السبت، 31 أكتوبر 2015

Short note on how to feel , think of and manage long staying patients

Ever since you went to med-school  you were confronted by a large number of patients  who you really can't do anything  for ,  patients you've recognized " unapproachable " right from the begging of your contacts with inpatients for learning purposes .  who's been in hospital bed maybe even before you got to med-school , even before your senior does ,  just setting there strapped and Hooked to tubes and bags with medications  infused to their system  and their vitals checked routinely with no one really telling  you or teaching you something regarding their conditions , and if it was because of something its because no one really have clear cut plans regarding what should be medically done for them , of course every one rushes when they're hypotensive or febrile or coded but other than that they really don't exist in the eyes of medical attention .
And because of that - that there's not much medically to be done for them - those patients
Are imposing an ethical and philosophical issue , what should you the doctor do to them even when you don't have much to do?
This piece of writing is trying to address that and even if management don't change much in their state , our thoughts and feelings might be little bit touched regarding their mere existence and their special brand of human suffering ,  The suffering of the unconscious , debilitated -  the trapped within one self and left to die - one .
Here's what I do  and what Ive been writing in those patients progress note routinely , all haunted by the doubts of what should be done and learned since I found no formal teaching or guidance regarding them .

- how did they get here?
Was it a recurrent CVA? Post road traffic accident ? Brain hemorrhages?
How did this person became the way he or she is now and for how long they've been this way .  And since the patient is not rally here to tell you , it would be a long and exhausting review of poorly organized badly written medical records , but for me this feels like the ethical right of this patient to have their story sorted and learned by the medical personnel caring for them . 

- blood sugar and  BP : 
Nurses never tend to go quite if patient is hypotensive or having  high blood sugar readings , But it's good practice to keep them within mental list for routine check . And since patients are not often seen by the team - or not with much care -  their vitals and blood sugar reading might for no surprise go unnoticed .

- thee shall speak  , describe  : 
 Describing the patient is yet another powerful tool of making them alive in your head and close to your attention , and when it doesn't change much of a management it does affects the way you perceive the presence of them . which is the whole point.
Mental and motor state  : 
what happens when you talk to the patient , do they open their eyes look at you have any interest in your presence. 
And if  not moving one side of their body , mouth deviation , any posturing ( decerbrate " flexed legs " or  decorticate " flexed elbows " poster ) ,  a Glasgow coma scale with a more personalized and easy to connect-to comments . A casual  "  most important  things you notice when see the patient" kinda of comment , it feels easier and more holistic.
Tubes , lines and Bags
 the presence of tracheostomy , NGT , PEG tube , colostomy , ventilation mechanices , central lines 
They  are mostly under the list of active problems of patient  and should be noted if present , and almost always are present in long staying patients .

-bed sores
Those tend to eat these patient  , know if they have any and ask the nurse about their size and grade and if they were healing or no , you can take  plastic surgeons opinion with them too . Again , to be stated with patient active problems . 

- signs of DVT/PE chest infections : 
Look for signs for those routinely in long staying patient , auscultate the chest for added sounds or creptation and have a look on their legs if swollen or red . 

  - lab investigation : 
The common practice I've seen and never knew if based on studies or mere intuition is ordering CBC  and chemistry panel for long staying patients twice a week . if you happen to practice that don't forget to review them and note when was it last done and not just let them pile up with no use  . I encourage you though to find a more solid say on investigating those patients since I have not . 

- reviewing medication : 
Don't just forget then antibiotic or medication aiming towards correcting their potassium or magnesium or what ever levels  , it's a shame . 

- DNR statues : 
Visit the patient DNR state ( do not resuscitate order ) and discuss it with the team consultant if they are not on it  , they deserve the quite - free of broken ribs from chest compression- death if attainable .