Chapter Seven: Audrey
Audrey made herself known to our emergency department during her early twenties when during drinking binges she would grace our facility with complaints of neck and back pain. These visits were usually the result of an assault from her consort of the day or weekend. An incident that stands out in my distant memory from the late 70’s was her tantrum when I refused to give her narcotic pain medication. She threw herself off of the gurney, on to the floor and proceeded to act out a phony seizure. To keep her from further head trauma, I picked her up from the floor and less than gently put her back on the gurney, yelling softly (=speaking loudly) to cut it out, quit the bullshit. She heard me and settled down. Maybe all she needed was the touch, in whatever form it came, conveying caring, however professionally distant. It was probably much more than she was used to.
It seems that whenever we start to see problem patients in the emergency department, they come in very often for months or years and then we don’t see them for a long time, or forever. It was this way with Audrey. After a year or two of visits, she vanished. We didn’t miss her.
Fifteen years later, around 1994, Audrey came back. Barely recognizable, she had aged thirty years. Her body weight was up fifty pounds from the grace period of youth and her skin color was a sickly shade of orange. Her skin texture was pasty with various sloppy jail tattoos adorning her failing body. Her nose was crooked from doing battle in the joint. She had just gotten out of jail, her residence for most of the prior fifteen years. Life at one end of the bell shaped curve had taken a massive toll. She had, however, ‘grown up’ considerably and engaged me in a sober conversation about her past, including an apology for past behavior. Amazingly, she remembered our ugly past together and wished to make amends. She appeared to have suffered greatly during the intervening years but smiled with the ‘oh well, I’m still here’ sort of resigned abandon.
Audrey had several major medical problems. Too many years on the unclean edge of life had given her hepatitis several times and of multiple types. Her blood tests revealed that she had contracted hepatitis A, B, and C. The latter two can produce chronic liver damage and ultimately can be fatal. Insult on injury, she was also an alcoholic, and although she was trying very hard to stay dry, she would binge at least monthly, sometimes weekly. The few liver cells left in her racked system did not take kindly to this organic solvent assault. Within a day of drinking, her liver would fail and she would become jaundiced, bloated, and disoriented. The level of ammonia in her blood would shoot up, a sign of major liver failure. This is the same chemical contained in household cleaning ammonia. Very nasty stuff. Normally, the body produces minuscule quantities of ammonia when protein is metabolized. When the liver is healthy, the ammonia is ‘detoxified’ by conversion to other non-toxic compounds that the body easily excretes. However, when the liver fails, the ammonia cannot be metabolized and accumulates in the blood and the brain. The brain ‘on ammonia’ does not benefit from its cleaning qualities. Just as the nose detects a terrible effect from this highly reactive chemical, the brain is ravaged, producing a state called encephalopathy. Audrey had her own unique version of encephalopathy that we were privileged to endure. Most people who develop this toxic brain state are moderately disoriented and hallucinate and babble conversations with demons and fat spiders. The impact of this behavior on health care providers can be amusing in a pathetic sort of way. Audrey, however, was a different story.
When she first started coming back here for medical care, she wanted very much to stay away from alcohol. Her other medical problems were in the orthopedic realm. Shoulder and knee pain would interfere with physical activity that she so desperately needed for mental and physical health. I could help her shoulder problem with cortisone injections but her knee needed surgical repair. She was caught between a rock and a hard place because no orthopedist would operate on her with liver failure (anesthesia danger) but physical activity was needed to strengthen her resolve to not drink. Her knee pain prevented adequate physical activity. I helped her as best as I could, trying to limit pain medication, while reinforcing her will to live actively and to stay dry. Amazing to me as it now seems, during that period in her life she began to come to the local health club where I was a regular. She suited up and did pool exercise. "Good for you, Audrey," I would smile and energetically nod. These days were not to last long.
Though she stayed sober most of the time, and gave exercise her best shot, her past kept catching up with her. The next chapter of her life landed her back in the slammer. Evidently, she had either written a bad check or was innocently complicit in some paper misrepresentation of the truth in someone else’s bad business. Pathetically, she was left holding the bag and having no resources to defend herself and having a long criminal record for other petty crimes, she ended back in a cell for eight months. Any ordinary citizen caught up in a paper infraction, with a minimum of defense and pleading, would get a slap on the wrist, a fine, and nothing more. This was not Audrey’s lot in life.
Upon release from servitude to the state, Audrey came home for another shot at life. Her resolve broken by her recent dose of pointlessness, she started drinking again. Before long, she was brought to the hospital by ambulance in severe distress with disorientation and toxic dementia (out of her mind) from liver failure. The song began. Audrey’s version of demented hallucination was non-stop screaming "No." Over and over, twenty-four hours a day, at the top of her lungs. Lying in bed otherwise motionless, orange with jaundice, unresponsive to any outside stimulation, she would howl as if in the most severe pain imaginable. Disruptive to staff and patients, unvisited by family, excreting on herself, she was in the most pathetic state imaginable. We tried to suppress her delirium with sedative medicines but she had little response to very high doses, making us wary about giving too much. Sometimes her screaming would spontaneously cease and a period of sleep would grace the entire hospital. Eventually my nurse Cleo discovered that if she softly sang Amazing Grace close to her ear, Audrey would quiet down. She would do this in the emergency department but once Audrey landed on the medical ward, she was on her own. Bear in mind that our entire tiny hospital is on one floor, all the patient rooms on a thirty-yard corridor. Everyone knew when Audrey arrived. Everyone knew when Audrey woke up. After three to five days of wild, noisy delirium and treatment for liver failure (no alcohol + enemas with a chemical that helps the body get rid of ammonia), Audrey would awaken with no memory for the preceding week. She was pleasant, cooperative, and willing to never drink again.
The admissions continued, as frequently as twice a month, through the next year. Sometimes gastrointestinal hemorrhage, vomiting and defecation of blood, complicated her condition. The blood in her intestine would serve as a nitrogen source and that elevated her body and brain ammonia levels. These episodes would, without exception, follow drinking binges. We began to dread Audrey’s return. Her management was so difficult, her presence so disruptive, and her condition the result of self-destructive behavior. The phenomenal hospital bill was of course carried by us taxpayers. None of the doctors on the staff was willing to be ‘her doctor’ any more. She had violated multiple agreements to stop abusing her body. And so, when she would arrive in the ER in need of another admission, the physician who was on-call for patients without their own doctors would have to manage her case.
The handful of physicians who took call for the emergency department, that is, the entire clinical medical staff, had their various personalities and demeanors that when put to the test with Audrey, would make our job in the ER more or less difficult. Two of the docs would swear and complain and try to find some way out of the job of admitting and caring for Audrey. The other four would accept their fate more graciously. Humble acceptance of fate is the key to getting through a medical career, especially in emergency or family medicine.
Some of what we do is gratifying and makes the struggle worthwhile. But, ten to twenty percent of or job is just awful. Dealing with self-destructive people, abusive and demanding adults who are still really children, pointless, expensive care for hopeless cases, and on and on, makes a difficult job thankless and troubling at the deepest levels. Some physicians never got that this is an integral part of caring for people and that embracing all parts of medicine is critical for sanity. This is even more so in the current medico-legal climate where we are prey for the predatory agendas of lawyers, medical boards, insurance companies, the press, and litigious patients. A physician’s attitude about hopeless patients with self-destructive behavior must not be turned against the patient in an act of ‘self expression’ or venting. To berate a patient and give them substandard care when they are in your hands is both unethical and unprofessional. It is also a good way to get sued. Angry patients sue, regardless of the merits of the case and once sued, the physician has lost. The loss may not be of the legal case but rather of time, legal fees, peace of mind, and happiness. The legal system eats physicians up and spits them out ragged and injured, never to be the same again. Unfortunately, one does not have to be guilty of anything, other than practicing medicine in this day and age, to be ravaged by this system. For instance, a patient with orthopedic injuries who is released to return to work before they want to return, but could perform the job if so motivated, might sue the orthopedist out of anger at having disability cut off. The case will be lost, but it will cost the orthopedist thousands of dollars and months or years of sanity to resolve the case legally.
Audrey bought out the worst in some of our staff, but, stepping back, out of the context of modern constraints, this is life. Fortunately, the negativity of the admitting physician was directed at the ER physician (kill the messenger), rather than giving substandard care for Audrey. Not that she would know the difference most of the time. There was simply no one home when she was admitted. Her delirium was our problem. She was spared any self-impact by the grace of her own derangement. She never had any memory for her acute state and as the admissions continued, there seemed to be fewer brain cells functioning, at best. I wanted so much to videotape her screaming madness for her to view later but there was no videocam available and I had lost motivation to have anything to do with her when I didn’t have to.
I do believe that there is no tool more powerful for behavior modification as watching one’s own pathologic activity. Denial becomes impossible. My first son developed an eye-blinking tic when he was twelve and no amount of family feedback could change this irritating behavior. When he saw himself on a holiday videotape, the tic in full view, he stopped at that moment and never restarted.
Audrey, Audrey, Audrey, what are we going to do with you. This is a time in a state, in a county, in a town with essentially no effective social aid resources. Her detox program was jail. Her follow up was acute emergency care in crisis. Her nutritional supplements were purchased in the liquor department of the grocery store. As no physician would follow her in their offices in between acute care episodes, she was not given the possible advantage of Antabuse (the drug that makes a patient very ill with the smallest alcohol consumption) or the newer treatment drugs that substantially lower alcohol use in the alcoholic population. Sooner or later, Audrey would come in for the last time.
One of my partners saw her on a Thursday afternoon for complaints of abdominal pain and feeling badly. However, when he did the lab tests, nothing was very much different from usual, her blood ammonia was not sky high, but her blood alcohol was. As she was more intoxicated than delirious, after a period of observation, she was discharged from the emergency department. She returned about twenty-four hours later, on my Friday night shift, complaining of weakness and some abdominal pain. Her breath did not smell of alcohol, and her physical exam revealed nothing new. She was minimally disoriented but cooperative. No screaming. No throwing up or pooping blood. Out of reflex more than intelligence, I ordered the usual battery of blood tests, just in case some unforeseen abnormality might direct an action other than scratching my head. My nurse Cleo had a ‘funny feeling’ about her, this time. Cleo is blessed, or cursed, with some degree of precognition. For most of her life, this power has been a very troubling talent, totally uncontrollable, and something she felt too embarrassed about to tell anyone. Two years ago, she confided in me about this. She often knows when disaster is about to strike, whether it is an earthquake, or an auto accident with injuries on our shift. She sees these things in dreams and also has daytime senses about things. I have seen it close up and it is a true, goosebump eliciting power. Now that she has admitted to someone what happens to her and has had some counseling to come to terms with it, she is less troubled, unless she has a symbolic dream and fear for one of her loved ones. Her sense about Audrey this evening was confirmed when the lab tests returned. Most dramatically, and as never before, Audrey had a life threatening blood sugar of 30 (extremely low, incompatible with survival for very long). This could explain most of her immediate symptoms and was also telling about the state of her liver. Inability to maintain a life sustaining blood sugar is a characteristic of the final throes of end-stage liver failure. However, unlike high blood ammonia, giving intravenous glucose could rapidly, however momentarily, reverse this. I told Cleo to start an IV and I would talk to the admitting physician of the evening.
Starting an IV in Audrey was anything but simple. From her prior life of intravenous drug abuse to the general ravages of her alcoholism she simply had no accessible veins in her arms. It would often take the better part of an hour to establish an IV. While Cleo labored with needle and catheter, I spoke with the admitting physician who wanted to see if we could just send her to a nursing home, bypassing acute care in the hospital. It seemed like a reasonable approach as Audrey clearly was unable to care for herself and further major expenditures of society’s resources were pointless. Making this happen was not simple, however. Many phone calls later, as I was pushing the system as hard as I could to do the right thing, Cleo left the ER and found me at the nursing station. "I think it is over", she said with a puzzling mix of clinical questioning and hesitation to conclude the obvious.
When we "call a code", when someone stops breathing or the heart stops, everyone runs to the bedside and begins the ritual of resuscitation, unless there has been a pre-designation (advance directive) of DNR or ‘do not resuscitate’ because of a hopeless condition such as terminal cancer. In Audrey’s case, no DNR order had ever been arranged, but when I saw her lying still, her first peace in a lifetime, or after a lifetime, I knew what was right. To not resuscitate, in this day and age, when the patient or family had not previously arranged this plan, was legally risky, but morally and ethically I knew with every fiber of my being that it would be wrong to try to flog Audrey’s body back to life. Her heart monitor showed a flat line (no cardiac activity) and there was no respiration. Patients who have a cardiac arrest with no cardiac activity (flat line), have a virtually zero percent chance of recovery. Cleo hadn’t been able to get an IV in yet, but that hardly mattered at this point. If I was going to give her resuscitation drugs, I could stick a big pipe (a large bore IV) in a fat neck vein and do what we are so well trained to do. Torn between moral clarity and legal fear, I plunged the needle into her neck, pushed glucose into her circulation, and pumped it around with chest compressions. A few other resuscitation drugs later, her body refusing to come back, I asked the nurses present if anyone thought we should continue. The consensus was uniform.
Standing next to Audrey’s freshly dead body, I was overwhelmed with a sense of relief and wonderment at the creation of this new moment of peace for Audrey, peace for us, and the magic of nature evolving. I thought to myself, in a moment of inner gallows humor, "Audrey, don't come back until you’re ready". I took her hand, gave it a squeeze and wished her good luck on her new journey. Cleo softly sang Amazing Grace. Inside myself, I thanked her for the opportunity to suffer with her and to be released now from the awfulness of it all. I thanked her for not doing this at three in the morning, and then I called her mother. The call did not come as a surprise to Audrey’s family. Her mother and sister thanked us for our caring, shed a tear, and went on in the world of the living.
undeniable relief of the moment had to be ritualized in some small
way. We sent out for pizza and spoke
of the ways in which the inevitable
so often comes unexpectedly, like ‘a thief in the night’.
All Rights Reserved © 2004 Jon Sterngold