Wednesday, August 25, 2010

Did I Miss Something?

The call came on my day off, asking me to go see a client who was not feeling well but was refusing to go the emergency room. So, I delayed my shopping and errands, changed my clothes, grabbed my bag, and headed cross town to her home, which was located about fifteen minutes from my neighborhood.

When I arrived, she was supine in bed, the home health aide by her side. Questioning her, I could perceive nothing more than neck and leg pain, something that the orthopedist had recently confirmed as being caused by worsening chronic osteoarthritis.

"Have you been taking your pain medicine?" I asked.

"Not really," she replied. "I don't like to take that stuff." She made a face.

"Well, you might want to think about taking it at least a couple of times a day when the pain is this bad. You might not like taking it but it may help you to feel a little more functional."

"Maybe you're right. I'll try it and see how it goes. They're sending me to the pain clinic, anyway."

I did a thorough head to toe exam. She was neurologically intact, her bowels were normal, her urinary function was normal, and her lungs were clear. All vital signs were perfect. She denied reports that she had vomited the day before, but her mild dementia could be the reason she couldn't remember. Checking the home health aides' notes, I realized that no vomiting had been documented, so who knows if it happened or not? A few recent falls were documented though, and the bruises on her shin and ankle told the story.

"Did you hit your head when you fell? Was it scary?"

"No," she replied. "Not particularly. I caught myself but I knocked down a lot of papers and magazines in the process." Her house is covered with piles of mail, papers and magazines that the aides are constantly trying to reduce. As if to illustrate that fact, the home health aide made a move to retrieve the bottles of medications from the bathroom, and yet another pile of magazines cascaded to the floor. We both stooped to pick them up as our client watched from her bed.

Sitting on the edge of the bed and chatting with my client and the home health aide, I evaluated her speech, made certain that her facial features seemed even and smooth, and had her push her feet against my hands to test her strength. All reflexes were normal, her grip was strong and even on both sides, and I could see nothing wrong aside from the chronic pain that has dogged her for years. I was perplexed that the home health aides had made the assessment that she was acutely ill.

"Well, I know you're not scheduled to have an aide on Saturday and Monday, but I'm going to recommend that you have daily care for the next week, at least until you feel a little bit better and can see your primary doctor and get that referral to the pain clinic." I began to pack up my things.

"OK. That sounds fine. It's just so frustrating to be so limited. The pain is horrible, and I'm lonely."

I held her hand, chatted for a few more minutes, and took my leave. The home health aide was going to stay an extra hour, and I called the office to have daily care approved for the coming week, and drove home to continue my day off.

The next day, my supervisor called to tell me that the morning aide arrived to the house, let herself in, and found our client dead in her bed, reclining in the same position in which I had left her the day before.

I was shocked at the news, and immediately began to question my assessment. Had I missed something? Was there a clue I had overlooked? Was I remiss at not sending her to the emergency room? Would my skills and license be brought into question?

There has been no answer as to the cause of death for this woman who appeared, for all intents and purposes, to be suffering from chronic pain, loneliness, and a slowly progressing dementia. I am certain that my assessment was accurate and that she was not acutely ill that day when I was called to her home to assess her. Still, the questions linger, and they are most likely questions that will never be adequately answered.

May she rest in pain-free peace.
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