The chief complaint was “weak and dizzy.” I had to shake my head. How many thousands of these have I seen in the last 35 years? Usually a vaso-vagal syncope. Maybe an arrhythmia, labyrinthitis? Sometimes it was serious – but usually not. But as soon as I laid eyes on Francis Howard, age 94, I thought, “Now this guy is sick.” I introduced myself, but he just laid there with eyes closed, pale as a sheet, seeming oblivious to my presence in the room. I noticed the hearing aids and stepped closer, speaking directly into his ear. He opened his eyes and almost immediately started retching. I grabbed the emesis bag laying beside him and put it to his clammy face before he could vomit on me. Then I called for a nurse.
“Good job, Doc,” Jill said upon entering the room. “He was starting to do better until you arrived.” “What do you know about him?” I asked with real concern. “Pretty much just what the crew put in the ambulance report. They did tell me that the family is on the way. The family said he had an episode like this several months ago. He seemed to get better with Antivert.” “Really? He looks sicker than that.”
“Oh, and he was treated by a ‘family doc,’” she said with raised eyebrows. “What does that mean?” I was confused. “He has a family member who is a doctor,” she said. “Oh boy,” I exhaled reflexively, “just what I need tonight. A second opinion to everything I do.” Jill responded with a knowing shrug. “Let’s start from scratch on this,” I said. “Lines, blood, monitors, O2 if indicated, cardiac profile, EKG.” “I’ve already ordered all that,” Jill said as she left the room and the IV team walked in. She was giving me the same bobble-head shake that my wife gives me. And I could see the eye roll through the back of her head. I wanted to call out, I can see your eye roll!, but I thought better. I said that once to my wife and regretted it for a long time.
I turned back to the patient with his head in a bag. “Mr. Howard, do you hurt anywhere? Are you short of breath?” “I can’t feel my face very well,” he mumbled as he touched the right side of his face. “Raise your eyebrows, Mr. Howard,” I shouted. “Puff out your cheeks. Give me a big smile.” Without opening his eyes he raised his brows symmetrically and puffed his cheeks. His ‘smile’ was more of a grimace, but it was symmetrical as well. The remainder of the neurological exam was relatively normal for a nonagenarian, weak but symmetrical. I finally got him to open his eyes, which caused him to be nauseous, but he really didn’t have much nystagmus. As the labs started coming back, I became even more baffled. The labs were completely screwed up. Sodium high, K low, Cl low. This had to have been drawn from a line. But nobody would own up to drawing the labs. They had to be repeated.
When the ‘family doctor’ arrived, he immediately saw the labs and looked to me for answers. I didn’t have one, except we screwed up doing something simple like drawing labs. The patient really did seem to have a facial sensory deficit. So I did the only thing I knew would get the young doctor off my back and ordered a head CT and MRI to look for a mass or stroke.
With the work-up in progress I finally got to have a longer conversation with the family. The doctor-son turned out to be an OK guy who gave a pretty good history. The family’s main concern was that their beloved grandfather seemed to be dying. Last week he was driving to church with his wife and now he couldn’t move at all. Not just nausea and dizziness. He didn’t have a bit of strength. None. When the nurses tried to disrobe him to get him into a gown, he was a complete dead weight. I remembered back to med school when I went through my ICU rotation. There were two rooms for the super sick that were callously referred to as the “launch pads.” Well this guy looked like he was on the pad and ready for lift-off. And I had no clue why.
As the night wore on and all the blood tests were repeated, everything started to come back normal. Everyone looked to me for answers, and I simply didn’t have any. But I did know one thing. I couldn’t send this man home. No way, no how. But I didn’t have a diagnosis that would survive a Medicare audit either. Thank God for observation. It was after midnight, so the hospitalist would have two midnights, a full 48 hours to see if Mr. Howard was improving or swirling the drain.
Besides being a real medical enigma, I had grown fond of the elderly gentleman by the time the shift ended. The family even grew on me. So when he was finally wheeled upstairs I was really concerned about him. “I’ll follow up on him,” I told his son honestly. They were relieved that he was being admitted, but like me, they weren’t convinced that this wasn’t the beginning of the end for this man.
The next evening I saw the hospitalist in the hallway as I was coming in for my shift. “Hey, remember the guy we admitted last night? How’s he doing? Did you ever figure out what was going on with him?” By the way, Raphael, the hospitalist, was one of the smartest guys I knew. If anybody could figure Mr. Howard out it would be Raf.
“I really don’t know,” he said with a deep sigh. “He looks to me like a guy who has given up. He doesn’t appear depressed. But I think he is preparing to die. All of his friends are gone. He doesn’t eat, move, or talk. He doesn’t appear to have anything life threatening now, but if things don’t change he will soon”.
After my shift the next morning, I went up to the Observation Unit to see Mr. Howard. Entering the room, I realized that I had accidentally stepped into a ‘the conversation.’ “If you want this to be the end of your life, Dad, that’s your business. But if you don’t want to die, you need to work with us. You need to eat. You need to move. You need to try your hardest.” “I know,” he said with the faintest hint of resignation.
I realized that I was in way over my head on this one. I said a few platitudes before wishing him well and leaving. My heart sank though as I walked down the hall. I know that death comes to every man. Certainly I have seen more than my share in 35 years. And this man, of all men, was prepared to go. His family had spoken in glowing terms of his life of love and service to his fellow man. But I still hated to see him go. I knew he would be sorely missed.
I almost walked by the hospitalist the next day as I was coming into my shift. I hesitated to say anything. But I finally stopped and said, “How’s Mr Howard?” I expected the worst. “Oh, he’s much better. He stood by the bed yesterday. He shook like a leaf in the wind, but he did it. I think the nurses told him either stand up or go to the nursing home. The family’s taking him home today.”
I was stunned. “I’m so sorry, but I thought he was dying.” “Don’t feel bad, I thought he was too. Everyone did. He even told me he was ready to go.”
“What changed?” I asked. “Not anything I did,” he said with a wry smile. “He told me he couldn’t die and leave his wife. It just wouldn’t be fair to her. His wife said he was just hungry and hated the hospital food. She promised him a pie. I think it just wasn’t his day.”
