouldn't be anything more to this story when social services investigated. But, by Charlene's account, the paramedics had said the whole house was in disarray, not just the kitchen. "My brother is over cleaning Mother's house now as we speak," the daughter added.

I continued. "And your mother has dementia but lives alone, I see?" She nodded 'yes.' "Why hadn't anyone seen her for at least a couple days? How often do you check on her? Who cooks and cleans for her?"

The daughter shifted in her chair. "Well, either my brother or I go over every day, but both of us were busy and thought the other had been over. We were wrong. We have a cleaning maid and meals delivered, too, but not on weekends."

Although most of the answers seemed adequate, something still made me uncomfortable about this case. Something I couldn't put my finger on. At this point, though, I saw this daughter's eyes glisten. "Maam," I said, acknowledging her first signs of compassion, "I'm sorry if these questions might upset you, but they must be asked. Your mother's health and care depend on your answers." She nodded her understanding.

After a few more minutes of talking with the daughter, I said goodbye to both her and her mother, but not before thanking the nurses for yet another awesome job of patient care. They are worth far more than what their paycheck reflects. I made a conscious decision to leave the rest of the social questions to our case management team and focus on the patient's medical care.

Unfortunately, the patient's kidneys had begun failing her, both from her moderate dehydration and from being clogged with muscle-wasting metabolites (rhabdomyolysis). She was admitted, obviously, for further medical care before ultimately being placed into a safe nursing home environment. She would never again be left alone at home.

I refuse to sit in judgment of this daughter. And the son I never met. But in my line of work, a healthy dose of suspicion is sometimes what the doctor must order. So I did. I have to trust that our system works.

I have several friends who recently lost their fathers. Just last week, my brother-in-law suddenly lost his mother. My world is filled with people who, regretfully, have lost one or both parents. Who have lost their spiritual guiders. Who would give anything to have just a few more minutes with their deceased parent. Who would do things a bit differently than this patient's family, I'm sure.

I know I would.

As always, big thanks for reading. This post is dedicated to those who give of themselves to benefit an elderly person in their lives. May your kindness and compassion be returned tenfold...see you again in a few days.

Intern Report Case Discussion 3.2

Case Presentation by Dr. Jeanise Butterfield



Discussion:
This patient is in adrenal crisis which is likely precipitated by abrupt steroid withdrawal following a long hospitalization for acute COPD exacerbation and pneumonia.  Recognition of adrenal crisis and prompt administration of hydrocortisone is critical to patient survival.  Adrenal crisis may result from an acute exacerbation of chronic adrenal insufficiency, adrenal hemorrhage, or abrupt withdrawal of steroids in patients with adrenal atrophy.  It usually occurs in response to major stressors such as sepsis, myocardial infarction, surgery, major injury or trauma. 

The predominant clinical manifestation of adrenal crisis is shock.  Symptoms include weakness, abdominal pain, anorexia, confusion, and fever.  Patients may be hypotensive and hypoglycemic but other physical findings in patients with adrenal insufficiency may be subtle and nonspecific.  Laboratory evaluation may reveal hyponatremia, hyperkalemia, and hypercalcemia. 

Glucocorticoids are essential to the management of adrenal crisis and should be administered immediately upon clinical suspicion.  The preferred glucocorticoid is hydrocortisone 100 mg IV.  Dexamethasone 6-8 mg IV can also be used and has the advantage of not interfering with ACTH stimulation test

As always, treatment begins with maintenance of airway, breathing and circulation.  Should a patient require intubation, etomidate should be avoided as an agent for RSI because it is a steroid synthesis inhibitor and may worsen hemodynamics in shock patients.   Aggressive fluid replacement may be required as well as correction of electrolyte abnormalities including hypoglycemia, hyponatremia, hyperkalemia and hypercalcemia.  Fluid replacement should be initiated with 0.9% normal saline, but may be changed to D5NS.  D50 may be required depending on the extent of hypoglycemia. 

It is important to uncover and treat the underlying problem that precipitated the crisis.  

Answers

1. D.  In the setting of adrenal crisis, glucocorticoids, preferably hydrocortisone 100 mg IV, should be administered immediately.  Do not await results of ACTH stimulation testing. CT scan and surgical consult may be indicated after steroid replacement to help diagnose or treat the precipating cause. 

2. C.  Patients in adrenal crisis may present with several electrolyte abnormalities including hyponatremia, hyperkalemia and hypercalcemia.  An early EKG manifestation of hyperkalemia is peaked t waves.  U waves are present in hypokalemia.  

3. E.  Ketoconazole and etomidate impair adrenal hormone synthesis.  Phenytoin and rifampin increase steroid metabolism. 


Pearls:
Think of adrenal crisis in the setting of hypotension refractory to volume resuscitation and catecholamines.

Patients with history of primary adrenal insufficiency (eg Addison’s Disease) will require increased doses of steroids in the event of increased stress or illness. 

The most common iatrogenic cause of adrenal crisis is rapid withdrawal of steroids in the patients with adrenal atrophy secondary to long term steroid administration.

If you suspect adrenal crisis, immediately administer glucocorticoids.  Do not wait for ACTH stimulation test or serum cortisol.