Monday, January 20, 2014

Pulm/CC

This month I'm on the pulmonary service. The patients on this service are mostly consisting of people who were recently in the MICU, so we do have quite a few sick patients that are making their transition from MICU to hospital to LTAC/SNF/ECF/Home. Most of the patients have several chronic illnesses which are near the end-stage. I've sent several patients from the hospital to hospice, and I've sent several from the hospital to LTAC, and a few to home after hospital. One thing I'm learning from this service is the importance of good social workers (I don't know how they do it, honestly...finding a place and dealing with insurance and contacting a million people for a seemingly simple task...). I've also had a fair amount of frustration from the insurance companies.

I have a patient now who was recently shifted out of the MICU after having seizures. He's otherwise relatively healthy, but after an extended stay in the hospital, has lost quite a bit of muscle use. He needs to go to rehab. So I ask the physical therapists to see him, but its a weekend and they're short staffed- it will have to wait until Monday for a full assessment. Until I have that assessment, the social worker can't begin the search for placement upon discharge, as we need PT recommendations for subacute rehab versus acute rehab versus outpatient rehab. Once that's completed by the PT and the social worker submits information to the patient's insurance company. Again, they aren't open on holidays or weekends, so it has to wait. Once the insurance company gets the information, it can take several days for them to make a decision as to whether or not they would pay for the placement. In the meantime, they need daily updated notes and progress notes submitted to them. And before you know it, someone who was ready for discharge ends up sitting in the hospital with no reason for a week. Being someone who hates to waste healthcare dollars, this makes me so upset. Not to mention the fact that NO ONE likes to be in the hospital (and if they do, they must really hate where they live or are malingering or something). I get so frustrated.

Another patient I had came in with a hip fracture. She was completely independent at home prior to her fall, and in unbelievably good health for her age. Unfortunately, she had a complicated hospital course and suffered irreversible anoxic brain injury. For several weeks, the family insisted upon "doing everything in our power" to make things better, which we did. Everything was looking great, but when it came time for discharge, we ran into another hold up. Insurance issues. The patient was improving every day, but this patient ended up staying in hospital for an extra 8 days waiting for approval. While waiting to get out of the hospital for some rehab, she continued to lose muscle strength and ended up getting a mucous plug in her mainstem bronchus which completely made an entire lung nonfunctional. It's easy enough to remove - just a quick bronchoscopy (percussion and drainage was not working) - but it was at this point when the family decided that enough had been done, and it was time to shift our focus from aggressive treatment to comfort care. I'm having troubles coming to terms with this - there was at least a small chance that she could have make a good recovery with intensive physical therapy, but instead we elected to keep her comfortable, which will likely lead to a pneumonia, sepsis, and eventual death. I can understand comfort care with cancer, end stage liver or heart disease...but from weakness? I just can't wrap my head around it...but pneumonia is a leading cause of death in the elderly, and I am sure this is a large reason as to why. I suppose if we did the bronch and removed the plug, it would only happen again and again...which it did during the hospital course...so in a way, why prolong the suffering? It's just hard, my most difficult ethical dilemma of intern year. It just seems so treatable...but the underlying problem could really never be fixed. When I shared this information with the MICU team who cared for her, they were devastated. We all knew that the underlying problem would never be fixed (not likely anyway), but it's still so difficult to see someone we've invested so much of ourselves in to do so poorly.

People constantly tell me how sad oncology is, but I'd take it any day in place of this!

Anyway...I'm officially halfway through intern year! :) :) :) :)

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