13 March 2008

Dealing with patients you might not "like" for whatever reason.

I received a call about a consult for placement of a temporary dialysis catheter in the Medical Intensive Care Unit. When I arrived I quickly scanned the chart (coagulation profile, patient’s medical information etc.) and entered the room of the patient who needed the temporary dialysis catheter. Just before I entered the room, one of the resident physicians pulled me aside and said, “This guy weighs 500 pounds and let himself get to this point. On top of that, he smells. I just want to warn you to have your gas mask ready”. He laughed and I “thanked” him for the information and entered the room.

Lying in the bed was a 500+ pound gentleman who was restrained and mechanically ventilated. In one hand was an intravenous line which was leaking intravenous fluid. He had a very large abdominal pannus (apron of adipose tissue), multiple scars on both arms and both legs with both legs having open venous stasis ulcers that had become infected. I walked up to the bed and spoke to this patient to explain to him that his kidneys were failing and that he was going to need to have a dialysis catheter to help them along. He nodded to me but I wasn’t sure he could understand. I explained what I was going to do and that it might be uncomfortable but I would use as much local anesthetic as needed.

The nurse told me that the small intravenous line in his hand was not going to be adequate and that it was the only source of IV access that the patient had. It was tenuous at best. I asked if the patients family was present and the nurse said that they were in the waiting room. I told the nurse to gather the equipment for both a central venous line and a temporary hemodialysis catheter insertion while I went to speak with the patient’s family.

The patient’s wife was sitting in the waiting room with her daughter. She was tearful and spoke lovingly about her husband. She said that as he gained more and more weight, he became immobile. Finally, she said that nothing could get him out of his room and that she had difficulty getting him to comply with medications for diabetes and hypertension. She said that he would become angry and depressed when she attempted to help him with his personal hygiene or care of his venous stasis ulcers. I explained the need for the central venous line and the temporary hemodialysis catheter. I also explained the risks and benefits of the placement of these lines so that she could make an informed decision. She asked me to do what I could to help her husband get back to health.

After washing my hands and washing the areas of the patient where I intended to insert the catheters, I used a portable ultrasound machine to locate both the subclavian vein and the femoral vein. Both were fairly deep because of the large amount of subcutaneous fat that was present in this patient. I was able to mark off some landmarks and get to work. With the aid of a couple of nurses, I used adhesive tape to tape as much of the patient’s fat out of my way so that I could get to my intended target. After 30 minutes, I had inserted a central venous line into this patients left subclavian vein after taking about 20 minutes to carefully prepare the site. The more time I spent in prep, the easier it would be to get the line in under the best and most sterile conditions. I also had asked the nurse to give the patient a small amount of sedation so that the whole experience would be a little less alarming.

I then turned my attention to the femoral vein. Since temporary hemodialysis catheters were very large, I chose a long catheter and moved closer to the inguinal ligament as the vein would be larger there. As with the subclavian vein, I used a large amount of adhesive tape and three nurses to hold this gentleman’s large fat pannus out of the way. I inserted the line and had great blood flow and return. I also carefully secured the line with locking tape and sutures. I wanted to make sure that the patient would not be able to easily “pull” the line if he became disoriented and unrestrained. I also gave the local anesthetic plenty of time to take effect as most patients are pretty still if they are comfortable.

After a chest radiograph to confirm that my lines were in good position (with no pneumothorax), I phoned the nurses to let them know that the lines were safe to use. I also had “blocked” the hemodialysis catheter with an anticoagulant and thus I let the hemodialysis department know that this line was ready for use. I spoke with the patient’s family and let them know that the procedures, while taking a couple of hours, had gone well.

For the next three days, I went into the intensive care unit to check on the those lines and make sure that they were working fine. I spoke with the residents who kept congratulating me on “getting the lines in the whale” and laughing about this patient’s body habitus. On the third day, I didn’t see the joke and I didn’t see where calling this man a “hippo”, “whale”, or anything other than a sick patient was necessary. I asked them why they felt obligated to demean this gentleman that they didn’t really know (because he had been intubated) and they were charged with treating.

One of the residents said that he just doesn’t like “fat” people because they don’t take care of themselves and won’t follow his direction. He said that they could follow a good diet, exercise and not end up using up our precious health care resources for something that they “did to themselves”. Another resident said that he could “stand” the smell of the venous stasis ulcers and that he had to get out of the room as quickly as possible. While I appreciated their honesty, I couldn’t help wondering why they didn’t have a problem with treating an alcoholic or a drug addict who had become ill because of self-inflicted abuse of a substance. I had encountered some “skin popper” IV drug abusers who had multiple cutaneous abscesses that smelled far worse than a couple of venous stasis ulcers.

I find it difficult to blame the patient for their disease. In my mind, just as a diabetic can’t make insulin, a morbid obese patient has a metabolic problem that is not under their control. By the time a patient winds up weighing 500 pounds, all personal control is lost. If you couple the massive weight with psychiatric disorders such as depression, one finds a very difficult and challenging patient with multiple problems that need to be addressed. I can’t just afford to “like” or “dislike” any of my patients because they need my help and not my judgment.
Two weeks later, I received a call from the hemodialysis unit secretary. The nephrologist wanted me to stop by the unit so that I could “speak” to this patient. He was off the ventilator and was not going to need hemodialysis as his renal function had greatly improved. When I saw him, he said that he remembered my speaking to him in the ICU. I was amazed that he would remember me with his condition but he remembered how I explained everything that I was going to do for him and how I spoke to him with respect.

I later heard from his attending physician that he entered a rehab center and was on his way to losing 100 pounds. His hypertension was greatly improved and his diabetes was managed by diet. Though he had a long way to go, he was moving along on his journey. Hearing this made me remember why I went into medicine in the first place. It is simply to help people regain their health.

I can’t make judgments on my patients because “there but for the grace of God, go I”. I have been given the privilege and opportunity to touch the lives of thousands of people. I have also been given the trust of those thousands to also have only the best of intentions when I treat them. This is what makes medicine like no other career on earth.


Anonymous said...

I really enjoy reading your blog. Thank you for this post.

Anonymous said...

I greatly appreciate the approach you seem to take with your patients and your humility as their physician, the one entrusted with the privilege of caring for them.

DoctaJay said...

I really appreciated this story. In our "Understanding Your Patient" class, we learned about this. We learned that many of our patients may want to change, but don't for a variety of reasons. Our teacher told us that we need to be the coach for our patients...that we should cheer them on. At first I really balked at this idea. I thought as your colleagues did that these patients needed to take responsibility for themselves and lose weight, or stop smoking, or stop drinking, etc. As I read and studied more, I realized that I was poised to become one of those doctors who never really got their patients to change their behavior patterns due to my mindset about them. I realized that their is more to a patient's decision to change than what I see with my 2 eyes.

Reading your example of the respect that you showed to your patient was encouraging, especially knowing how easy it is to go with the crowd and joke about the patient. Thanks for your example!