“JOAO” (GLOBAL HEART FAILURE,
and PLACEBO EFFECT?)
Monday evening was very sombre by
comparison. I was about to go home at 6 PM, but as per Murphy's Law,
was informed by a nurse that a new patient just arrived to the
Emergency Room.
“Joao” was a boy who came
with his parents, feeling quite short of breath. Karl and Maria were
still busy in their afternoon ward rounds but would soon check him
out. His legs were both swollen with pitting oedema, abdomen and JVP
distended, all from Right Heart Failure. There were crackles in the
bases of his lungs, suggesting Left Heart Failure too. His heart was
already beating very fast. Unfortunately, he had Mitral Stenosis
which was untreated for years, and now we were looking at the end
complications. Dr. Dan already commenced him on a very low dose of
Beta-Blockers to slow down his heart rate, in addition to taking
Frusemide (a diuretic Rx). I was really anxious for him to get rid of
his “excess” fluid as much as possible.
He was already on medication, I
thought. This is a medical emergency, so ABC, ABC. I quickly looked
at his palms and the inside of his mouth. He wasn't cyanosed yet, but
clearly had increased work of breathing. I ran out of the room to get
a pulse oximeter, returned and clipped it to his finger. 94%
saturation, so still ok-ish. Joao and his parents didn't understand
what the pulse oximeter did, so I basically said it shows how much
oxygen is in the blood, and that anything above 90% is still
acceptable. Joao and his parents then became very focused on the
displayed number. But inside, I felt uncomfortable because I wasn't
sure if that number was correct though. It also displayed his pulse
which was completely inaccurate. I was hoping that by focusing on a
number, that it would help quantify his status and calm him down.
I was confident he needed Oxygen for
comfort and asked Joao if he wanted to try it. He immediately said
yes.
I ran to the nurses' room, and brought
back the oxygen tank with a mask. He looked relieved when it arrived,
and I started putting it on him. I tried to switch on the Oxygen Tank
and turned the delivery rate to 6 Litres / minute, but there was a
leak in the delivery device connecting to it, releasing a small “air
stream”. Barely any of the Oxygen was going through the tube.
I felt devastated. Was Murphy's Law
cursing me again? What should I say to him?
I dramatically increased the delivery
rate, and a bit of the Oxygen was now flowing through the tube, with
the “air stream” producing a prominent hiss. Oh dear, lots of
wastage. I asked Joao if he could feel it coming through, and he said
yes, but only a bit.
He looked much calmer now, but inside
I felt guilty. A lot of Oxygen was leaking out and being wasted,
which could've gone to other future patients in Cardio-Respiratory
distress. How far should one go when there are limited resources?
His Oximetry sats was hovering at around 94 or 95%. But how much
Oxygen is he really receiving? I couldn't quantify it, and was
wondering how much of his calmness was from actually receiving
significant Oxygen, or from the placebo effect of looking like he's
receiving a treatment. Calming his parents down would also have
influence on him.
I holding his hands for a few minutes,
and the room was silent apart from the hiss. Karl and Maria soon
arrived, and ceased the Oxygen delivery as it would be unsustainable
at the current delivery rate, rapidly depleting the Oxygen tank. I
offered to lower it to the original 6 Litres / minute, but this was
also considered a bad idea: If Joao wasn't actually receiving the
Oxygen, then wearing the mask would only result in him breathing back
in more Carbon Dioxide, worsening the situation. His Oximetry sats
was still acceptable in room air, but Joao clearly looked more
distressed / upset.
Karl and Maria were medically correct,
but in my mind, I was still anxious. I was using the Oxygen Tank as a
psychological crutch, and obsessed about giving Joao Oxygen. I called
a BPC assistant who also did some device repair, but he was unable to
repair the leak.
There was one more Oxygen tank, but
much heavier. Joao got admitted to the main ward, with that Oxygen
tank placed next to his bed for “comfort”, even though the
attached device also leaked. I felt really sorry for him. No working
Oxygen tanks at BPC tonight.
Please don't die, please don't die,
please don't die.
It was getting dark and I had to
return home. I said bye bye to Joao and his family. That was the last
I saw of him.
At home that night, I realized how
obsessive I was about the Oxygen, and how emotionally “soft” I
was. I felt so bad/sad to see him suffer, and wanted to give the
Oxygen not only to comfort him psychologically, but myself as well. I
wanted to give them the impression that I was doing something, even
though clinically it wasn't doing much, and resources-wise, unviable.
There was an element of selfishness and I felt guilty. I was
being empathetic, but I had the wrong application.
When there are limited medical
resources, you have to be prudent as much as possible. It's always a
challenge to help many people in such a setting, where there's only
so much you can do. There'll be many times where you just have to be
brutal and ration things out (eg opioid analgesia), when in a
developed country, everyone would have far more access to it. You're
not being intentionally mean or cruel, but trying to use resources
wisely based on priority.
In fact, it could be argued that in
the process of “overtreating” 1 Patient, you'd be impairing the
outcomes of many others, which some would consider as even more
selfish. I suppose in Australia, where rationing of this degree has
yet to take place, Drs have far more breadth to order investigations
and prescribe medications to please Patients (demanding or not), in
addition to covering their asses Medico-Legally. At the end of the
day, you are working as a Dr, and not as a “People-Pleaser” (even
if it attracts more referrals and repeat appointments). For the sake
of good Clinical Practice, there'll eventually come a point where you
need to set boundaries and say “No”.
Note: Joao was transferred to GVNH the
next morning, but died several days later. I couldn't get any further
details from the Ward Clerk at GVNH. RIP... : (
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