how much do i need to take?

Accesses for hemodialysis fail; every single one. They all eventually need to be revised or abandonded in favor of creating a new one. The issue then becomes how do dialyze them in the mean time.

A patient currently on my service is having access issues. We tried to de-clot his graft with this slick endovascular device that is like a squishable egg beater. When we were done, we didn't think it was going to work and that he'd need to be revised in the operating room the following day. But he still needed to get dialysis. So I had to place a quinton (a non-tunneled central venous catheter).

Before having to place the quinton, I was his room with my attending so we could let him know what the plan was. From the start he was belligerent and not listening. He was yelling at his wife. Then my attending told him to not yell at his wife like that. He proclaimed that we weren't helping him and he was going to leave. He stated that we never explained anything to him and he had no idea what was going on. He just kept going on and on...

I'm sure having renal failure and getting dialysis is a very frustrating life. I can't even imagine how much so.

A few hours later, I was back at his bedside, ready to place the quinton. He kept touching the sterile field and his groin so we had to keep re-prepping. I kept trying to explain what I was doing, since he was awake and all. But every time I opened my mouth, he would just start yelling, stating that he doesn't understand what we're doing. Keep in mind, it's been explained about 10 times at this point.

"Sir. Do you want me to explain what I am doing right now, or not?"

"I don't know what's going on or WHAT you guys are doing."

"Ok. I'm going to take that as a no."

I placed the quinton without any problems. Accessed the vein with one stick, so he couldn't even complain about that. I warned him when I had to stitch it in. And, yes, I used lidocaine. I told him when I was done and he literally sat up and started yelling "PRAISE GOD!" and waving his hands around my face.

"Here! Let me praise you some more! You need lots of praise, don't you?"

"No, sir, I don't need any praise. I'm just trying to take care of you. I don't need any thanks for it."

"You're not trying to take care of me. I don't know *what* the hell you're doing. And you can leave now."

"Ok. Well, please try to remember to not eat or drink anything after midnight so you can have your surgery tomorrow. The dialysis nurse will be here soon. Can I get you anything?"

...

"Can I have some ginger ale? please."

So I bring him his ginger ale.

I can usually take patient abuse pretty well. I know they're sick and I'm a safe target and all that. But he got under my skin. Don't know why. Should I have set better boundaries? Told him to be quiet? I know I could have handled things better.

vip's

There are several things that drive me up a wall in my chosen profession. One of them, if not the worst, is the concept of the "VIP." It's the idea that a patient gets preferntial treatment over other patients because they are a professor, or a dean, or own some influential company.

Everyone should be treated the same way. Period. If you call the families of your patients to update them on a regular basis, good. Do the same for the "VIP." Don't do it more.

Some families need more time spent with them so they understand what exactly is going on. Usually they are either very, very smart or they're... not. If your practice is to routinely spend whatever time a family needs, good. But don't do it just because they're "VIPs."

Everyone gets sick. People get in traumas. People get cancer. Yes, even the people society labels as "important" are susceptible to such things. But that distinction should disappear when they walk through the door. Which, by the way, is where I leave my ego.

old and trauma don't mix

I'm a firm believer that ER's get busier around a full moon. Add this month's full moon to the fact that it's Halloween weekend, and our trauma bays have been hopping.

One of today's victims is a sweet octogenarian who got hit by someone running a red light. (I wonder if he was coming from a Halloween party?) He's got 9 ribs and a scaupla fractured on one side. Alone that may not be such a bad thing, aside from the fact that it hurts. Add to that situation his age, his extensive cardiac history including an aortic valve replacement, requiring full anticoagulation, and it's a different situation entirely. For someone like this, this could be his terminal event. Even though he's a walkie-talkie (admitted walking and talking).

It reminds me of a situation I was in not too long ago. I was covering a patient who was recently extubated and was recovering from multiple rib fractures and ARDS. When he was intubated, he was fully awake and communicative, writing notes on greasboards and such. One of the repeated messages was "Get this tube out!" When we extubated him, we thought he'd fly. But he didn't.

I went up to see him before the accumulation of carbon dioxide in his blood renered him incapable of making decisions for himself. I oriented him to time, place, and situation, just to make sure we were all on the same page. I then told him that the way he was breathing would not be sustainable for much longer and if he wanted to live, he would need to be intubated again. His eyes got wide and he shook his head and hands an emphatic "NO." I told him I thought his condition was reversible with time and the tube wouldn't be permanent. "NO." I also had my head on straight that night and thought it a good idea to ask him about the specifics of his DNR wishes.

So, I called in his family so they could come and be with him in what would likely be his final hours. The daughter was first, and she really didn't know what to say. She deferred to her mother, who was the durable power of attorney.

"You have to intubate him," was the answer I got.

"I know this is a difficult situation for you, but based on what your husband told me, I can't do that. I need to follow his wishes."

"Ok. We're coming. My son lives in the area and he'll be there soon."

They were a 2-3 hour drive away. Soon the patient's son arrived and again insisted that I intubate. I tried to explain to him several times that we had a converation witnessed by at least four members of the staff whereby I could not intubate him. He started to get verbally belligerent, but I stood my ground. I knew what my patient's wishes were. And I was going to follow them.

I did. To the letter. And he died shortly after his wife and daughter arrived.

I really hope this doesn't happen to my new patient.