Текст книги "Dude, Where's my Stethoscope?"
Автор книги: Donovan Gray
сообщить о нарушении
Текущая страница: 6 (всего у книги 14 страниц)
As we stripped off the patient’s smouldering clothes and started IVs I advised him of my concerns regarding his airway. When I told him I thought he needed to be intubated he said: “Are you saying you want to stick a tube down my throat and put me on a breathing machine?”
“In a nutshell, yes.”
“Yeah, right! Like that’s ever going to happen! No way, man. I’m out of here.” He sat up and pulled out one of his IVs.
“Mr. Cotard, I think you’re making a big mistake. Any minute now your throat might begin to swell. If it does, you could suffocate.”
“I already told you, there’s nothing wrong with me. I’m going home.” He started tugging on his remaining IV.
“Hang on,” I parried. “What’s the big rush? Why don’t you stay a little while and let us keep an eye on you? If nothing happens, we’ll let you go.”
“Okay,” he agreed grudgingly. “I’ll stay for 10 minutes, max.”
With each passing minute he grew more restless and agitated. We had to continually remind him to leave his oxygen mask on. Eventually his oxygen sats began to drop.
“If we wait much longer to intubate you, it may be too late.”
“Not a chance!”
Moments later his voice started getting raspy. The ER nurses and I exchanged worried glances. Vocal cord swelling. Not long after that he developed stridor, a high-pitched inspiratory wheeze indicative of a precariously narrow upper airway.
“That noise you’re making each time you inhale tells us we’re running out of time. We have to intubate you now before your airway becomes completely obstructed.”
“No way!” he squeaked. “Stay away from me!”
“All right then, at least let me give you something to help you relax a bit.”
“Okay.”
I drew up four syringes of RSI drugs: thiopental, succinylcholine, pancuronium and diazepam. My patient eyed the syringes suspiciously.
“Are you sure this stuff is going to help me relax?”
“I guarantee it.”
I injected the thiopental and succinylcholine into his IV port. Within a minute he was unconscious and paralyzed. I then squeezed a pediatric-sized ET tube through his flambéed vocal cords, hooked him up to a ventilator and shipped him off to the closest burn centre.
We were later advised his inhalation injuries were so severe he required mechanical ventilation for more than a week. His subsequent convalescence was uneventful.
As you can see, occasionally we're forced to override an irrational patient decision in order to save someone from themselves. These situations have the potential to ignite ethical and medicolegal firestorms. Whenever I'm caught in this type of quandary my guiding principle is to do whatever I feel is morally imperative and save the worrying about potential repercussions for later. In other words, do the right thing! So far this axiom has not let me down.
How Come She’s Not Breathing Anymore?
One night I was paged to the Special Care Unit to evaluate a teenage girl in respiratory distress. The nurse caring for her informed me the patient had presented to the emergency department earlier in the day after having ingested a large quantity of unknown pills. She had been treated with activated charcoal and observed closely in the ER. Nothing untoward had happened, so after a few hours she had been transferred to the unit for further monitoring. Her breathing had started to become laboured a few minutes prior to my being contacted.
The patient’s breathing was rapid and shallow. Despite maximal supplemental oxygen, her sats were only 80 percent. Examination, bloodwork and a portable chest x-ray failed to reveal any obvious cause for her abrupt deterioration. I wondered about the possibility of a pulmonary blood clot. Before I could pursue that line of thought any further, her respiratory status took a turn for the worse. I decided to intubate.
I selected my airway tools and calculated the appropriate RSI drug dosages. While the nurse got the medications ready I studied the patient’s mouth and neck in an attempt to gauge how difficult it was going to be to intubate her. Her receding chin, small mouth and big tongue all suggested the procedure would be technically challenging. If I paralyzed her and then found myself unable to get the tube in I’d be up the proverbial creek. Like the saying goes, bad breath is better than no breath. I therefore decided to do an awake intubation, meaning I would numb her throat and upper airway with the topical anaesthetic Xylocaine and then gingerly advance the ET tube into place. Once the tube was in, I’d quickly sedate and paralyze her in order to eliminate the possibility of her inadvertently yanking it out. I went over the plan with her in detail. She said she’d try her best to cooperate.
First I flattened her tongue with a tongue depressor and sprayed the back of her throat with Xylocaine. A minute later I instructed her to lie down. I then slid the laryngoscope blade to the back of her throat and sprayed the zone between the posterior throat and the voice box. This caused her to cough and splutter so much I had to withdraw the scope and give her a minute to recover. On the next attempt I was able to get the blade a bit further down, but when I began spraying she reached up and tried to grab my hand. Not good. I removed the scope again.
“Are you okay?” I inquired.
“Yes. Sorry about that – it was just a reflex,” she panted.
I turned to the nurse and whispered: “This looks like it’ll be a tough intubation. I’m going to want to give her the thiopental and sux to sedate and paralyze her as soon as the tube’s in place so she doesn’t pull it out.”
“Okay, I’ll have them both ready.”
I went in again. This time I saw a sliver of the epiglottis, which is the lid of the voice box. The vocal cords lie directly beneath it. When I squirted the epiglottis with Xylocaine she started coughing violently. She then began twisting and rolling around on the bed. I withdrew the scope and waited for her to settle. When she calmed down I asked, “Are you okay?” No answer. “Miss Pickwick?” Silence. Something was wack. Was it just my imagination, or did she appear to be unnaturally still?
“Hey, wait a minute – how come she’s not breathing anymore?”
The nurse checked the patient’s IV line and gasped.
“I inserted the loaded syringes of thiopental and succinylcholine into her IV port and left them there so we’d be able to inject as soon as you got the tube in! Both syringes are completely empty – she must have self-injected just now when she rolled over!” Yikes!
Her oxygen sats entered free fall. I asked the nurse to apply firm pressure to the patient’s cricoid cartilage to reduce her risk of aspirating stomach contents. In the meantime I attempted to ventilate her lungs with the Ambu bag. Even using both hands I couldn’t get a good seal with the mask. Her sats hit 70 percent. I put the laryngoscope back down her throat and hunted for her vocal cords. I could barely see the epiglottis, never mind the cords.
“O2 sat 60 percent!” shouted the nurse. A multitude of monitor alarms started beeping simultaneously. I went into Hulk mode and pulled on the laryngoscope so hard, it’s a wonder the patient’s entire body didn’t lift off the bed. Miraculously, her vocal cords popped into view. I vaguely recall my hands trembling a little as I guided the ET tube home.
Miss Pickwick went on to a complete recovery.
Let Me Help You With That, Doctor
A while back I was called to the medical floor to see a patient who was developing pulmonary edema, or fluid on the lungs. Despite aggressive medical therapy and BiPAP she was becoming increasingly short of breath. She needed to be tubed and put on a ventilator. I set out my equipment and assessed her airway. Her anatomy was favourable and there was nothing to suggest she’d be a difficult intubation. The only wrinkle was that if I knocked her out with thiopental, her already-lowish blood pressure could bottom out completely. I elected to sedate her lightly with midazolam, paralyze her with succinylcholine and then slip the endotracheal tube in. Once the tube was in place I’d sedate her more heavily. I explained the game plan to her and she gave me the green light to proceed.
I injected 3 mg of midazolam and 100 mg of succinylcholine into her IV port. Succinylcholine usually effects paralysis within a minute or so. After a minute of cricoid pressure and bagging I put the laryngoscope in her mouth. I could see her vocal cords clearly. My ET tube was on a sterile towel next to the patient’s head. I didn’t want to lose sight of my target, so I said, “Could somebody please pass me the tube?” The patient picked it up and handed it to me. I almost quailed. “Hey! Aren’t you supposed to be paralyzed?” I asked.
“Am I? I guess it didn’t work,” she mumbled around the laryngoscope blade in her mouth. “Are you almost finished? This is kind of uncomfortable.”
I removed the scope and inspected the bottle of succinylcholine. It was nowhere near its expiry date. I checked the patient’s IV line. It was patent. What the hell?
“Ms. Selwyn, we’re going to try that again.”
“Okay, doctor.”
I gave her a touch more midazolam plus another 150 mg of succinylcholine and waited for her to go limp. Nothing happened.
“Aren’t you paralyzed yet?”
“Sorry, no.”
I sprayed her throat and upper airway with Xylocaine and tried to do an awake intubation, but when the ET tube reached her vocal cords she started thrashing about. Attempting to pass the tube was like trying to hit a moving target. I was worried about traumatizing her epiglottis and cords, so I pulled the laryngoscope out.
Before I could work out a Plan C, her oxygen sats fell off a cliff. I gave her a ton of midazolam plus a whopping 200 mg of succinylcholine. She still wasn’t paralyzed, but at least she was adequately drowsy. When I put the laryngoscope back in her mouth I nearly gagged. It looked as if a tiny grenade had just exploded at the base of her throat. The trauma of the preceding intubation attempt had caused the soft tissues of her upper airway to swell so grotesquely, I couldn’t spot anything even remotely recognizable. More and more alarms bleeped as her oxygen sats continued to tank. I was on the verge of asking for the cricothyroidotomy tray and a scalpel when a tiny air bubble appeared on the surface of one of the bruised lumps of flesh at the back of her throat. That bubble must have just exited the trachea! I aimed for it and pushed firmly. The tube slid underneath her distorted epiglottis and lodged neatly in the windpipe. Bingo!
A few months later I attended an advanced airway management course. One of the instructors informed us that once in a blue moon you run across a bottle of succinylcholine that simply doesn’t work. Apparently the anaesthetists call it “Bad Sux.” The solution? Toss it out and open a new bottle!
In my next life I’m hoping to come back as a librarian. I can’t handle all this excitement!
Koyaanisqatsi (Life Out of Balance)
“ Things fall apart; the center cannot hold;
Mere anarchy is loosed upon the world… .”
– William Butler Yeats, The Second Coming
Remember that high school science experiment with the tin can? Allow me to refresh your memory. You took a large tin can, sucked all the air out of it with a vacuum pump and then resealed the lid. Within seconds the can caved in, crushed by the surrounding atmospheric pressure. Kids applauded, your science teacher bowed theatrically and the jocks loitering at the back of the class rained an apocalypse of spitballs down on the hapless geeks in the front row. Ladies and gentlemen, I present to you Exhibit A, the Human Tin Can. Watch carefully as the pressure generated by running a busy medical practice while simultaneously attempting to be an involved parent, an attentive spouse and a dutiful son threatens to crush him like a bug. Will he implode? Place your bets, everyone, place your bets!
I, Carnival Duck (Apologies to I, Claudius)
I’m on call for our ER every Wednesday night, so I usually take Thursday mornings off. Or at least, I try to. In theory it makes sense – if I give myself a chance to repay my sleep debt, maybe I’ll be able to avoid premature flameout. In reality, though, it doesn’t always work out that way. Yesterday was Thursday. Here’s how the morning went.
Whether it’s my morning off or not, my daughters still have to get to school on time. Accordingly, my alarm clock went off at 6:55 a.m., same as always. I had just gotten home from the hospital about two hours prior, so I spent the next few minutes lurching around the room like an extra from the set of The Walking Dead. Eventually I woke up enough to help the girls with their morning rituals. At 8:15 I walked them to the bus stop. A few minutes later I was waving goodbye as their bus pulled away from the curb. I picked up my usual bagel and coffee at Tim Hortons and drove to the hospital. As I ate in the doctor’s lounge I formulated a battle plan. I would go directly to the medical floor, see my four inpatients as quickly as possible and then beat a hasty retreat home. I figured if I eliminated all nonessential intra-hospital contact I could be back in bed as early as 9:30. That would give me a solid three hours of sleep before my afternoon office began. The plan sounded good, but was it too optimistic? For doctors, sometimes going from Point A to Point B within a hospital is like running a gauntlet – everyone wants to take a whack at you. Nevertheless, I was determined to succeed. Avoid all side skirmishes, I reminded myself as I prepared to exit the lounge.
Beep-beep-beep! I checked my pager’s LCD screen. The number for the medical floor flashed at me ominously. Uh-oh. I picked up the telephone and called.
“Hi Dr. Gray! Just wanted to let you know two of your patients transferred back from St. Elsewhere last night, so we’ll be needing some orders for them.”
“Okay.”
“You should probably have a look at them, too. One of them keeps dumping his pressure and I think the other one’s starting to circle the drain.”
So much for getting home by 9:30.
I headed for my locker, which is located a few steps down the hall from the lounge. I hadn’t made it a third of the way when the nursing supervisor stopped me.
“There’s a problem with that patient of yours who was supposed to go to Timmins for a CT scan of his head today,” she declared. “He’s a DNR, and the other patient he has to share the ambulance with is a full-code.”
She waited for my response. Try as I might, I couldn’t identify the point where these two seemingly unrelated lines of data intersected. Eventually I sighed.
“The suspense is killing me.”
“According to the new EMS policy, they’re not allowed to transport a full-code patient and a no-code patient in the same rig. Two full-codes can share an ambulance, but DNR patients have to be transported by themselves.”
“ What?”
“New policy.”
“Which moron came up with that one?”
“I don’t know, but it means they won’t be able to take your guy.”
“But he already got cancelled once last week due to that blizzard! Besides, he’s perfectly stable. Just because he’s DNR doesn’t mean he’s planning on dying anytime soon. He’s probably less likely to cash out today than I am.”
She smiled wryly and said, “That is exactly what I told the attendants, but they said it didn’t matter – rules are rules. Should we rebook him for next week?”
“Don’t bother. What’s to stop the same thing from happening again next time? Tell you what, let’s temporarily switch him to full code.”
“What do you mean?” she asked.
“Discontinue his DNR order and send him in the ambulance with the other guy. When he gets back from his scan I’ll reinstate his DNR.”
“If central dispatch finds out you’re tweaking DNR orders to facilitate transfers, they’ll go bananas.”
“I’ve got broad shoulders.”
As I was putting on my lab coat one of my colleagues entered the locker room.
“Morning, Donovan! Say, I just noticed that on the new ER schedule you have me on call on the 16th. I won’t be able to work that day – my wife’s parents are going to be in town.”
“You didn’t tell me you weren’t available to work that day,” I whined. Every month I end up revising our call roster six or seven times due to last-minute changes.
“I know, I forgot. Sorry!”
I pulled a copy of the schedule out of my locker.
“Miles is on call the next day. Could you just trade with him?”
“No, that won’t work – the outlaws’ll be staying the entire weekend.”
“Okay, I’ll rework things and get back to you.”
I sat down with the timetable and brainstormed. Five minutes later I had a viable alternative figured out. All right, time to get to work!
I left the locker room and angled across the hallway to our mailboxes. I was glumly eyeing the two new admission cards taped to the front of my box when I heard someone inside the emergency department mention my name.
“… I think I just saw him go by. Maybe he stopped at his mailbox.”
Oh no. Before I could make like Jimmy Hoffa and disappear, one of the ER nurses stepped out into the hallway and collared me.
“Oh, there you are! I have an outpatient sheet from last night that you forgot to sign.”
“Is that all? No problem!” This’ll only take a second!
I trotted over to the main desk and applied my hieroglyphic scrawl to the sheet.
“Oh, and one more thing,” she said. “Remember Mr. Carbuncle? He’s the man who had that nasty abscess on his buttock. You lanced it on Monday.”
“Yes?”
“He’s due to be reassessed this morning to see if his IV antibiotics can be discontinued.”
“That’s nice.”
“He was really hoping you’d be the one to recheck him.”
I was on the verge of deferring the task to the doctor on call when Mr. Carbuncle and his wife both leaned out of the doorway of the nearest treatment room and waved at me cheerily.
“Um, sure, I’d be glad to.”
When I stepped out of the treatment room, the administrative secretary ambushed me.
“Sorry to bother you, Dr. Gray, but we need to schedule a medical advisory committee meeting. There are a number of pressing items on the agenda that need to be addressed.”
“Like what?” Omigod! Wait! Is it too late for me to retract that question?
As she summarized the lengthy list I tried my best to nod at appropriate intervals. When I couldn’t stand it any longer I interrupted her in mid-sentence.
“How about if we have the meeting next Friday at noon?”
“Next Friday at noon sounds great! I’ll send out a memo to everyone.” I turned to go. “By the way,” she said, “The CEO is going to need your help with the upcoming hospital accreditation. Do you think you’ll be able to… .”
Administrative duties fulfilled, I made a beeline for the medical ward. As I was passing switchboard the operator waved me over to her desk.
“That specialist you were trying to track down yesterday is returning your call,” she said.
“Oh, that’s okay – I managed to get the patient I was calling him about stabilized and transferred somewhere else, so I don’t need to speak to him anymore.”
“You might as well tell him that yourself – he’ll be on the line any second now. What number should I put it through to?”
“But – ”
“Here he is now. I’ll patch it through to the phone right behind you in Medical Records.”
Dr. Verbose was in a particularly chatty mood. At his request, we reviewed the details of the case I had been trying to reach him about. He seemed to be satisfied with the way things had turned out. While we were talking I noticed someone from the business office begin to hover nearby. Before long an ER nurse joined her. The instant I hung up they descended like ravens.
“Dr. Gray, the architect wants to know when he’ll be able to meet with you to go over the new medical clinic plans.”
“How about next Friday at noon?”
“Didn’t you just book the next MAC meeting for that time slot?”
“Oh, yeah, that’s right. Okay, make it this coming Monday at 12:30.”
“Super.” She tagged out and the ER nurse took her place.
“When do you want to do that elective electrical cardioversion?”
“What cardioversion?”
“Mr. Brugada.”
“I thought he had decided he didn’t want Ontario Hydrotherapy.”
“He telephoned just now to say he’s changed his mind.”
“Hang on. I’ll check.”
I called the OR and worked out a date with our anaesthetist. The nurse took down the information and departed. Before I could get out of the Medical Records department our transcriptionist asked me to help her figure out a muffled word on one of her tapes. The mystery word turned out to be “dysphoria.” Hmm… .
On my way to the medical ward I stole a look at my watch. It was already 9:30 and I hadn’t even started rounds yet. Now I had six patients to see, two of whom were allegedly falling apart. Cripes! So much for my carefully laid plans. I was within arm’s reach of the door to the ward when the respiratory therapist tackled me.
“Would you be able to help me get approval for a sleep study for Mr. Ondine?”
I don’t even recall the details of the conversation. I just remember a sudden moment of clarity in which a single thought crystallized in my mind: Now I know how those carnival ducks felt.
When I was a kid, every summer a couple of travelling carnivals would come to our town for a few days. Armed with the contents of our piggy banks, my friends and I would wander through the amazing chaos together. We’d go on all the rides, eat loads of candy and try our luck at the games. One of our favourite games was Shoot the Duck. For a dime you’d get to shoot pellets at a metal duck at the far end of the booth. It was “swimming” from one side to the other, but if you nailed it just right it would spin around and go back in the opposite direction. Each time you hit it a loud Ding! would reverberate throughout the booth. Ding! Ding! Ding! Ding! It kept trying to get to the other side, but somehow it never made it. Some days I feel like that duck.
Eventually I arrived at the ward. I had just cracked open my first chart when one of the ambulance attendants bellied up to the counter beside me. He looked annoyed.
“So your guy’s not DNR anymore,” he said.
“That’s right.”
“You know that means we’ll be doing a complete resuscitation on him if he goes sour while we’re on the road, right?”
“Go for it.”
“Does his family know his code status has been changed?”
I lost it.
“The whole world knows, okay? Go ahead and run a full code! Do a heart transplant if you have to! Just do the goddamn transfer!”
“Okay, okay, take it easy,” he muttered. “Just making sure.”
I got home at noon with a newfound understanding of the relief Xenophon must have felt when he and his fellow warriors finally clawed their way to the Black Sea. Thálatta, thálatta! (The sea, the sea!) I was so exhausted, I went straight to bed. Sleep claimed me within seconds. Half a minute later the bedside telephone shrilled. I nearly jumped out of my skin.
“Hi, Sweetie,” said my wife. “I’m stuck in a meeting and Ellen just called to say she forgot her lunch at home this morning. Do you think maybe you could run it down to the school for her?”
The Simple Math of Medical Errors
Medicine’s a tough gig. For one thing, there are so many diseases out there it’s almost impossible to learn them all. Although we physicians spend the majority of our time treating a core group of relatively common disorders, we still encounter the bizarre and unexpected often enough to keep us on our toes.
Next, some diseases are protean. It’s not uncommon for two people with the same ailment to have entirely different presentations. The converse is also true – unrelated diseases can sometimes generate remarkably similar signs and symptoms.
Another stumbling block is the fact that some patients are poor historians. A portion bury vital clues beneath mountains of irrelevant trivia. When that happens, we have to dig like archaeologists to excavate the information we need. Others have a frustrating tendency to withhold critical details when relating their histories. And then there are always those who just can’t seem to remember exactly what it was they came in to see us for. That never portends well.
On the other side of the coin, there are certainly times when we doctors impede the diagnostic process. Sometimes things like being hungry, tired, stressed or swamped reduce our effectiveness. Sometimes we’re lazy. Occasionally we develop tunnel vision and fail to consider other potential diagnoses. And sometimes we just plain screw up. How could we not? We’re made of the same flesh and blood as everyone else.
In my office I see about 40 patients a day. By the end of most of these encounters I have to make several management decisions. Is this person sick, or not? Is their illness primarily physical or psychological? Do they need investigations? If so, which ones? In what sequence? Within what time frame? Should their medications be adjusted? Do they need to be started on something new? Would they benefit from a visit to an allied health professional or a specialist? What type? How soon? I have approximately 15 minutes to extract an accurate history, perform a relevant examination and come up with a game plan. Does that sound like a tall order? Well, it isn’t. It’s just business as usual.
In addition to the continuous flow of patients, dozens of reports cross my desk every day. Blood tests, urinalyses, cultures, stool studies, EKGs, x-rays, ultrasounds, CT and MRI scans, bone scans, bone density studies, mammograms, Pap smears, pathology reports, pulmonary function tests, ambulatory blood pressure readings, cardiac monitor reports… . The list is endless. As I review each report I have to try to recall why the test was ordered. If the result is normal it can usually be filed away. Significantly abnormal results are flagged and dealt with promptly. Mildly abnormal results are tricky, because they require an answer to the question: Can this be safely filed, or are further investigations required? Not every abnormal test result needs to be acted upon. Part of the art of medicine is knowing when it’s appropriate to ignore a result that falls slightly outside the normal range. “Incidentalomas” abound in clinical medicine, and they don’t all require a million-dollar workup.
For as long as history has been recorded, most societies have held their healers in high esteem. This respect has usually been accompanied by a certain degree of tolerance vis-à-vis medical errors. We physicians have always been extremely grateful for this unspoken buffer zone of forgiveness. Doctors are human beings, and all human beings make mistakes. If the guy at Domino’s makes a mistake, someone could end up getting anchovies instead of mushrooms on their pizza. If I make a mistake, someone could end up dead. It’s a terrifying responsibility.
Over the past 30 years there has been a seismic shift in our collective attitude towards mistakes in North America. All of a sudden errors are no longer permissible. Now if something goes wrong, someone has to be held accountable. Our current zeitgeist fosters the belief that if you look hard enough, eventually you’ll find someone to blame. Someone to blame equals someone to sue. Successful lawsuit equals big money.
Given the prevailing cultural mindset, it’s no surprise the public’s tolerance for medical errors has all but evaporated. Nowadays if a physician makes a mistake, there’s a fair chance their patient may be more angry than forgiving. Even sympathetic patients are often tempted to initiate litigation when family, friends or the media inundate them with stories of lucrative malpractice settlements. I’ve seen sweet little old grandmothers morph into near-psychotic greedheads after having been advised what their injury might be “worth.” It’s not a pretty sight.
Between patient encounters and interpretation of test results, I estimate I make at least 50 significant decisions a day. Even if I’m right 98 percent of the time (a near-impossibility in clinical medicine), that still means I make one mistake per day. That’s a minimum of five a week, or roughly 250 per year.
All of these mistakes are incubating in an increasingly hostile milieu in which highly-informed patients are demanding perfection. Practicing medicine in North America in the 21st century is like juggling hand grenades – no matter how good you are, eventually one of them is going to go off in your face.
Humble Pie
Buried within the classifieds of our local biweekly newspaper is a small “Thank You” column. In it community members thank one another for various acts of kindness. I receive a handful of these notes every year. Jan and I have a running gag – whenever the latest paper arrives, if there are no messages in it for me she jokes that the “Dr. Gray Thank-You Supplement” must have fallen out again. Pretty droll, but it always makes me laugh.
On those occasions when she mentions there’s a note for me, I like to try to guess who sent it before I read it. Over the years I’ve learned there is surprisingly little correlation between the acuity of the illnesses I treat patients for and subsequent thank-you notes (or lack thereof). Most times it is not patients I literally snatched from the jaws of death who send a note to the newspaper, it’s people I assisted in more mundane ways. I never expect to receive thank-you notes, so it brightens my day whenever one comes along. They serve as a reminder that I really am making a difference out here in the trenches.
Mr. Anderson was an 80-year-old patient of mine. He had an acerbic wit and a flawless memory. Although he tended to be fairly cranky with most other health care providers, he always had a good yarn and a devilish wink for me. Unfortunately his body wasn’t quite as resilient as his mind, and over time his internal organs began to fail. Despite our best attempts to quell the escalating mutiny, he eventually succumbed to multi-system failure. His death saddened me.
A few days after Mr. Anderson’s funeral I was scanning the paper when I came across a thank-you note submitted by his family. It was a long one. In it they thanked several friends of the family, some hospital and Home Care nurses, a couple of ambulance attendants, their minister, the funeral home and the florist. In short, everyone but me.
