The Doctor Will See You Now [Non-Fiction]

Chapter 83: Acute Medicine

My colleague admits a 91-year-old woman coming in with what looks like a chest infection into one of the tiniest hospitals in the area, which has no ICU or HDU support. Because it's so small, it only takes in straightforward cases, like mild pneumonias or UTIs. It's paired with Hospital A, which is a bigger hospital with ICU and HDU and if there are any cases that has a chance of deteriorating, Tiny Hospital throws the patient to Hospital A. Preferably as early as possible without the patient deteriorating en route.

Old woman is drowsy and requiring a lot of oxygen and she has a few past health problems, including a bad heart and old kidneys (chronic kidney disease).

I speak to to the son about a DNACPR, because there is a chance she could deteriorate tonight and we need a plan of action. If she were to deteriorate to the point of being unable to breathe (respiratory arrest), the chance of her actually recovering from that, regardless of whether we intubate her or not, is slim to none.

"So my medical opinion is CPR isn't in her best interest. However, our practice is to inquire regarding the family's thoughts and we would respect your desire for CPR — provided you're aware of its traumatic nature and poor chances of success. If the family is sure they do not wish for us to resuscitate or intubate, then she stays here and we treat as best as we can. However, if you have strong urges for intubation if required or if you're not sure, I'd advise to transfer her to <Hospital A> right now before she gets worse and you can continue to think about it when she's there. What will it be?"

"Oh, she's been intubated before. Twice, actually," says the son.

I blink at him. What. This wasn't in the records. And he didn't answer my question.

"Yeah, it was at <Hospital B>. She had the tubes up her nose." He demonstrates by shoving two fingers up his nose.

Oh. He means the nasal prongs, little clear plastic tubes that go up the nostrils. Nasal prongs give up to 4L/min of oxygen max — the least invasive way of giving a tiny bit of oxygen.

He has no idea what intubation means.

"No, I mean intubation as in a tube shoved down her throat," I say, deadpan. "And CPR as in rib-breaking internal-organs-bleeding traumatic chest compressions."

Realisation dawns on his face.

"I have to decide now for intubation?"

"No. I want you to tell me if you feel strongly against CPR and intubation. If you're even remotely unsure, then I'm transferring her to <Hospital A>, our sister hospital, as soon as possible. You can make up your mind there later, if you wish."

"OK, I want to talk to my family first."

Not an entirely unreasonable request.

Until two hours passed and he comes up to me again with more questions. I'm pretty sure my words of 'as soon as possible' flew right over his head, along with my first mention of 'intubation'.

"So if she needs intubation, then she might not get off the machine, right?"

"Yes. That is possible."

"But it keeps her alive?"

"For a bit longer. So have you decided?"

"Well, I have to feel like I have done my duties as a son."

I fight not to roll my eyes at yet another unanswered question, and not to respond with 'Well, I'm not actually treating your conscience nor do I have any duties to your feelings. I'm treating your mother but respecting your wishes as the next-of-kin.'

He then dives into a long monologue about why deciding to crush his 91-year-old mother's ribs and shoving a tube down her throat to force her to breathe before she dies an inevitable death (in the event she deteriorates further due to this severe pneumonia) makes him an excellent son and somehow we're depriving him of a chance to fulfill his duties if we actually let a dying person die peacefully. All I wanted was a 'No, don't even consider intubation' or 'I'm not sure / Yes, go for it if needs be.' It's quite black and white.

And when I'm on call as the only duty physician for an entire hospital, I really don't have the time to listen to his spiel when his mother's oxygen level is actively dropping in a place with no intensive care support.

"OK, we'll transfer her. Tonight," I cut in.

"I want her to go to <Hospital B>."

I blink again. I have never mentioned Hospital B. Hospital B is not our sister hospital. There was never a possibility of transferring her to Hospital B. I wonder what planet the son hails from. It's almost like we're speaking in entirely different languages.

"She is either staying here or going to <Hospital A>. Those are your two options. DNACPR and stay, or consider intubation and go to <Hospital A>."

She goes to Hospital A in the end, four hours after the start of the conversation. It should have been decided within the hour whether she was being transferred or not. I breathe a sigh of relief. I can only imagine the son deciding for DNACPR, me getting the arrest call for her overnight, and then son suddenly changing his mind.