Wednesday, October 22, 2008

The Dwindles

There's nothing more frustrating than a dwindler. You get the 83 year old lady with free air to the OR expediently (3am). The operation proceeds quickly and smoothly. You promptly get her off pressors and restore renal function with timely and appropriate resuscitation. Post op she gets extubated by day 2. The stoma looks pink and fleshy and starts putting out stool by day 4. You get her up in a chair. She smiles. Her labs all normalize. Things are progressing swimmingly.

But then she won't eat. She refuses to participate in physical therapy. She lays in bed all day. The smile fades. You enter the room and she barely looks at you, a blank gaze, dull-eyed and lifeless. You try to keep her spirits up. You encourage family members to get involved. But every day you see yet another full tray of cold, uneaten food. She starts to cough a little. You have to commence tube feeds via a nasogastric tube to supplement her nutrition. Then one night you get a call from the nurse. "Dr. Buckeye, Mrs. Dwindles is short of breath and her heart rate has jumped to the 130's. She looks like hell." You send her down to the ICU. CT scans are done. Labs are drawn. She looks septic. The white count is elevated. There's an infiltrate in the lower lobe of the lung. She spikes a fever overnight and continues to deteriorate. She's saturating 89% on a non-rebreather mask. The family opts for intubation and that seems to help for while. Antibiotics are started and she begins to semi-stabilize as the pneumonia clears up. But she never really gets over the hump. She just doesn't seem to have the heart for it anymore. Maybe she stabilizes enough to be transferred to an LTAC, maybe not. Either way, she isn't anything like the woman she used to be. Everything good and vibrant and distinctive about her as an individual has already dissipated. She simply dwindled away.

These sorts of patients can be very frustrating. No matter what you do, no matter how textbook the operation, no matter how perfectly you manage the recovery phase, sometimes the patient fails to progress. You bang your head against the wall searching for an underlying reason. But the explanation is quite simple. A patient needs to want to get well. They have to want it with every ounce of their being. It doesn't matter how hard you work or how many tests you order. Once a patient loses the heart for the good fight, the ultimate outcome is inevitable. For a young surgeon, this can be one of the most difficult pills to swallow...

11 comments:

rlbates said...

Very frustrating -- the dwindles. I never found a good way to deal with them. I've taken knitting & crocheting & sewing supplies to some little old ladies. Sometimes it helped, not always.

I don't wear much lipstick, but may have to start as I get older. One of the best signs is coming in to round and finding that Mrs Dwindles has put on some lipstick. I love that "sign"!

MedZag said...

My grandfather was a dwindler. His esophageal cancer was completely resected by an esophagectomy but after his wife passed away he just lost the will to rehabilitate. It's a sad reality in our elderly population.

Health Train Express said...

Buckeye....buckup you did your best, and it is hard to accept not getting a 'A' for your hard work and results. Elderly people are not only physically elderly, but some times mentally depleted by life's events....
Acting early by engaging family, grandchildren friends sometimes can make a difference, not always, but sometimes SSRIs can alter this mental depletion.
Don't give up on the next one...
gml

surgster said...

Buckeye--
You're speaking my language!!! Right now I have a previously healthy/vibrant 79 yo woman with pancr CA, went thru a 6 hour challenging and technically beautiful resection for cure, now just 'dwindling' away...decided she wants to be DNR/CMO because she 'has nothing to live for.' Can't help but be frustrated that my co-surgeon and I poured our hearts into the surgery and early postop care, and now ...

Buckeye Surgeon said...

Ramona- I like that idea! Tomorrow im going to start sharing my lipstick with my little old lady patients.

Bianca Castafiore said...

My internist gave me this advice prior to a surgery: "Only do it if you can go into it absolutely convinced that everything will go well. If you have any doubt at all, postpone." Of course, the patients you seem to be discussing are not in an "elective" category, and are older. Paralyzing fear -- somatic and psychic -- seems to be at the heart of it, somehow. Not fear of dying, but fear of living, and of the "complications" that life might bring? The lipstick idea makes me smile -- I always pack several -- and whether I wear them or not, I am reminded of hope at the sight. Especially Sassy Cinnamon. But is there an equivalent for dwindling man?

Annie said...

Difficult, but all of the cases mentioned in the post and comments would appear to have sx. of acute depression.

Has anyone considered getting a psych consult or at least a soc. work. consult for therapy assessment? If so, did the outcome improve?

Family dynamics, perceived degree of loss of independence, anticipatory grieving, fear of dying, etc - all and much more may be in play.

Do any of your facilities have a gerontology dept? That would be an ideal consult source, if available.

Bongi said...

reminds me of a patient in my training. not only didn't she want to get better, but she wanted to die. and she did everything the opposite of what we told her to do. maybe i should blog about it some time. even lipstick wouldn't have helped.

Buckeye Surgeon said...

annie-
I have involved psychiatrists in these scenarios. Usually nothing much comes of it. An order is placed for Zoloft and you never see Dr Shrink again. Plus, it's an unfair situation for the psychiatrist. The patient is recovering from an illness, maybe hooked up to a billion lines and tubes in the ICU and it's difficult to do the kind of intense cognitive based therapy that some of these patients need....

liz4cps said...

My father-in-law had surgery last February, and it took a long time for him to recover from the anesthesia and a subsequent move to assisted living. He had been a very intelligent man but moves and anesthesia seem to really set him back. He went from being oriented 99% of the time to being oriented about 50% of the time.

I wonder how much these factors could be contributing to dwindling...

Dr. Val said...

I couldn't help but wonder if she might have had a swallowing problem... as many as 50% do after extubation. This can lead to an aspiration event, perhaps complicated by nausea from meds... then pneumonia. The elderly are very fragile and should avoid the hospital whenever possible. :)