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 Provided by: Clinician 1
My office got a phone call from the local assisted living facility. Mr. B., age 86, was not eating well, after two cycles of chemotherapy for B-cell lymphoma. They were sending him in for evaluation.
I know this patient and his wife well. A courtly gentleman, he had regaled me with stories of his service in WWII, his life with his second wife, his care of her as she progressed through dementia, how he sold their home and moved with her into the assisted living facility. “They take care of everything here.” He was happy with the move, loved working on his computer, and interacting with others in the community.
I was horrified when, in February, he presented to my office with a huge neck mass that sprouted overnight. I shed tears when he was diagnosed with B-cell lymphoma, and tried to comfort his wife, who really did not understand what was going on. My heart sank when, after two rounds of chemotherapy, he went into acute renal failure and almost required dialysis. He pulled through, but decided that he was not going through any more treatments. He made himself a do-not-resuscitate, do-not-intubate status. After some rehabilitation, he went back to the assisted living center. I spoke with him and his daughter by phone. He sounded weak, but his daughter stated he was much better than before the rehab.
After she put Mr. B. into the room, my medical assistant told me, “I didn’t recognize him,” so I should have been prepared. However, I did not expect to see a shell of the man I saw three months ago...he looked 10 years older, had lost hair due to his chemo, was very pale, in a wheelchair...and unshaven.
Never, ever, would Mr. B. have not shaved. He prided himself on his appearance.
I stopped dead in my tracks, speechless at seeing the man in front of me. It was like looking at a ghost.
“I’m sorry, I haven’t shaved in five days...haven’t felt like it,” were the first words out of his mouth. Amidst the significant shortness of breath. Palest color in the world. Mottled fingertips. I called my medical assistant to get the pulse oximeter.
After saying a concerned “hello,” I asked him how his breathing was doing. “Not good,” was the response. “My legs are really heavy. I’m using the wheelchair because it’s easier.”
One quick glance showed me...(+3) edema up to the knees. A quick listen to his lungs showed crackles half-way up the posterior fields. By now, my brain is screaming, “and they sent him in because he wasn’t EATING?!?!” Did NO ONE notice his shortness of breath? The severe edema? His paleness?
I wanted to cry. Scream. Bay at the moon. Whatever. This man, who had spent time telling me about his life was dying in front of me, and I was helpless to stop it.
But...wait. I had a responsibility to him. Save the emotions for my own time. I held his hands in mine, and told him that he was in congestive heart failure. He knew well what that meant, as we had chased this demon many times before. I told him, “I know that you have chosen to be DNR, and I agree with your choice. However, this is an issue where you have fluid in your lungs, and we can help you with that, using the Lasix. If you want me to call hospice and keep you comfortable, I will do that. However, this late in the afternoon, I doubt that they will come to your apartment today. But it’s YOUR call. I want to do what you want me to do.”
He looked at me, and said, “Let’s treat the CHF.” I made the call to 9-1-1. He went to the hospital, and today’s cardiology consult said he lost six pounds of fluid in under 24 hours. Turns out that the assisted living facility was handing out “salty snacks,” according to the note.
So we’ve weathered the storm for another day. The seas are calm...for the time being. Until the next big one shows up...and the boat capsizes.
Kim Spering is a family nurse practitioner who currently works at Brndjar Medical Associates, P.C., a family practice in Emmaus, PA. Her past experience includes the fields of medical/surgical ICU, open heart/trauma ICU, labor and delivery, nursing education, nursing supervision, and as a nurse practitioner in both family practice and OB/GYN settings. She currently serves as a NP preceptor for her graduate school alma mater, DeSales University, as well as for local baccalaureate programs. She is passionate about patient education and helping patients understand that they are ultimately responsible for their own health. She also firmly believes that the public needs to be educated on the value of NPs and PAs in meeting the health care needs of the next decade and beyond. In her free time, Kim enjoys family vacations with her optometrist husband, Mark, and her two sons, Matthew and Connor.
The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.
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