My mouth fell open!
I rubbed my eyes and read the message from the patient again that had been sent 20 minutes ago! I had just received an urgent warm handoff by phone from one of the phone bank staff that received this message.
The message from the patient stated that she felt that she was going to die. It went on to describe the kind of funeral she wanted, specifics on the coffin-white cherubs on them, and which cemetery she wanted to be buried next to her closest relative!
I glanced at the clock at 2.30 pm and quickly scanned her chart-Young noncompliant female with multiple commodities, on three antihypertensives with a history of manic depressive psychosis, depression, substance abuse, and domestic violence. Was this a medical issue or a psychiatric issue? Only Philomena, the patient could tell me!
I pulled up a phone note and called the five numbers listed one after the other. I was able to leave a message on one of the numbers but the patient never picked up. I looked at the clock - 2:37 pm. I called 911 and was connected to Emergency Medical Services. I read the note out, gave them a brief history including allergies (none), the patient's address, and my callback number. I then called the patient's emergency contact and Linda her friend, picked up. I asked her if she had a number for Philomena. She gave me a sixth number and told me that she just got off the phone with the patient. My mind racing, I casually asked her how she sounded.
"She seems fine. Laughing and talking!"
"Did she sound depressed?"
"Not at all. We spoke for around 20 minutes!"
"Thanks! Let me try that number!"
I hung up and called the patient who picked up!
"Hi, this is Dr. Annie from the clinic. I work with Dr. Smith, your doctor. May I speak to Philomena?"
"This is she!"
"Hi! Philomena! We got your message. Are you OK? What's going on and how can I help you?"
"Oh! I have a killer headache and feel like something bad is going to happen!"
"I see! Did you take your meds and eat anything today?"
"Yes! I can't get my pressure under control!"
"Anything else going on? Are you depressed? Do you feel like you want to hurt yourself or someone else?"
"Not at all!"
"OK! I have already called an ambulance. Please unlock your door, get dressed, and have your purse ready. Take your meds in a bag and make sure you have your insurance card. They should be there in the next 15 minutes."
"OK. Thanks! I will !"
"Philomena, call me if you can't get through to the clinic for any issues. May I give you my number?"
She took my number and I hung up.
I called 911 and asked them to connect me to EMS dispatch. They did once I gave them the patient's address.
I spoke to EMS and told them that it was a medical issue probably a hypertensive crisis and definitely not psych. They thanked me.
I called the PCP on his cell (he was working from home doing telephone visits )and informed him. He told me this patient's issues were complicated by her noncompliance and psych issues. I give him her number and he told me he was going to call her in the evening. This was a Friday. The clinic was closed for the weekend.
I called back the patient on Monday. She told me that she was in the ICU and her BP in the ED WAS 240/130. Since she was in a different hospital from our system, I did not have access to her information. I spoke to the ICU nurse who cited HIPAA and would not speak to me! I gave her our contact numbers and she promised to have the doctor call back but no one did. I kept in touch with the pt and finally got to talk to her team when she was sent to step down. She was positive for drugs on the urine toxicology screen. She was being treated for hypertension and now Clostridium difficile colitis. Apparently, she was sent home with a prescription which she never filled. She never picked up her phone for 2 weeks. Our calls and messages went unanswered.
The next time she called me she was back in the ED with worsening renal function. She refused dialysis as she stated that she had some bad examples. Her mother died after having issues with her shunt and a roommate died too.
I discussed her risk factors, family history, and her ongoing issues with her blood pressure. We discussed hemodialysis, peritoneal dialysis and even being on the transplant list.
"I don't want to live hooked up on a machine, I would rather die!'
"I get it that you are afraid but you may not die as soon as you wish. You could have a long drawn out affair and also end up with a bleed or stroke! It is your choice. You are 38 years old and you have your whole life ahead of you! What do YOU want for yourself!"
"I am very independent. I want to live my life MY way!"
"Alright! It's your body and I will respect your choices. Call me if I can be of any help!"
"Thank you! Merry Christmas and Happy New Year Dr. Annie! Thank you for being concerned about me! I have your number and will call you if I need you!"
"OK! Philomena! Stay safe!"
I had to back off and watch an impending train wreck.
Last week, I called her. She is back in the ED, this time has a head bleed and HTN. She was waiting for a bed upstairs for four days. Dr. Smith and I called and spoke to the ED attending. They thought she was still using drugs in the ED as every time she came out of the bathroom, her pressures spiked up and she looked spacey. I am not sure, why they didn't do a check on her, but then she can be very convincing and talk her way out of anything apparently! Her partner at home is on drugs. We hope she comes out of this, consider emergency dialysis, and get her blood pressure back to a normal range. Otherwise, it is only a matter of time before I see her in her coffin with white cherubs!
It is a hard pill to swallow! You can't save them all! You can only try your best!
References:
Hypertensive Crisis: When You Should Call 911 for High Blood Pressure
JBMmom, MSN, NP
4 Articles; 2,537 Posts
Thank you for sharing your experiences. Your patient is lucky to have you, and your persistence, in her corner. Some of my coworkers call me the pollyanna because I try to talk to the detoxing alcoholics or drug OD patients like I'm going to change them. But I go back to a patient that was admitted a few years ago after a DUI. I walked into the room a little annoyed that this person was so irresponsible that they could have killed someone! But, I kept those feelings to myself and approached the patient as non-judgmentally as I could. My internal dialogue quickly changed when I saw a patient who was truly shattered by her actions. She really was not in her right mind when she got behind that wheel and she was devastated at where her disease had brought her. She was also a fellow employee of the hospital and was so embarrassed that people might find out. I took care of her that night and at the end of the shift I drove to the car lot where her car was towed to return her keys and cell phone to her. She had no way to contact her family or her AA sponsor without her phone. I didn't hear anything about it for about a year. I was floated to another floor one night and at the end of my shift I heard "are you JBMmom from the med surg floor?". I said yes and I was completely unprepared for the hug I received. She said she had wanted to find me for months, but she wasn't sure whether she should. She said she hadn't had a single drink since the night she was admitted. She also said the way I treated her made her feel like a person and not a monster. And me driving to get her phone and return it to her meant so much so she could reach out to the people she needed. She said she thought about me almost every day and added me to her regular prayers. It was a moment I carry with me through the tough shifts, knowing that if nothing else, one time I made a difference.