I was just covering for the weekend. "Just covering" means doing a lot of dancing on thin ice. I round on dozens of patients, none of whom I have ever seen before or will ever see again. All I know about them is what I read in the chart in the previous 5 minutes before I go into the hospital room. Though I know the medicine concerning every patient -- pneumonia, pulmonary embolism, or squamous cell carcinoma of the lung -- what I lack is knowledge of the specifics of the case. I know the science, but I don't know the patient. When I go into the hospital room and start talking, I immediately start my ice dancing routine, telling them everything I know about the science of their illness, and nothing about their personal situation. It may not be fair, but it gets me through most of the time.
Room 441 looked easy. DNR was written loudly on the chart, telling me that the patient and family recognized that the end was near and were requesting that no resuscitation measures be taken. The most recent progress note from the primary care physician was even more assuring. The patient, who had had advanced lung cancer, suffered cardiopulmonary arrest at home when a blood clot from her leg flaked off and lodged in her lung. The heart stopped for 15 minutes, and she now had severe brain injury. The last remark on the note was a nice, clean skating line: "Comfort care measures only." A simple, straightforward case of a patient waiting for death. All I had to do was play the babysitter, as easy a gliding path as I could hope for.
I went in, and found myself surrounded by anxious family members. My stomach told me this would not be as easy as I had hoped. Yes, the family had consented to abandon all medical intervention except comfort measures, but they were not entirely comfortable with their decision.
The patient's middle-aged daughter was at the bedside, and I could tell that the eye of this storm of anxiety quietly spun around her. She had many questions.
She was probing me. Every doctor has this experience from time to time. A patient or family member is not entirely satisfied with another doctor's opinion, so she probes another doctor to see if he agrees. Each question and statement she made seemed a test to see if I would answer the same way my partner did. Did I agree with the diagnosis? The prognosis?
I strapped on my skates. Carefully I spiraled around every question, throwing in triple loops and double axels of knowledge to keep my answers sounding credible. This lady was very sick, and she would not last long. I tried to assure the daughter that the decision to limit treatment to comfort care was indeed the right one, even though ten minutes ago I did not even know this patient existed.
Everything kept coming back to a single concern. In the intensive care unit, her mother continually ran a low blood pressure. As soon as she got to the floor, her pressure jumped up fifty points higher and has remained there ever since. How could it be that her pressure suddenly rose?
I tried the typical dance moves. Maybe the equipment was different. Maybe a medication had been changed that raised the pressure. Patients often have variations in blood pressure from day to day. Anyway, I said, it was nothing to worry about. High pressure or low pressure, I assured the nervous family, her prognosis was the same.
Still the daughter pursued the issue. I couldn't figure out the concern, but it was obvious that the blood pressure discrepancy was important to her. During her queries, my eyes wandered, and I spotted a blood pressure cuff (technically, a sphygmomanometer) mounted on the wall. I sighed impatiently. I was busy. I was running way behind. It had been a long day, and I didn't want to do it. But she was not going to stop, so I did something I haven't done in a long time.
I took a blood pressure measurement myself. With my own, pristine, doctor's hands. As every eye in the room focussed on me, I velcroed the cuff around the woman's flaccid arm and adjusted and readjusted its position. I pumped up the bladder, and slowly bled the air. Then I did it again, just to be sure.
"Ninety over fifty-eight," I said. It was the same measurement the ICU nurses had been getting. I had just proved the floor nursing aides wrong.
Trouble. That was my first thought. The daughter would use this information to argue that the floor aides were incompetent. Now I would hear it: the floor nurses don't know what they are doing, they have given up on my mother because she is dying. I braced myself.
The daughter surprised me. Her face relaxed as if a great hand had passed over it, delivering the blessing of peace. I had made her happy.
Then I realized what had happened. The daughter had been fearful that the higher pressure meant her mother's heart was getting stronger. She was having doubts about her decision. When I demonstrated that the low pressure was real, she relaxed in the knowledge that indeed her mother's heart was as weak as ever. It reassured her she was right in continuing with comfort care.
She was wrong to doubt herself. Her mother's brain was gone, no matter what the blood pressure was. Strong heart, weak heart, no matter. She was still a vegetable. The daughter logically knew this, but she needed proof.
When the daughter expressed her relief I was able to excuse myself at last and left the room. I closed the door and walked down the hall thinking, I just did nothing. Absolutely nothing. Yet the nothing I did mattered very much to that patient's daughter.
The patient died that night.
It was a typical day's work for me. I am often at my best when doing the least,