Potpourri from clinical work VII

by: Alex Smith, @alexsmithMD

The following are some reflections from being on service recently.  Not enough time to develop these into full posts.  If these issues tickle you, please respond in the comments!  To see previous potpourri’s from clinical work follow the links to I, II, III, IV, V, and VI.

1. David Reuben wrote a terrific perspective describing “The Hospital Dependent Patient.”  These are patients who, usually elderly, who have chronic illness exacerbations that frequently land them in the hospital.  In the hospital they have a high quality of life, when surrounded by nurses and treatments that can only be delivered in the hospital.  I cared for one such patient.  He had frequent episodes of low blood pressure following dialysis, landing in him in the hospital over and over again.  He also had early dementia.  He could remember enough to think that he should be in dialysis most days, even when it wasn’t his usual day.  Normally tired and sleepy, in the dialysis unit of our hospital, he came alive, talking animatedly with his “community” of care providers.  In goals of care discussions, this patient was clear that he enjoyed his quality of life and had no issues with returning repeatedly to the hospital for care.  As Dr. Reuben points out in his perspective, hospital-dependent patients are a product of our medical progress.  We have yet to grapple as a society with how to provide care for this increasing population of patients.  Nor have we addressed in a mature way the ethical issues around setting limits – if any – around what care our system should support and can afford for Hospital Dependent Patients.
2. Cough is a tough symptom to treat sometimes.  I had a patients with cough and dyspnea on exertion due to idiopathic pulmonary fibrosis.  He did not believe that the opioids were helping him.  The pulmonary team suggested gabapentin, but my read of the literature is there is only case report level evidence.  The patient died before we could try alternatives.  What have you used for chronic opioid refractory cough?
3. We had a patient who we communicated with just fine in his room.  No issues.  Then we had a family meeting.  Big room, lots of providers, including the medical team and 3 consulting teams.  We get about 1/3 of the way into the meeting and the patient says, “I can’t hear what your saying.”  Turns out he had hearing loss and we had no idea!  Brings home to me the importance of this issue.  In the room, alone, with the door closed, and 3 feet away from the patient’s head, communication may be just fine.  But in a large family meeting, you may find a completely different experience.  Should we be screening for hearing loss in all of our patients over the age of, say, 75?  How should we screen?  Do you have ready access to pocket talkers for patients who have hearing loss?
4. We cared for a man who experienced a hip fracture in the nursing home the other day.  His geriatrician care providers and surrogate decided that, as his pain needs were minimal, and he was in his 90s with dementia, they would not persue surgery.  Several months later we saw him and he was able to walk short distances to the bathroom, but did not try to venture out to the front desk as he did before the fracture.  Hindsight is 20/20, but it seems they made the right choice.  Other people’s experience with non-operative managment of hip fracture?  Eric wrote about outcomes of hip fracture among nursing home residents last month.
5. One patient requested that we start each mornings visit to his room with a joke.  What fun!  I told him some from my 6 year old son, like:
   1. “What’s your favorite jam?” “Peach” “What’s your least favorite jam?” “Grape” “But what about a traffic jam?”
   2. “Why is a nose not 12 inches long?” “Because then it would be a foot”
   3. This one is from Darth Vader’s twitter feed (you follow him, right?) “How did Luke Skywalker stub his toe on the planet Endor?” “Ewoked into a tree.”
   4. This one is from our team psychologist, “How do you make seven an even number?” “Take out the S”