Thursday, February 24, 2011

Way to go! 2

“Jaded Julie, in last week’s posting you were playing the role of a senior citizen hospitalized with a serious lung disease. Please bring us up to date on your condition.”

“Do I have to, Curmudge? I don’t want to be an ill person, even though it’s just imaginary. It was much more fun when you and I were pretending to watch the sun come up over the city of Florence, Italy
400 years ago.”

“That posting was a year ago in Curmudgeon’s Wastebasket. Now please, Julie, let’s go back to the script.”

“So there I am in my bed on a med/surg floor. It is around 11:00 Saturday night and oxygen is flowing through the cannula into my nostrils, but the percentage oxygen saturation in my blood is dropping. Crisis! I would have died then and there, but the ‘partial code’ on my chart directs the hospital to try to maintain my respiration until the rest of my family can arrive from out of town. That requires that I be moved to the Intensive Care Unit (ICU) and be put on a ventilator.”

“Why must crises occur in the middle of the night? The physician and available family members are called, and they rush to the hospital. There you are, apparently asleep, intubated with the ventilator puffing regularly for you, IVs in each arm, and monitors blinking out your condition in impersonal digits. What can we do? The experienced nurse is seeing to your every need, and the doc feels that you can hang in there for a few more days.”

“But Curmudge, aren’t the family members going to stay with me and keep a vigil?”

“Some families do, but we are confident that you are in good hands. For us, it’s back to bed.”

“It’s now Sunday, and I sense that some of my family have returned. Of course, I can’t say anything with all of this hardware down my windpipe. In addition, the IVs are giving me fentanyl (more potent than morphine), lorazepam to manage anxiety, and vecuronium bromide, a paralyzing agent. The result of all these meds is that I am feeling no pain and not attempting to breathe in opposition to the ventilator. Oh, I almost forgot; there are electrodes stuck to my forehead to sense my brain activity.”

“Family members say, ‘good morning,’ and squeeze your hand. We believe you can hear us because your brain monitor goes up. Actually, I now know that you could hear us because of a story I heard (1). A man was on a ventilator in an ICU, and his nurse kept singing the familiar polka, ‘Roll in the Barrel.’ After he recovered and was off the ventilator, he asked why the nurse couldn’t get the lyrics right for ‘Roll out the Barrel.’”

“Despite the nurse’s combing my hair occasionally, I must be quite a sight. Friends who hadn’t seen me for a couple of weeks come into my room, look at me and squeeze my hand, and walk out with tears in their eyes.”

“It is evident that you are failing irreversibly. The nurse turns off the monitors so visitors will focus on you and not on the steadily falling numbers. You are being weaned off the drugs so your body will not be paralyzed and will be physically able to attempt to breathe when the ventilator is turned off. The high carbon dioxide content of your blood is acting as your body’s own sedative.”

“I am able to rest more easily after my sons arrive—one on Monday and one on Tuesday. The end is near.”

“The family members are ushered out of the room; and according to your wishes, the ventilator is turned off and all the tubes and IVs are removed. The family and clergy return. You make a few snoring-like sounds and become quiet. The physician puts his stethoscope to your chest and pronounces, ‘she’s gone.’ After prayers appropriate for your religion and last good-byes, it is over.”


Affinity’s Kaizen Curmudgeon

(1) Personal communication, Bernardine Nitz.


Note: An observation on the practice of emergency medicine in a primitive location may be accessed via this link.

Thursday, February 17, 2011

Way to go!

“Curmudge, our title sounds like the congratulation that a ball player receives upon returning to the dugout after hitting a home run.”

“No way, Jaded Julie. Our topic is an end-of-life issue, and the title might be more appropriate if we changed it to A Way to Go. We’ve all heard the chilling announcement, ‘Code Blue,’ in the hospital. It has been described quite graphically in Nurse Gina’s codeblog.com, ‘How do you suppose being coded feels?’ For the patient whose heart has stopped, the process involves starting IVs, intubation, defibrillation, and chest compressions. None of this is comfortable for the patient, but for about 20% of 40-year old heart attack victims it might be the key to a longer life.”

“It’s been a long time since there were 40 candles on your cake, Curmudge. I’ll bet that your interest is what happens when a ‘code’ is called for an elderly patient with multiple diseases and infirmities.”

“Right as usual, Julie. The odds of success go down and the discomforts go up. Resuscitation (CPR) is apt to fracture the elderly patient’s ribs, and to what avail? To my knowledge I don’t have multiple diseases and infirmities, but I don’t want to have my chest crushed under any circumstance. I guess I’m a good candidate for ‘No Code’ or DNR (‘Do Not Resuscitate’).”

“But, Old Guy, what if you are unable to say that? Pulseless, non-breathers are also non-speakers.”

“That’s why one must have an advance directive. Your health care power of attorney authorizes someone who knows your wishes to speak for you if you can’t. You should discuss this with your providers and have a copy of your document put in your file.”

“Are there special situations where one might want something between a ‘Full Code’ (which seems to be the default) and a DNR?”

“There can be a ‘Partial Code’ that specifies actions to be or not to be taken, but Gina’s blog doesn’t speak very highly of them. But let me tell you about a case where a partial code was ‘just what the doctor ordered’ (literally, because your physician must order your code status to be put on your chart). You are going to be our model patient, Julie, and you have just been brought to the ED with a severe respiratory problem.”

“But I feel fine, Curmudge.”

“C’mon, Julie, play your role. You are a senior citizen and you are critically ill.”

“Okay, I know what happens now. They see that I am gasping for breath despite breathing oxygen from the tank on my lap and take me right back. Someone sticks an IV catheter in my arm, and someone else takes the list of medications that I brought and starts doing the med rec (medication reconciliation). An emergency medicine physician comes in, performs a brief, focused examination, and asks a lot of questions. After viewing my chest x-ray, he and my pulmonologist (who happens to be on call) decide to admit me to a med/surg floor in the hospital. Of course, more time than I would wish passes before I am taken upstairs.”

“Wow, Julie, you really know the drill. When you are settled in your room the hospital provides lots more oxygen than you could get at home; it’s either via a mask or a cannula in your nostrils. Because pneumonia seems to have catalyzed your chronic lung disease, you are given antibiotics via IV.”

“Now I feel better. Maybe I’m on the road to recovery.”

“That may be wishful thinking, Julie. When your pulmonologist comes by, you ask, ‘Do you think we should call our son home from overseas?’ His answer is, ‘yes.’”

“That’s a real bummer. I must have had a premonition that things were not going to go well. Because our son’s trip will take several days, perhaps we should revisit the DNR order on my chart.”

“Actually, that’s the whole point of this posting. You definitely don’t want a code blue if your heart quits, but you will accept more help with respiration until your whole family is here. And in the interim you want to be kept comfortable without pain or gasping for breath. We are all in accord, and your pulmonologist specifies the partial code on your chart.”

“And to end this chapter of our two-part posting, night is falling and I am left in the care of the excellent nurses on the floor.”

“Hang in there, Julie, so we can bring this to a conclusion next week.”

Affinity’s Kaizen Curmudgeon

Wednesday, February 9, 2011

The Middle Years

“Curmudge, it doesn’t look as if we’re going to talk about Lean.”

“Right, Jaded Julie. We are going to talk about health, especially in one’s middle years.”

“Do you mean middle age? It’s been many years since you were that young.”

“No. I mean the years between when one is in his/her 70’s or 80’s and death. To a younger person, good health is almost assured, but for those in these middle years, poor health at some point is almost inevitable. Here is an example. A group of us senior citizens gets together every Independence Day. On average, one group member dies every year. The wife of one of the men is his third; one widow has buried two husbands, and both members of another couple are deceased.”

“Thanks, Curmudge, for cheering me up. I assume the multiple spouses you mentioned were successive and not concurrent.”

“Let’s look more specifically at the health of older couples. When both spouses are healthy, they are able to do the normal retired-couple things, like traveling, attending concerts, serving as volunteers, or even working part time. But when just one member of the couple becomes ill, everything comes to a halt. The healthy person often becomes the caregiver for the one in poor health.”

“Although it’s obvious, I never thought of it that way. I always felt that as long as I am in good health, I’ll be able to do all the things I want to do. But in reality, what I can do depends on the good health of both my husband and me. It’s sort of like ‘a chain is as strong as its weakest link.’ In marriage, it’s a two-link chain.”

“Here, Julie, are some extreme examples among our acquaintances. A middle-aged woman suffered a traumatic brain injury in a car accident; her husband was her caregiver for the next 20 years. A couple in their 60’s drowned together when their tour bus ran off a mountain road in Switzerland and into a lake. As you see, the caregiver’s role can last from zero in the case of simultaneous deaths to many years, with all sorts of durations in between. I was a caregiver for only a week but was willing to go on for much longer. In all cases the ending is sad, but in some instances it is a blessing and in others it is tragic.”

“Curmudge, all I can do is shudder. So what’s our lesson?”

“It’s pretty simple. Do the things you want to do in life while you are young, i.e., younger than 70. Take care of your health, stay safe, and be lucky. And also, choose a spouse who appears healthy. As our family doctor—a horserace enthusiast—used to say, ‘pick a lean horse for a long race.’”

“But it doesn’t always work that way, Curmudge. As you know so well, your originally-lean spouse’s race was much too short.”

Affinity’s Kaizen Curmudgeon

Wednesday, February 2, 2011

What shall we do with you?

“During the past Holiday Season Mrs. Curmudgeon entertained quite a bit.”

“You’ve told me about those events, Curmudge. Apparently your role was door-opener, drink-mixer, sandwich-cooker, cleaner-upper, and all-around lackey.”

“That’s right, Jaded Julie. Most of the guests were musicians; and when they gathered around the grand piano in the living room to sing, I chatted with the non-singing spouses in the family room. Sometimes we talked about what we do for a living, or in my case, as a volunteer.”

“Presumably you described your writing about health care and occasionally, management.”

“One woman, who doesn’t work in health care, was distraught over her supervisor’s seemingly exasperated question, ‘Penny (not her real name), what are we going to do with you?’”

“Wow, Curmudge! In these days of big organizational changes, that sounds ominous, and in any case it’s an outrageous thing for a supervisor to say. When you hear a question like that, you almost expect to see Alice in Wonderland’s Red Queen run into the room shouting, ‘Off with her head.’”

“It’s almost that bad, Julie. One would certainly anticipate being fired later if not sooner. A young employee would conclude that her future lies elsewhere, and an employee over 50 would experience gross insecurity.”

“How did you feel, Curmudge, when you heard Penny’s story?”

“I was appalled. Irrespective of the supervisor’s intent, she shouldn’t have spoken that way. It reflected a lack of sensitivity as well as poor training of middle managers by her employer. We have the Affinity Learning Center. Don’t other major employers have something comparable? If they don’t, a middle manager should train herself. There are easily a hundred books on management in Barnes & Noble and the Public Library. I’ll bet that not one of them advises a manager to brow-beat her employees.”

“I fully expect that you, Old Manager-from-Long-Ago, have some advice for the offending supervisor.”

“I certainly do, but it’s from my reading, not from my experience. According to Marshall Goldsmith (1), ‘Good manners is good management.’ What distinguishes an advancing manager from one who has hit a plateau has nothing to do with experience and training and everything to do with behavior.”

“I’m not sure that I agree totally, Curmudge, but poor behavior is certainly a death knell for advancement.”

“Another characteristic of a successful manager is ‘mindfulness.’ You must always be aware of who you are, what you are doing, and to whom you are speaking. And this doesn’t apply only to managers. At Walt Disney World, each member of the ‘cast’ (all employees) is expected to remain ‘in character’ except for emergencies.”

“We once talked about one’s personal brand, the way a person acts consistently. Mindfulness sounds like an essential component of a positive personal brand.”

“That’s right, Julie. If one’s personal brand is an old grouch, his career will be limited to either a manure shoveler or a blog writer.”

Affinity’s Kaizen Curmudgeon

(1) Goldsmith, Marshall. What Got You Here Won’t Get You There. (2007, available from Amazon)