Messages from Unexpected Places
Letter to Louie 6-10-13
Another Confined to the Treatment Center
Dear Louie,A number of years ago, nearly a half century ago, during my residency, I was privileged to hear words of wisdom from an unexpected source. If you have heard this before, forgive the repetition.
As I recall, we were making ward rounds, on the old 3 West communal ward in Milwaukee General Hospital, and were rounding in a four bed ward. The patients were four old women, old at the time; about 70 to 75 and were suffering from diseases of the aged; from urinary tract infections, from congestive failure, from strokes, heart failure and probably other chronic afflictions. At that time patients were hospitalized for days on end, were treated quite vigorously, sometimes in retrospect inappropriately, and consequently for a significant time.
During that time a casual attitude was adopted, an attitude initially of hope and optimism, but later of mature insight and awareness of the downhill slide of chronic disease with the inevitable elderly orthostatic pneumonitis, congestive failure, multiple pulmonary emboli and death.
The process was played out too often, but on occasion a vigorous old woman would maintain and recover.
This individual would have been just a bit more vigorous, more aware and, although not always demonstrative, be just a bit more observing and sometimes most observant; a real fooler.
One such patient had recovered from multiple disease entities and was awaiting discharge back to Unit 2 , a long term care facility. She sat quietly in her chair - an old wicker wheelchair, with the high back and pushing rod; dressed in the striped gown of a Unit 2 patient holding the tray of her belongings as she awaited transfer. We warded around her, spoke over her, pushed the chair from the adjacent bedded area, and nodded to her, wished her well and set her up for an outpatient visit. She was for all intents and purposes on her way back to the long term old folks home.
The women of the four-bed ward had been subjected to a rather violent upper respiratory infectious disease and the mortality had been high during the past number of weeks. Our patient had been a vigorous survivor, had been most quiet on her stay, but had been always alert and with shiny eyes had penetrated the ward rounds and unknown to us had assimilated the medical jargon. That morning, one of the ward occupants had “taken a turn”and was being placed on the “last medical rights” ; a concoction of high dose penicillin, intravenous chloromycetin, and gamma globulin. A concoction only sometimes effective; many times expensively ineffective and death took over.
She, with the penetrating eyes, had heard, observed, and I suppose, documented the deaths which occurred in spite of the heroic doses of antibiotics and other supportive medications. She knew of the outcomes, and probably of the futility of care; she was well aware; and we were not aware.
It was such a surprise when out of her wheelchair confinement came a little voice... in response to the residents orders for “ a million units of aqueous penicillin, two grams of chloromycetin, 100mg of solu medrol over the next twelve hours.”
Her voiced response responded with insight and some authority, ”Aha, another kiss of death."
The remainder of rounds was very quiet, the remarks were discussed at Residents Rounds and some insight was gained. Over the years her remarks have been thought of many times, and a certain humbleness has replaced the cocksure attitude of the second year resident.
This week has given an insight, again into an attitude of treatment in what has been treatment failure. Treatment failure of modern medicine. Failure to be able to change the course of the modern black death. The death of so many minds; the modern scourge of Advanced Cognitive Disease; Alzheimer's Disease. One of our own, one of the Class of ’44 has been admitted to Cedar Lake Campus for management of aggressive Alzheimer's Disease. This classmate is following the course of his older brother. He’s following the course and is aware of it. As I recall, and neither of them has been a patient of mine in the past, the brother developed a highly malignant, aggressive, belligerent, difficult to manage form of dementia. He was confined, “over my dead body” to the Dodge County Home For Mental Illness and there remained.
During his stay our classmate worried, there seemed to be a family problem in the past. He voiced his concern many times to me, his worry of the disease. And now it appears that “Aha, another kiss of death” is occurring.
This business of aging, Louie, is distressing.
However on occasion, like last night, when Gomez of the Brewers leaped high into the sky in the outfield, against the fence, and against all odds, to catch the baseball and save the game; on those occasions “all are young again,” and the martinis taste better, and hope springs eternal.
And the elderly lady in bed 2, with the dark penetrating eyes and great insight... might “just not always be right."
So, “Keep the faith Louie.”Jim