Indian Medic

There is a patient in our ward, a 60 year old lady with restrictive lung disease, and severe kyphoscoliotic deformity. She has been with us near about 3 months now. She has history of recurrent admissions with exacerbations of her condition, usually mandating a short stint in the ICU with a moderately long one in the ward. But this time, it looks like she is here to stay.She is in a persistent state of metabolic alkalosis and needs continous oxygen. Mostly nasal prongs with regular bronchodilating nebulisations are enough to keep her happy. She had set a routine for herself, a neb each, before and after a poop or a meal.

The thing, however, is that our hospital is always in a bed crunch and every single bed is essential especially in what we call our emergency cubicle, which is nothing more than a glass walled room with four beds, adjoining the nurses station from where we can keep an eye (literally), on our ‘bad’ patients. And the lady in question has been on one of those beds longer than we care to remember. Frankly speaking, we are not doing much for her, all she needs in strict bed rest, and someone to care of her 24X7.

So about a month back we had planned it out with the family and one of our bolder consultants, decided to discharge her, all arrangements made at her home, O2 cylinders, nebulizers, bed pans, the whole gamut. And not to forget a fulltime, maid to care for her alone. Since there are no nursing homes in India, to take long term care of patients like her, a point I have stressed a lot in one of my previous posts, there really was no other option. It would be prudent to mention here that the lady has a bit of an attention seeking behaviour, and quite often we find it difficult to make out if her symptoms are really as grevious as she states them to be. For instance she complain of shortness of breath every time any of us walks into the room, but all her monitors would be showing perfectly right figures.

Her complaints increased exponentially as the day of her planned discharge grew nearer. We could but only reassure her that she was going to be fine, and even pretend not to have heard her occasionally. ( I know that’s rude, but she could get on your nerves real bad).

D- day - 12. 10 am - I was on call, it was a night as any other, a continous spate of admissions, me in a chronic state of fatigue. Suddenly everything went haywire, all alarms started sounding, we rushed in to the emergency cubicle to find our lady breathless. Initially I had my doubts, but one look at the monitor and I knew this was the real thing. A quick ABG and down she went to the ICU again.
It was hypercapnia like none other I had seen before, 90% PaCO2.

Anyway, she stayed down there for a couple of days, got all stable and came up to reclaim her old bed.

Things moved on again and about two weeks back, when she seemed better, we plotted her discharge again, this time taking care not to let her in on the secret. Her family was in on it though. One fine morning, I walked in and just let her know that she was being sent home that very same day. I was all prepared for a reaction, which could take any possible form, another bout of breathlessness… of protests to let her stay on…. But she took it rather well, and I think even seemed a bit glad about it.

That evening for the first time ever I saw her walk, a few steps from the bed to the wheel chair to be whisked away to the ambulance. She was really short, but then again, with a spine that crooked, she had to be. There were a lot of heartfelt good byes, for a variety of reasons, and the ‘chronic one’ as we used to call her, left for home.

Her bed was duly cleaned up with extra disinfectants and made ready for the next patient who might need the emergency cubicle.

I was on call that night as well. Somewhere in the middle of the night I got a call from the ER to check out a patient with chest pain. If the ER doctor is not able to decide if the patient needs to be admitted, we ward people go down and evaluate the patient. I was just about to leave the ER, when an ambulance screeched into the bay, and a stretcher was whisked in with a patient who was gasping. There was no mistaking the frail frame of my old patient. The ‘Chronic one, was back, and in as bad a state as possible. A few more minutes and she would have arrested.

Four days in the ICU on the ventilator, 2 days off it, and back it was to the ward, the emergency cubicle and bed no 17.

This was two weeks back. We have had no more scares yet. This time too, we residents have started doing the ploting. But this time the consultant who is ultimately responsible for her, is the ‘no risk taking sorts’. So he pointedly ignores it on rounds when we try to suggest that she is stable enough.

I’m sure only one thought comes up in everyone else’s heads, like in mine, every time I enter the emergency cubic. The first time we were to discharge her she got bad, the second time we actually did it, she came back within hours and barely made it.

What would happen if we discharged her the third time???? Would she make it???

Would it be third time unlucky for her???