The other day in the office, one of my favorite 80+ yr oldie's came in to see me. She was quick witted as usual but after checking out, she started "checking out". First she started slowing down her snail pace to almost a stand still. Then she remained silent while standing (this is one of those souls who makes play by play commentating like she is talking to a radio audience...."it's cold", "it's so white out", "that will take forever"......) Then as I sat her down the well known slump of death started. It's when a human that was previously made of flesh and bone suddenly is a 110 lb bag of melting ice. You would be surprise at how difficult it is to carry someone when there is no life, turgor, or blood flowing through the body. I'm pretty fit but as I picked her up like a sleeping child, she started sagging like gravity was pulling body parts between my arms. Got her up on an exam table and had her in semi flat (in the field if someone passes out I place them in trendelenburg with head down and feet up to pour life restoring blood into the brain but with her age, I wasn't sure if she was having a stroke out so I rigged this first aid position). Blood pressure was really low and she was unresponsive so I asked relatives if she was DNR-they said yes and after some debate, we decided to postpone calling 911. As I mentioned hospital and IV ...she suddenly started speaking with a muttering in a barely audible voice. I went closer and she said "I don't like the hospital". Huumm.......I decided to get her grand daughter on the phone and asked the kid to say hello. Guess what, grandma started talking louder....albeit her blood pressure wasn't reflecting any level of what I would consider normal for a human, in fact it was still dropping. I was very uncomfortable with keeping her in the office; because the experience I have working in ER's the resources available to orchestrate resuscitation in second and begin a diagnostic work up makes it temping to use the God Complex to say I can fix this. But then...my Dad popped into my head (-being guided by my favorite mentor). He told me...wait. So I continued to observe, provide comfort and just reassure the patient I was there for her. I felt like I was back in med school where I was the "human cardiac monitor" and had to repeat vital signs every 10 minutes and assess color, turgor, heart sounds, neck veins, level of consciousness to determine what the cardiac output was; preload, after load, cerebral perfusion, peripheral perfusion - all the basics of human physiology which will give just as much information as a $10,000.00 monitoring system in the ICU (yes, this is why a 10 minute trip to the ER for a fever and Tylenol will cost you and your insurance a thousand bucks).
Bag-o-Jello suddenly started to take human form again, voice strengthened, color returned, blood pressure was normal.. then she said she wanted soup (probably the brain triggering the need for fluid volume and salt?!) I asked her how she felt and she said I'm OK, can I go now? What the #@$@, such a resilient generation this lady was born into. I told her she had to take it easy because she just went through a life threatening experience. She just said "I'm hungry" as if nothing just transpired over the last 60 minutes that in my mind was like an eternity. She got back up, finished checking out at the front desk, proceeded to the parking lot and left with her care giver. I heard her say in a loud voice...."it's so cold!!". They went on to eat Sinigang and Lechon at a Filipino restaurant (2 pork heavy traditional meals!).
The hour of "back country" monitoring this tough but delicate lady was more than a a review of basic physiology and wilderness medicine. More importantly it showed me that sometimes there is more to lifesaving than just running protocols and algorithms....the human soul ultimately decides when it's time to check out. Learning to listening to it is good for the patient and the healer.
