Pronouncing Death

Every now and then, I'd get a page from the ICU or the floor to pronounce a patient's death. I know people who absolutely hate it; but hey, if you think of it as the rare time when you are 100% certain of your diagnosis, it doesn't really sound like a bad task!

The strange thing about pronouncing death is that it is usually not taught in medical school. It's one of those things that you somehow just know eventually, and everyone comes up with his or her own style after a few runs. As easy as it sounds, to legally pronounce a patient dead requires a systematic approach to avoid the 1 in a million chance that the "dead" patient is still alive and kicking!

When there is no one accompanying the patient, I usually start by greeting the patient by his name. Then I usually examine the patient in this order:
- Watch for spontaneous breathing
- Auscultate for heart beats and lung sounds
- Palpate for carotid and/or radial pulses
- Check pupils and negative "doll's eye sign"
- Apply pressure to sternum for response (I usually skip this if family members are present)

The above should be suffice to pronounce a patient, unless for brain death cases. It may not be comfortable alone with a dead patient, but knowing that the patient's suffering with sickness has ended may come as a relief.

A Tale of Two Young CHFers

Last night on call, we admitted 2 patients with CHF (Congestive Heart Failure) exacerbation. CHFers are nothing new, but what's interesting is that they are both young. They are both obese, and present with shortness of breath as their chief complaint. The similarities end here, however.

CHFer#1 is an obese African male who presented to the ER with SOB for 1 week. He has a long history of atrial fibrillation/flutter that is refractory to chemical cardioversion. He did undergo a successful electrical cardioversion a few years ago. He has a history of medication non-compliance, but apparently has finally been taking his diuretics and rate-control meds regularly. Last echocardiogram shows marked decrease in cardiac function and an enlarged heart. He is a mild-mannered gentleman who has never smoked, only drinks occasionally and denied any drug use.

CHFer #2 is an obese Caucasian diabetic female who presented to the ER with SOB and difficulty sleeping for 1 week. Symptoms started after she ran out of medications last week. She has a history of methamphetamine abuse in which she snorts about $20 worth of the drug every day. She stated her last use was 4 days ago. Her last echocardiogram also shows marked decrease in cardiac function. In the ER, she threatened to leave because no one is taking care of her difficult sleeping, and was uncooperative to the ER staff. At one point, she refuses diuretics, saying that she wouldn't able to sleep if she has to pee every 30 minutes. A Foley catheter would have solved this problem, but she refuses as well.

It is easy to feel pitiful to CHFer #1 because of his pleasant manner and overall tragic history, and as the same time feel angry towards CHFer #2 because of her "obnoxiousness" and her apparent "she has done all this to herself" history. A family physician is all about caring and solving his patients' medical and social issues, but what do you do when your emotions affect your desire to help your patients? What do you do when your patients don't meet your expectation?

You Woke Me Up For THIS?

4:30 in the morning:

Me: This is Dr. L, I was paged.
Nurse: I have your patient here in Room ####; his Accu-chek is 46 so I gave him 1 amp of D50. So I need an order for that.
Me: But you gave the D50 already right?
Nurse: Yeah. I just need an order.
Me: So you ask for an order AFTER you carried it out?
Nurse: I gave him D50 because his sugar is low.
Me: So do you know when you are going to check his sugar again?
Nurse: In about 30-60 minutes.
Me: Okay. Just so you know, you can call me at 6:30am instead of 4:30, and it wouldn't change a thing. Please tell me you are not calling me in the middle of the night just for this...
Nurse: So can I get an order for the D50?
Me: (Arrrrh!) Yes, you may have the order.
Nurse: Thank you. [Hung up]

Just wondering: Can I have an order to not call me for a retrospective D50 order?

Leuprolide for Alzheimer's

One of the clinical trials I was involved in, the ALADDIN study, was terminated abruptly last year because of financial issues from the sponsoring pharmaceutical company. The study had a promising start - Memryte, which is basically an implantable form of leuprolide, has shown to be effective for Alzheimer's treatment in Phase II trials. Some of the patients that I had been following showed improved cognition as well. The theory behind leuprolide, which involves LH production and cell division, is very interesting but is beyond the scope of this entry.

I am glad to see that they are still working on reviving the study. Alzheimer's is a hot research field right now because of its lucrativeness but to the end, the general public will benefit so let's keep them running!