Tuesday, September 19, 2006

Patients that make you say grrr

Mrs. Starbuck
Mrs. Starbuck has made a series of phenomally poor choices in her life. She has decided to smoke, two packs a day, for the past 20 years. The second poor choice she has made is deciding, after being diagnosed with asthma, to continue smoking. Her husband, perhaps considering "till death do us part" as incentive to hasten that event, has continued smoking as well.

So it wasn't exactly surprising to get that history from the pale woman sitting in the ER on continuous albuterol nebs, with an oxygen saturation of about 88%. For the non-medical reader, albuterol (in a nebulized form, aka "nebs") is something we give patients to dilate their airways in asthma attacks. Usually, it is administered once every few hours, every two in pretty bad disease, but even every half hour if someone is about to die from airway closure. So continuous nebs means someone is really worried. In point of fact, continuous nebs aren't shown to be much more beneficial than 30 minutes apart, but the exasperation of internal medicine with ER docs will have to wait for another post.

Anyway, Mrs. Starbuck was speaking only 3 words at a time before taking big gasps of the nebs, so we admitted her to the ICU, where she is on a BIPAP machine, something between full out intubation and nasal cannula oxygen.

Why people smoke, I have no idea. Why people with asthma smoke is so far beyond me I get angry with their stupidity just thinking about it.

Mrs. Solson

Real, live, Munchausen's syndrome. This marks the second time I've seen something similar. This patient came in and requested a central line. I've only ever seen that in drug abusers. Sure enough, about ten minutes after she was brought up to the ward, she threatened to leave AMA if she wasn't given IV morphine.

I would probably have stayed strong on this one, and offered Tylenol instead, especially since she didn't complain of any pain at all in the ER. But my resident is nice (or just fed up) and wrote an order for morphine. She didn't completely cave in though, and wrote the order for 2mg q4 hours, which is about enough morphine to cover really bad hangnail pain.

I did enjoy one aspect of this admission though: making the phone call to psychiatry.


Melchizedek said...

I don't know how people with asthma can smoke. I had asthma as a kid and I couldn't even be within about 20 feet of someone who was smoking.

Thainamu said...

I know why people smoke--they're addicted. I don't know why people start smoking.

Anonymous said...

agreed, thainamu. Nicotinic acetylcholine receptors are so-called for the very reason that nicotine is an ACh agonist.

Addiction is chemical. It's strong and sometimes will power just might not be enough in some folks. A good thing to remember.

Another question for you medicine folks (concerning the central line requesting morphine addiction): is it really a call to doctors to ease pain? If the addiction means that absence of a harmful chemical is pain-inducing, then does that mean doctors are morally required to ease that pain?

Ibid said...

Point 1: I don't know where you find time to post so compellingly. Or is this a nice way of venting?

Point 2: Someone should invent the stultulogist: the person in the labcoat hired to provide perfect platitudes and to listen to people who won't listen.

Nathan said...

s. lee - yes, we are called to ease that pain, but, we are first called to "do no harm." Since addiction is harmful, we try to deal with that first.

ibid - thanks for the compliment, and yes, this is a bit of a way to vent.