I don’t quite know why I decided to do this. I don’t know if anybody wants to read it. But I wanted to look at the doctors notes during my month long hospitalization at Poudre Valley Hospital in Colorado. It’s harrowing. When I was first admitted I had the flu and a lovely gift basket of other ailments, including sepsis which claimed my mother’s life in 2015. I am luckier than anybody has a right to be. So here are doctors notes, with my comments in italics. Some of this stuff is amusing (perhaps only to me), some of it is sobering. And away we go!
“The patient is a 50 y.o. male with past medical history of adrenal insufficiency, primary hypogonadism, polyglandular autoimmune syndrome type II, hypothyroidism who presented to Box Butte Hospital by EMS, unclear how.
I am pretty clear about the how. Kalin Krohe was wondering why I was not at the radio station Christmas party, so he dropped by my apartment and saw me sprawled out on my bedroom floor. I remember Kalin calling 911. I remember being put into an ambulance. I remember being told I would be flown to Colorado. And that’s about it.
He remembers hanging out with friend Saturday night then afterwards went home. He had not been feeling well that evening with some SOB and cough, but went to bed. The next thing he remembers is waking up feeling terrible, does not remember how he got to the hospital but notes a friend found him.
Of my encounter, he is having fevers and chills and has a minor HA. Feels as if his L foot has decreased sensation. He is having some shortness of breath and feels as if he is wheezing. He otherwise denies any abdominal pain, nausea, vomiting, dysuria, chest pain.”
I was hanging out “with friend”, Dangerous Dave Kuskie. Who is not an SOB. “SOB” in medical lingo is “shortness of breath.”
Assessment of patient’s performance today: The patient performed fair, needing aide for walker management, sequencing, safety awareness, and general mobility at this time. He is well below his baseline and seems to have signs of confusion. The patient demonstrates weakness and seems to have drop foot along the L ankle. The patient is recommended to follow up with 3 hours of rehab a day pending medical stability/discharge.
I have signs of confusion to this day. (Kidding. Mostly.) Also, “drop foot” sounds like something a pioneer would get on the Oregon Trail.
Assessment of patient’s performance today: Pt pleasant and agreeable to OT evaluation. Pt presenting with decreased activity tolerance, impaired balance, generalized weakness, impaired cognition, and impaired fine motor coordination (tremulous). Currently requiring one person assist to safely participate in ADLs and functional mobility with FWW. Not safe to return to home and would benefit from continued skilled therapy services provided at post acute rehab.
I try to always be “pleasant and agreeable” to people who may save my life.
Mr. Wentworth is seen in his room this morning. He is trying to eat breakfast. Does not answer questions reliably as he is somewhat slow in answering even the simplest yes and no questions. Has a catheter in place with clear appearing urine. Currently on IV bicarbonate infusion at 150ml/hour.
Patient already since this morning with worsening mentation, answers yes but does not elaborate on answers, does not follow commands. Stares into space.
This is where my trustable memories of this experience fade into loopy-goopy fever dreams or something similar. I can’t honestly say how much of what I remember is real, brain games, or a mix thereof.
Across the room the patient is lying in bed, his eyes are open, he tracks with his eyes and he responds to his name.
Vital signs reveal that he is febrile, temperature 101F, tachycardic heart rate 115, blood pressure elevated when he was sitting up in the chair to 171/95, repeat blood pressures remain elevated, respiratory rate is between 19 and 23. He is tolerating room air. Bedside blood glucose was checked and was 67, he was given juice, able to drink half of a cup, blood sugar on repeat check is 110. Lactate is 1.1
Assessment and plan:
# altered mental status
– Unclear etiology at this point
– Difficult exam as patient does not comprehend commands, some myoclonic jerking of the left upper extremity noted
– will check CT head without contrast
– will transfer to PCU for closer monitoring
– Morning labs significant for worsening acute renal failure, as stated in my progress note I do not see any centrally acting medications that could potentially accumulate in cause his mental status change
Spoke with sister Johanna. She describes Jason as “very social and very articulate” at baseline. He is a bachelor and lives independently. He performs ADLs independently; can be “a little clumsy” with fine motor skills.
“ADL”s = Activities Of Daily Living. Also, bless my sister Josie Berry for saying I’m “a little clumsy.” I’m a little clumsy the way Orson Welles was slightly overweight.
Inquired re: Left eye looks a little droopy compared to Right, mouth also asymmetrical. Johanna states that this has been normal – over the past year Jason has developed some tics and tremors and has been receiving Botox injections in hopes of lessening them.
I eventually gave up on the Botox. It made the left side of my face droop which made at least one friend ask me if I’d had a stroke. I’d rather have a twitchy eye than a droopy face.
Johanna encourages us to call her with any concerns, at any time. Try cell first and home second.
P transferred to PCU d/t near unresponsiveness, inability to communicate meaningfully, unable to follow simple commands. PT will continue to follow, but will need new orders d/t decrease in medical status.
Pt seen at bedside for clinical swallowing evaluation. Oral mechanism exam reveals: dried oral mucosa which SLP attempted to clear with cloth and suction as pt would allow. Pt presents with SEVERE oropharyngeal dysphagia characterized by poor following commands, decreased bolus formation/control, poor acceptance of trials. Attempted trials of thin liquid via tsp, ice chips, and pureed solids. Pt spit out all trials after initially accepting them from the spoon. At this time, pt is judged to be at HIGH risk of aspiration. Skilled ST is indicated for ongoing assessment of pt’s swallow function to determine pt’s ability to safely manage recommended solid/liquid consistencies, to determine when pt is ready for solid/liquid upgrades, for teaching of compensatory strategies and precautions, and for pt/family/staff education and training to help decrease risk of respiratory complications.
Oh, the ice chips. Can’t a brother get a drink of water?!! Nope. But here, suck on some ice chips. I’d like to think that my spitting things out was beyond my control…but they fed me some really gross stuff…banana mush and pudding and stuff….so maybe I spit it out in a furious rage.
Patient Jason Wentworth is a 50 y.o. male who is being evaluated for delirium.
According to the Mayo Clinic, “Delirium is a serious change in mental abilities. It results in confused thinking and a lack of awareness of someone’s surroundings. The disorder usually comes on fast — within hours or a few days.” Considering some of the things I thought happened while I was in the hospital, I’d totally go along with the delirium diagnosis. I absolutely had a lack of awareness of my surroundings.
As of 1/17/2022 Jason was able to express that he was feeling short of breath but was not reported any distress and was generally alert and well-appearing. On 1/18/2023 mental status was gradually deteriorating. He initially was able to answer yes to questions but over the next couple of days less responsive. Staff had noticed some “myoclonic jerking” of the left arm and an EEG showed diffuse triphasic pattern. Nursing today report no improvement of clinical status -he is nonverbal but says “ouch” to noxious stimulation. He occasionally developed some stiffness of his body and developed some hypertension. Wonder about the possibility of subclinical seizures. Diagnostic lumbar puncture is planned for 1/21/2023.
So…mentally soupy…fever, dying kidney, sepsis….this can’t get any worse, right? WRONG, BEDPAN BREATH!
Significant Event by Nurse Michael E at 1/29/2023 2:31 AM
At approximately 0215, bed alarm sounded. This RN entered the room and found patient laying on the floor beside the bed after an unwitnessed fall out of bed. Charge RN was notified, RRT was called and on-call hospitalist was notified. C-Collar was unable to fit on patient’s neck but rolled towels were placed around patient’s neck to stabilize neck. Vital Signs obtained. Patient was moved onto slide board and assisted back into bed with RRT staff members. Hospitalist assessed bedside. Stat CT ordered. Patient has a new swollen lump/laceration/bruise on L eyebrow with small amount of bleeding after fall. This RN attempted to call both sister and brother (phone numbers listed in chart) but neither answered.
Remember when I said I was having “fever dreams”? After this fall, which really hurt like hell, my brain concocted a scene with me being dropped, kicked and knocked around by a sarcastic, evil doctor. This, and all the other oddball one-act-plays my brain concocted, are as clear and real to me as any memory from my entire life.
Exam:
Gen: awake and interactive, chronically ill-appearing, does appear younger than his stated age
Well, I am the Dick Clark of Box Butte County.
Pt seen at bedside for dysphagia tx targeting diet tolerance. Pt reporting that his stomach is hurting following dialysis. Pt did accept trials of thin liq via straw and puree. Pt declined crackers. No signs of aspiration/ penetration noted with trials presented. Pt req feeding assistance to move dobhoff tube out of way when self feeding. Pt appeared mildly SOB following PO and when talking pt O2 at 94%, RN notified. Drooling noted on right side.
I want it known that this is the only time I have ever declined a cracker. If I were a nurse making the report I’d have said “drooly noted.” That’s why I’m a disc jockey.
Recommend assistance during meals as warranted. Pt and RN were instructed re: recommended diet and liquid consistencies, swallow precautions and general dysphagia education.
Pt seen at bedside for cognitive-linguistic tx and f/u. Pt scored 27/30 on the OLOG. Pt is reporting he feels “a little dotty”. Pt expressing concern for not being able to recall the day, daily tasks completed, and procedures completed. Pt presents with delayed response time, and difficulty following directions.
Currently, pt is below baseline and unsafe for return to PLOF due to severity of deficits. Skilled ST is recommended for education and training to improve functional communication and cognitive-linguistic skills for safe and successful return to home, community, and vocational settings. Pt and RN instructed and provided with handouts re: results, recommendations.
“A little dotty”…yep, that sounds like me. And it is me! Just ask my coworkers.
Patient presents significantly below functional baseline with deficits including balance, strength, safety, and activity tolerance.
I still have a low tolerance for many activities. But the other stuff seems to be doing better.
Resting in bed comfortably. No complaints. No issues with tunnel cath placement yesterday. Tolerating HD. Oral intake remains low. Encouraged him to try to eat as able.
HD is not “high definition”. It’s “Hemo-DIalysis”, the beginning of my year or so of thrice weekly (and eventually twice-weekly) dialysis treatments. “Tolerating” dialysis is about the best you can ask for. I am overwhelmingly blessed to have my kidney function return…for however long it may be.
Pt seen at bedside for speech therapy. Pt was alert, pleasant, and participatory. Pt’s sister present. Pt reports feeling better cognitively compared to a few days ago. Pt was joking throughout session. Sister reported feeling as though pt was close to cognitive baseline. Some responses were vague/tangential and unclear, thus needing clarification. Pt verbalized insight to situation and verbalized appropriate planning and executive function skills when discussing discharge plan and how there are many moving parts that they are waiting on prior to going to rehab. Pt reported having no rush to return to work and to do whatever is recommended to him. Adequate recall of physical therapy session details and fall that occurred two days ago. Adequate recall of what he ate for lunch. Pt may be demonstrating improvement in cognition. Pt may benefit from a repeat SLUMS evaluation in the near future. Currently, pt is below baseline and unsafe for return to PLOF due to severity of deficits. Skilled ST is recommended for education and training to improve functional communication and cognitive-linguistic skills for safe and successful return to home, community, and vocational settings.
PT’s sister present. And brother. My mental state happened to improve at around the same time my siblings came to visit me…not a coincidence, says this observer.
Pt also seen for swallowing therapy. DHT in place. Of note, congested cough present prior to PO trials. Pt self-fed trials of thin liquid via cup and small bore straw and regular solids. Adequte mastication, oral containment, and oral clearance. Swallow appeared timely. No overt s/s aspiration. Pt denied globus sensation. No SOB or drooling like what was observed in yesterday’s session. Pt denied s/s dysphagia or aspiration but reported occasional coughing when taking pills. Pt reported feeling more so that it is difficult to coordinate self-feeding due to hand-eye coordination deficits and DHT being in the way. Educated on safe swallow strategies – pt verbalized understanding. SLP to f/u x 1-2 times to ensure safe tolerance of diet, although suspect pt is approaching baseline swallow function.
The tubes in the nose….make it hard to eat. Maybe only I have this particular problem. The happiest day of my life was the day those tubes went bye-bye.
Comfortable in bed, alert. No complaints. Overall feels well and ready for next step of leaving the hospital. Tolerating dialysis. Eye swelling improving, but his eye is a little sore.
Assessment of patient’s performance today: Pt demonstrates significant increased tolerance for participation in OT today. He states he feels “more motivated”. He is primarily limited by decreased activity tolerance, decreased balance, and decreased gross motor coordination. He tolerated functional mobility to bathroom distances with minA and FWW, goal to sit up in chair x1 hour. He remains a great candidate for acute inpatient rehab.
Objective
Patient Specific Goal: “To be able to do my daily routine.”
After my time at Poudre Valley I moved over to Northern Colorado Rehab Hospital, where they had solid food and people who could make me walk like a man (Frankie Valli we salute you). After having done this blog post, I still don’t know exactly why I wanted to do it. Is it me looking at Death and spitting in his eye? Maybe a little. Mostly I just am stunned that I got through all that awfulness. And it’s another reminder that once Fall rolls around I need to get my flu shot.
What does kill you makes you stronger? I’m so glad you came through with the way you did keep it up.