The Doctor Will See You Now [Non-Fiction]

Chapter 75: Acute Medicine

In the middle of teaching, my pager goes off.

"We just admitted a man from A+E resus room," says the nurse on the phone. "Sixty-five-year old male, found unconscious at home... he's looking quite flat. Blood pressure is 85/40, heart rate 120, saturation 96% on 100% oxygen."

I excuse myself from my lesson. It happens quite often because we're tied to our pagers and they have to be answered. Meetings and lessons are often interrupted or cut short or start late because of work obligations, at our loss. But this guy can't wait. Even pneumonias and UTIs can usually wait up to an hour, but this guy is haemodynamically (that is, his heart rate and blood pressure) unstable.

I clerk him in. Sixty-five-year-old man with a past history of glioblastoma multiforme (GBM), one of the most aggressive cancers in adults, and a type of brain cancer. He was diagnosed about nine months ago. The usual survival for GBM is less than a year.

The man lying in bed before me is barely rousable, his eyes closed despite painful stimuli, his chest heaving away. His drowsiness makes his airway unstable. He's severely unwell, likely due to an infection on top of his already compromised health due to the aggressive cancer. I told his family that he's very sick. We'll treat him as best as we can with antibiotics, fluids, and oxygen, but they have to mentally prepare for him not able to survive this admission. If his heart were to stop because of the severe illness, we won't be able to resuscitate him. I'm gearing them towards consideration of a Do Not Attempt CPR order -- because if he is going to die from this infection (which he will if he does arrest, regardless of whether we CPR or not when the time comes), it will be more humane to let him die without us crushing his chest and shoving a tube down his throat to make him breathe.

They ask me about future chemo potential. His chemo was recently postponed because he just got discharged from a neighbouring hospital for a similar drowsy episode due to an infection and they're awaiting an MRI brain in two weeks' time.

I blink. They don't get it. He's super sick. Likely nearing the end of his life. And they're asking about potential chemotherapy.

Naturally, they wish for everything. They haven't yet grasped how sick he is yet.

I end up talking to the family on three separate occasions on the same day because other family members want an update. I can empathise with them for being anxious about a super sick family member, but at the same time it's frustrating for me because I have fifteen or so other patients and half a day's worth of outpatient appointments to see and they have taken up a significant amount of my time with no progress. They still don't get he's very sick. They also don't seem to be able to relay to each other about what has been discussed. Another son comes up and want the same discussion as I already had with son #1. Then again with another family member. There's a village of people here.

I ask ICU to intubate the patient. It isn't in the patient's best benefit because he will die the way things are going any way. Intubation will prolong this unwell period when he's barely breathing and barely conscious. But it was the family's insistence and, once again, I find myself treating the family, not the patient.

As I mentioned in a previous chapter, although this isn't medically nor ethically the right thing to do, the dead won't be filing complaints or lawsuits against us for making their deaths traumatic. The living will if they perceive us as not having done as much as we could.

The next day I come in to see my patient on inotropes (heart-strengthening medication that is meant to temporarily boost blood pressure and heart rate in a patient with unstable haemodynamics). Even with almost-full dose of Dopamine, his systolic blood pressure barely reaches 90, whilst his heart is hammering away at 120. It'll be difficult to increase his inotropes any more without putting severe stress on his heart and raising the heart rate and we can't have central lines and noradrenaline on a general ward.

The on-call doctor last night spoke to the family about his deteriorating condition. They still insisted on full interventions.

I speak to the family again, giving them an update on recent events. His heart is now failing to meet the requirements of the rest of his body. He's in heart failure. He's requiring almost-full dose of heart-strengthening medications and still his blood pressure is not enough. I don't push them again about the DNACPR order; it felt too repetitive and they're already aware. They just haven't come to terms yet. I hope they do come to terms before this man dies and we have to CPR a cancer-ridden frail man.

On the third day, I come in to see a DNACPR order in place. The family had discussed amongst themselves and reached a consensus last night for DNACPR. The doctor on duty last night signed the form. Twenty hours later, the man died with his family by his side.

When I typed up his death summary, I found he was a fit and healthy man until just under a year ago. No medications, no regular medical follow-ups, no long-term illnesses. A father of three adult-aged children working full time. He had a seizure at the office and on admission, a CT brain showed a 4cm tumour in his brain. That was the start of it all, then endless chemo, radiotherapy, admissions, biopsies... and all that ended yesterday.