Can’t We All Just Get Along?

A relationship without communication ends in expletives, tears, and likely a breakup.  A hospital stay without communication ends in close calls, medical errors, and in the worst of cases, death.

The patient had a complicated history, with a recent kidney transplant managed with immunosuppressants, a subsequent ear infection, and complications which led to him to get parts of his facial bones resected in order to avoid any further spread of the infection. Nevertheless, by the end of that hospitalization in July, he was doing fine and was on the road to recovery.  With some help, he was walking short distances and overall was showing signs of improvement.

That being the case, it was quite a surprise when he came back just a month later, with leg weakness so severe that he could barely lift a foot, let alone take a step.

So he was admitted to the hospital once again and was placed under the primary care of the transplant service, despite the fact that his current symptoms were likely neurological in origin.  Now, it’s important to understand the logic here, which in itself isn’t wrong:  given his complicated medical history and kidney transplant — the complexities of which are likely to complicate any course of medical treatment — it was absolutely appropriate to have the transplant team see him.  However, the unfortunate design of the medical system (records, billing and all) meant that this initial determination of primary service precluded any other specialty (for example neurology) brought in to care for him from making medical decisions; anyone other than the transplant team were consultants, and would ultimately have limited control over his clinical course.

For the neuro team, this meant that we could only make recommendations for tests and procedures to be done, all of which would have to go through the middle-man approval of the patient’s primary team before being executed, slowing diagnostics and impeding treatments that would prove to be time sensitive.  In the case of our patient in particular, the decline was quick and severe.

Though he had come into the hospital with generalized muscle weakness, he was still able to move all of his extremities, even if that meant only a little lateral movement of his legs and wiggle of his toes (remember, his legs were the worst off).  He was also able to speak, only requiring occasional help from his daughter when communicating with us, and overall, seemed to be in no acute distress.  Over the next few days, though, he began a steep decline, as his speech rapidly worsened along with his motor capabilities.

On the second day I saw him, he was barely understandable, with marked facial weakness and the beginning signs of labored breathing.  The neurology attending I was working under realized the gravity of what she was seeing and told us to make sure we put in an order for a blood analysis known as an arterial blood gas, a test of oxygen absorption which would help us determine how well the patient was breathing.

At the top of out differential diagnosis was something called Guillain Barre Syndrome, an autoimmune disease where the body produces antibodies directed against a certain type of myelin (the fatty material that insulates nerves) found particularly in the peripheral nerves of the body.  Over a variable period of time (the process can be slow or fast, as was the case of this patient) these antibodies destroy the nerves, leading to both loss of reflexes, sensation, and ultimately paralysis of pretty much any part of the body.  In its classic presentation, the paralysis ”ascends” or goes from the periphery inward, starting in the feet and legs, (sometimes the arms) and heading towards the trunk, where it ultimately paralyses the most important muscle of all: the diaphragm.  This is the main muscle reponsible for breathing, and its paralysis basically means death.

This was our main concern, and more than anything else, we wanted to make sure that our patient didn’t progress that far.  But alas, per the system, he was not actually our patient.  And so we had to go through convoluted means of communication to get anything done, with every suggestion we made seemingly under-appreciated with regards to the urgency at hand.  So our attending, fearing that the patient could (and would) go into respiratory failure any minute, offered to take responsibility for the patient and have him transferred to the neurology service and moved floor where we’d be able to expedite the treatment plan which we thought, from a neurological standpoint, would serve him best.  Unfortunately, likely due to some inane hospital politics that never fail to surprise me with their absurdity, the primary team refused the transfer, and our poor patient stayed in the same room, on the same floor, and under the same primary service, when hour by hour he needed more and more monitoring and urgent care.

And so, with a growing sense of frustration matched only by our resolve to do right by the patient, we set out to make sure that our treatment plan would be carried out as quickly and efficiently as possible, despite the communicative obstacles. We had to breathe down the necks of the primary service to get the arterial blood gas we’d requested the day before drawn, and had to jump through hoops in order to ensure that he was getting the proper work-up for his condition.

This included an invasive procedure known as a lumbar puncture, in which a sample of cerebrospinal fluid (the fluid that surrounds the brain and spinal cord) is drawn up through a needle inserted between the patient’s 4th and 5th lumbar vertebrae while lying on their side.  So we went about preparing to do the procedure, and positioned the patient accordingly.  My job was to hold him in place from the front while the residents did the procedure on his back.  While holding the patient in this position, alternating words of encouragement and comfort, I noticed something odd about the movement of his abdominal muscles that coincided with his now erratic breathing pattern.  It looked like something I vaguely remembered from my pulmonology lectures years before called paradoxical abdominal breathing, a unique phenomenon which signified exceptional impairment of the respiratory muscles, top among them, the diaphragm.  In other words, if this were the sign I thought it was, our patient was in trouble.

But never having actually seen it outside of an illustrated textbook diagram, I was less than positive that I was actually seeing one of the harbingers of respiratory failure, and not wanting to bother the residents during the stressful procedure, waited until I saw the attending shortly thereafter back on the neurology floor to report what I had seen.  By that time, she was already on the phone getting word that the patient’s respiratory rate had doubled with decreased oxygen saturation levels (the ultimate sign of respiratory failure) and that he was about to be intubated and placed on a ventilator to make sure that he would continue to breathe while we worked on getting his muscle function back.

Fortunately, he was successfully intubated minutes later, for which the primary team deserves the credit; indeed he received the care he needed when he needed it most.  Since then he has been receiving various treatments for his condition with some improvement of motor and respiratory function (although he’s still on the ventilator). All that aside, the question remains as to whether or not we could have prevented the close call and stopped him from progressing to that stage of severity had we been able to act more preemptively and aggressively. It’s debatable, but certainly not outside the realm of possibility.

Whether it was the lack of cooperation/understanding between the teams, delayed diagnostic testing, or my own personal failure to convey a significant physical exam finding in a timely manner, better communication probably could have made a real difference in the case of this patient.  And while disaster was averted this time, it warrants thought for the future.

It seems, as in the case of a relationship, a little communication early on can go a long way in preventing less-than-ideal outcomes down the road.

Picutre of author

About Justin Fiala, MD Candidate

Justin is currently in his third year of medical school at UIC's College of Medicine, and is hoping to pursue a career in internal medicine. He has a strong interest in addressing the health needs urban communities and is part of the College of Medicine's Urban Medicine program. Aside from academics, Justin enjoys cooking, listening to public radio, and perusing the New York Times website. He is also a trained pianist and self-professed lover of all kinds of music.

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