It started last week because we had several moribund patients, patients who we knew were imminently going to leave the hospital through the back door. Every morning, when I walked into the hospital and check my team’s patient list, this awfully morbid game played through my head.
If we’re talking in programming terms, the “_Medicine Red” list is an unsorted set of entries of patient names representing the patients we are currently managing. Names are added to the list when they are admitted through the emergency department or transferred from other teams. Names are dropped from the list when we discharge them, when we transfer them to other teams, or when they die. In simpler terms, our list of patients tells us who to treat, and changes in our list are a big deal.
We do most of the work during the 12 daytime hours between 7 and 7, but half the events happen during the 12 night hours when I’m not watching the list. Thus, at the beginning of the day, I get lots of updates from notes that consultants wrote after hours and when I get signout from the night team. But when there are patients on the edge, there’s tension from the very moment I sit down and boot up the EMR. Are they still here on the list, or has death taken them off?
There was our man with end-stage cancer with a primary tumor so big it was most of his belly and mets filling the rest of his organs. His family was really struggling to accept his disease, but eventually they came to terms with it. We got him ready to ship off to hospice, but one morning he got really sleepy and started agonal breathing. Throughout the day, his blood pressure and pulse rate started dropping and he became drowsier. Before leaving for the night, we wrote him the prescriptions for pain management for the end, and by the next morning his name had left the list.
Then there was the 94-year-old demented lady with failing lungs. _Medicine Green knew she was going to die, but they transferred her to our list so that she could occupy our available single room because maybe she was infectious. She was already nonverbal and bedbound and dependent on oxygen, so basically we received her so she could die in an isolation room. She actually lasted longer than expected and was still on the list on Thursday and Friday mornings, but on Saturday she wasn’t.
Then there was my patient I’ve been following for two weeks, fighting a severe disease process with complicated therapies and so many transfusions. He was a grouchy but reasonable dude, and most he urgently wanted to get better as soon as possible. For most of it, we were all optimistic, but on Saturday suddenly he destabilized and we could do little to stop it. When I left late that evening, his fluid status was tenuous, we were struggling to transfuse fast enough, and it seemed like he was ready to give up too. I spent all weekend thinking of what other therapies we could try, could we have done anything more optimally, and what in the world was was happening to him while I was gone. I dreaded that moment Monday morning when I logged in and pulled up “_Medicine Red.”
He was off the list.
*details about the patients and EMR altered for privacy