Monday, October 6, 2014


   As a child I learned the story of the crying wolf .I have thought about it on many occasions in life . We may be talking about the politics (it is always a crisis of some kind for some politicians), or your own son or daughter, or it may be in medicine, this phrase and the story is illustrative of our response.I have myself experienced this in my own decision making , even though I try to sort out my 'feeling' and the findings. Some ties it may have to do with the circumstances , but one must be careful.
      I had seen this elder,y patient , over 90 years of age,who was admitted to the hospital with the diagnosis of pneumonia. She had no fever nor did she have any elevated white cell count,( which is elevated in case of any infection)I saw her old chest X-ray done about 4 weeks ago.It was similar to the one done now. So I was not sure if she had indeed the pneumonia the diagnosis that she was admitted with.I wanted to do some investigations, but she was older , more than 90 years of age , and I was not too sure what did she want. I spoke to her and her son . She was not very keen on many "tests".But after discussions she was agreeable for the CT scan and an endoscopy. (Bronchoscopy.) Even though she was 90 plus she was quite clear in her thinking. She was allergic to many drugs and it was difficult to treat her. I did the CT scan and it did not add much . She had congestion , findings similar to the one seen on plain chest X-ray.The bronchoscopy also did not help. It showed no cancer , which was helpful .But the cultures were OK .The infectious disease consultant wanted to give 3 antibiotics.He did not want to stop any even though all the cultures were negative. I had no other choice as I did not know anything more.
      My plan was to do follow up X-ray in 3-4 weeks and then decide. But every day that I saw her, she had some complaint. One day the IV got out and they had hard time starting another one.Then she was constipated and the medicines thy gave her was not good and caused her to have abdominal pain. Then she had diarrhea.She did not want the breathing treatment and then felt that steroids were causing problem . Her physical findings were not any different. Her oxygen was OK and there was no fever and she sounded clear.The one day she got the laxative that she wanted and then felt like throwing up. She had 4 or 5 loose stools and may have been mildly dehydrated.Her blood pressure dropped and she almost passed out . I saw her in less than 10 minutes. She was fine and her oxygen saturation was OK and blood pressure was OK . I ordered some blood tests and new X-ray and gave her some fluids. The X-ray was better and labs were OK except one which was borderline for heart attack.Her ultrasound of the heart was normal and there was nothing to suggest heart attack on cardiogram.She continued to do OK , but every day had new complaint from stomach upset to constipation to diarrhea to problem with IV site and so on .
       One night the nurse called me stating that she had 'worked herself' up and was short of breath , The oxygen was OK, she sounded OK and blood pressure was normal She wanted an inhaler ,that she had stopped on her own before. I had respiratory therapist give her a nebuliser treatment and gave the inhaler . I also ordered new Chest X-ray. It was 1 am As soon as I hung up the phone I realised that I was brushing aside the complaints as she had complained too often . I called the nurse again .I ordered new cardiogram, blood test for heart attack and blood test for congestive heart failure. I also ordered IV Lasix, a diuretic.
       She did have the congestive heart failure and the X-ray and the blood test showed the congestive heart failure. So the diuretic helped . She was better.Next day I spoke to her and her son . She was doing much better and in next day or so was discharge to rehab unit.So I was about to be caught with the "crying wolf" and not doing the right thing . But I did OK.and so did the patient.

No comments:

Post a Comment