(As always, the following narrative is heavily altered and anonymized, with numerous details changed. As such you could say this is “based on a true story.”
I reiterate this because the point of this thread isn’t to blame specific individuals; the issues are systemic.) 1/
I reiterate this because the point of this thread isn’t to blame specific individuals; the issues are systemic.) 1/
The pain is all she knows.
When it flares in her belly like this, it becomes her.
She cannot think, but through a disorienting haze. She cannot breathe, but through clenched teeth. She cannot see, but through tears.
And she cannot ask for help.
The pain is all she knows. 2/
When it flares in her belly like this, it becomes her.
She cannot think, but through a disorienting haze. She cannot breathe, but through clenched teeth. She cannot see, but through tears.
And she cannot ask for help.
The pain is all she knows. 2/
Shana has sought help before. Six times in the past month, in fact.
She is a dialysis patient, and the pain forces her to miss her treatments because she misses her bus.
The ER says she’s noncompliant with dialysis. They dialyze her, and give her pain meds that don’t work. 3/
She is a dialysis patient, and the pain forces her to miss her treatments because she misses her bus.
The ER says she’s noncompliant with dialysis. They dialyze her, and give her pain meds that don’t work. 3/
She resents the words she hears whispered. Non-compliant. Faking it. Drug-seeking.
In the midst of her agony, she is having her dignity stolen from her.
She had to leave the hospital once because her son was home alone.
“AMA” her doctor said.
Against Medical Advice. 4/
In the midst of her agony, she is having her dignity stolen from her.
She had to leave the hospital once because her son was home alone.
“AMA” her doctor said.
Against Medical Advice. 4/
She does not want their “help.” She does not need to be judged in her most vulnerable moments.
But she’s scared now.
Her young son stands in her bedroom doorway, worried. He heard her crying and it woke him from sleep.
He asks her what to do.
She tries to think. 5/
But she’s scared now.
Her young son stands in her bedroom doorway, worried. He heard her crying and it woke him from sleep.
He asks her what to do.
She tries to think. 5/
A neighbor is awake and offers to help when they knock on her door. She drives Shana to the closest ER, and offers to let her son stay over. Shana is grateful.
In the ER, the first thing she notices is the look in the eyes of the triage nurse:
“Here we go again,” it says. 6/
In the ER, the first thing she notices is the look in the eyes of the triage nurse:
“Here we go again,” it says. 6/
Shana’s information is taken. She is instructed to have a seat in the waiting room until called back.
She sits in a corner, not wanting to be able to hear their judgment. The pain is staring to crescendo.
She curls up, as minutes turn to hours.
Sweat laces her brow. 7/
She sits in a corner, not wanting to be able to hear their judgment. The pain is staring to crescendo.
She curls up, as minutes turn to hours.
Sweat laces her brow. 7/
The on-call nephrologist gets a page from the ER. Her name is Grace and she is a new attending, only recently graduated from her fellowship.
The idea of practicing medicine without a supervisory safety net is both exhilarating and a little scary.
She calls the ER back. 8/
The idea of practicing medicine without a supervisory safety net is both exhilarating and a little scary.
She calls the ER back. 8/
“Hey doc, we got one for you. Frequent flyer. 45 year-old, missed dialysis today, abdominal pain. Probably gastroenteritis. Had a CT a week ago, mostly just constipation. If you can dialyze her before we get her out of here, that would be awesome.”
“OK.” Grace agrees. 9/
“OK.” Grace agrees. 9/
She calls in dialysis orders to the inpatient dialysis unit and says she’ll be by in a little bit to check on the patient.
Logging on to a workstation computer she glances at Shana’s chart and rolls her eyes. Six visits to two different hospitals in a month?
Great... 10/
Logging on to a workstation computer she glances at Shana’s chart and rolls her eyes. Six visits to two different hospitals in a month?
Great... 10/
The dialysis nurses connect Shana to the machine.
One of them is trying to find a vapocoolant spray to numb Shana’s arm before the large-bore fistula needles are placed, but another one doesn’t bother to wait.
Shana lets out a gasp as the needles go in, and her eyes water. 11/
One of them is trying to find a vapocoolant spray to numb Shana’s arm before the large-bore fistula needles are placed, but another one doesn’t bother to wait.
Shana lets out a gasp as the needles go in, and her eyes water. 11/
Thirty minutes later, Grace gets a page from the dialysis unit.
Apparently her frequent flyer is in pain and requesting something stronger than the low-dose morphine that was ordered.
Shocker.
Grace sighs exaggeratedly, and leaves the physician lounge to head upstairs. 12/
Apparently her frequent flyer is in pain and requesting something stronger than the low-dose morphine that was ordered.
Shocker.
Grace sighs exaggeratedly, and leaves the physician lounge to head upstairs. 12/
As she enters the dialysis unit and sees Shana for the first time, Grace’s heart sinks.
A middle-aged woman lies in the bed before her, slowly writhing in agony. Her gaze is far away, and the only sound she makes is a fervently whispered repetition.
“Please, God, please.” 13/
A middle-aged woman lies in the bed before her, slowly writhing in agony. Her gaze is far away, and the only sound she makes is a fervently whispered repetition.
“Please, God, please.” 13/
Grace’s eyes quickly move to the vital signs monitor. Heart rate high, blood pressure normal, on the low side.
“Give her 1mg of Dilaudid IV, right now,” she says.
She sees one of the nurses look grateful, while another one looks annoyed.
She makes a mental note of this. 14/
“Give her 1mg of Dilaudid IV, right now,” she says.
She sees one of the nurses look grateful, while another one looks annoyed.
She makes a mental note of this. 14/
Grace examines Shana quickly but thoroughly. She is now even more worried than she was before.
She logs back in to the computer and takes a closer look, heart racing.
Chief complaint: “missed dialysis”?
No mention of abdominal pain until much later in the history. 15/
She logs back in to the computer and takes a closer look, heart racing.
Chief complaint: “missed dialysis”?
No mention of abdominal pain until much later in the history. 15/
She clicks back through prior visits and sees the pattern. Missed dialysis, missed dialysis left AMA, GERD, missed dialysis, constipation, missed dialysis.
She looks at the workup today: basic labs, a urine pregnancy test, and a drug screen.
A drug screen?
No imaging? 16/
She looks at the workup today: basic labs, a urine pregnancy test, and a drug screen.
A drug screen?
No imaging? 16/
She scrolls back and sees a CT scan from last week. The report is dense because Shana has had multiple surgeries before.
As Grace reads through each and every detail, she finds something buried in the report.
“Possible aneurysmal dilatation noted, obscured by artifact.” 17/
As Grace reads through each and every detail, she finds something buried in the report.
“Possible aneurysmal dilatation noted, obscured by artifact.” 17/
After Dilaudid, Shana feels the pain in her belly subside for the first time in weeks.
It’s still there, but the sensation isn’t a jagged shard of glass anymore. The edge has come off.
She licks her lips, feeling their dryness.
Her voice is hoarse as she asks for water. 18/
It’s still there, but the sensation isn’t a jagged shard of glass anymore. The edge has come off.
She licks her lips, feeling their dryness.
Her voice is hoarse as she asks for water. 18/
As she drinks the cool water, she’s able to think clearly. She looks around her, seeing everyone as if for the first time.
There is a doctor sitting at a desk. She looks young enough to be Shana’s daughter.
But it’s her expression that worries Shana.
She looks terrified. 19/
There is a doctor sitting at a desk. She looks young enough to be Shana’s daughter.
But it’s her expression that worries Shana.
She looks terrified. 19/
The young doctor comes to Shana’s bedside and explains. Something about needing an emergent scan, maybe surgery. They might have to fly her to a city hospital.
Fly her?
Shana thinks of the cost, the bills, and her son without her.
“I feel better, I’m OK now,” she says. 20/
Fly her?
Shana thinks of the cost, the bills, and her son without her.
“I feel better, I’m OK now,” she says. 20/
The doctor doesn’t seem to want to take no for an answer. She is insistent.
Suddenly, Shana explodes in anger.
Her eyes are filled with tears.
“I told all of you! I came to you! I said HELP ME! I came here over and over and you didn’t listen to a DAMN THING I said!” 21/
Suddenly, Shana explodes in anger.
Her eyes are filled with tears.
“I told all of you! I came to you! I said HELP ME! I came here over and over and you didn’t listen to a DAMN THING I said!” 21/
Grace is stunned by the outburst, and shamed.
She bites her lip, a sudden urge to run away and hide coming over her. But instead she pulls up a chair and sits down beside Shana’s bed.
The two women sit in silence.
The only sound is the steady whirring of the dialysis. 22/
She bites her lip, a sudden urge to run away and hide coming over her. But instead she pulls up a chair and sits down beside Shana’s bed.
The two women sit in silence.
The only sound is the steady whirring of the dialysis. 22/
Shana eventually breaks the silence.
She asks many questions about what’s wrong with her. She angrily asks why nobody saw it before. She alternates between hot fury, and cold fear.
Finally she calls her son, and tells him mommy might have to be away from home for a bit... 23/
She asks many questions about what’s wrong with her. She angrily asks why nobody saw it before. She alternates between hot fury, and cold fear.
Finally she calls her son, and tells him mommy might have to be away from home for a bit... 23/
Later that night, Grace is walking briskly back to her car.
She sees an elderly woman waiting at the bus stop near the hospital entrance. Her features seem drawn with pain.
Grace looks at her for a long moment.
And then she keeps walking.
The bus will come soon enough...
She sees an elderly woman waiting at the bus stop near the hospital entrance. Her features seem drawn with pain.
Grace looks at her for a long moment.
And then she keeps walking.
The bus will come soon enough...
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