With Hospice to start out my morning,
I didn’t get any warning
The things I would see
When up on OB.
I caught the baby a-borning
I took the position of Medical Director of Care Initiatives Hospice last fall because I wanted to broaden my horizons and learn about terminal care. I hesitated at first because a colleague whom I wholeheartedly admire headed Hospice of Siouxland during his semi-retirement years. I made it clear from the beginning that I didn’t want to take business away from the other program. Usually competition results in a bigger pie and more business for everyone.
They offered the position to eight other docs before me. The other docs declined for a variety of reasons.
But I wouldn’t have taken the job if it weren’t walking distance. Yesterday I walked down the hill from my office, past the melting piles of snow, with moraines of river rock and debris on the sidewalk. It was good to feel the gentle cold of March on my face, and hear the birds singing. I make that walk once a week.
The large and sparsely furnished meeting room showed an organization recently moved into larger quarters. A dozen people sat around a square of tables, and we talked about the seven patients on the roster. The first one was the triumph. With so much improvement since we started paring down the medication list, Hospice services might not be justifiable for much longer.
We have discharged three patients alive from Hospice.
Most of the elderly who come to my attention come badly over medicated. I try to follow the rule of never making more than one medication change per visit, but I figure that if a medication doesn’t do its job it needs to get axed. For some of the aged, the process can go on for the better part of a year. I take particular delight in stopping the Alzheimer’s medications and watching the patient’s “dementia” evaporate.
Palliative care stands in stark contrast to my usual approach. Hospice intends not to extend life so much as to relieve suffering. This approach has changed my point of view and enlightened me.
I don’t deal directly with the patients. I listen to reports from nurse, aid, chaplain, and music therapist, and I make suggestions to pass along to the patient’s attending physician. Some of those physicians accept those suggestions better than others.
While I was at the Hospice meeting I got a call from Labor and Delivery about my patient who had come in for induction of labor.
With that patient at the back of my mind all morning, I left the clinic at noon to rupture the membranes. Of course her water broke spontaneously just before I arrived, and I stayed around till I had to go back to the office. When I left her cervix had dilated to 7 cm, 3 cm short of the requisite ten.
That patient occupied my background thoughts all afternoon through my clinic duties and through my visit with the plastic surgeon who observed my forehead scar was coming along nicely. Then I could finally go to Labor and Delivery and not think about trying to do anything else at the same time.
Things went well till the baby’s head stopped descending and the heart rate dropped from the 120’s to the mid 80’s. The consultant I requested from Group A was doing a surgery downstairs.
Minutes count in those situations. The consultant from Group B came in seconds later.
That obstetrician was able to place a vacuum extraction device on the baby’s head much higher than I would have. Pulling at just the right angle, the baby’s head rotated like a corkscrew, and when the really scary stuff finished, I took over the rest of the delivery. All is well that ends well; the baby was large and healthy and cried immediately. I thanked the consultant profusely.
Four hours later the postpartum nurses called me to tell me the patient had suddenly bled a liter for no apparent reason. I ordered the right drugs by phone and the bleeding stopped, but I called every half hour till midnight to make sure the patient did OK. All in all, I didn’t sleep well.
I rode the rollercoaster again with no grab bar. Attending the birth of a child still brings a sense of wonder to me. I will enjoy the last delivery I do, and then I will thoroughly enjoy doing no more deliveries