OK, so it seems I have written yet another column about octogenarians or nonagenarians. I admit I have a particular fondness for this age group, as I believe they have so much to teach us. I certainly never cease to be amazed by them-including my own grandparents whom I decided to write about, in this month's column.
After retirement, my grandparents didn't take off in their RV, or travel the globe on cruise lines. Instead, they became babysitters - my babysitters, to be exact. Every day after school I walked to their house and they took care of me, until one of my hard-working parents came to pick me up. I loved those afternoons full of activities.
My grandmother and I would pore through her family photo albums again and again, gazing at our frowning, black-clad ancestors who settled and farmed the prairie. My grandfather and I would spend long hours in his woodshop building birdhouses while he told me stories about growing up on a farm in the Depression, and serving as a soldier in the South Pacific in World War II.
They are now approaching 90, living in the same house that they have lived in for 60 years. My grandmother still cooks for my grandfather and walks her elderly, obese Chihuahua (whose medi-set contains more medications than my grandparents' combined) and my grandfather still tells his war stories (more embellished than ever) to a crew of neighborhood kids. Recently, however, we had a close call - and I had a very educational experience at the other end of the stethoscope.
A crisis
My grandfather ended up in the hospital with pneumonia. By the time I made it back to the Midwest my grandmother was in the hospital too - one floor beneath my grandfather. Her doctors, I was told, really couldn't find anything wrong with her. Her lab results were fine, and her chest x-ray was clear. It seemed she had simply become weak and dehydrated from worry when grandfather was ill at home.
When I walked into her room and saw her for the first time I knew she was in trouble. She was profoundly exhausted and weakened to the point that the work of breathing was a terrible effort. She hadn't slept in several days; her nights had been fretful and she was beginning to hallucinate.
Part of me wanted to just be a granddaughter, to sit by her bedside and let her doctors handle the medical part; but the physician in me hunted down her doctor, who was covering for her regular doctor, so that I could discuss her condition with him. When I approached him he was visibly annoyed with me for throwing a wrench in his harried morning, but, I must admit, he became significantly more polite after I introduced myself as a fellow-internist.
He proceeded to tell me, in doctor-lingo, that he and the consulting lung specialist thought that my grandmother wouldn't make it. It was futile, and while she had already expressed her desire not to be resuscitated if it came to that, her doctor felt that, in addition, she should be given comfort care only. He pointed out that in the past decade she had survived cancer, severe osteoporosis, asthma, and a heart attack - and let's not forget that she's almost 90 and weighs 75 pounds, he reminded me.
The doctor in me knew that he was right; statistically speaking, things did not look good. I had seen too many people linger in nursing homes, in and out of the hospital, before finally passing away. I did not want that for my grandmother. I broke the news to my family, but my non-medical family didn't buy it. They pointed out that a week ago, my grandmother was practicing her newly-acquired, full-time job of battling Medicare, and her insurance company, over erroneous bills; she had been taking out the trash, and surfing the Internet. So what if she weighed 75 pounds? They refused to give up on her. The granddaughter in me knew they were right.
Nevertheless, we decided my grandfather should know about the gravity of her condition. He took it as well as could be expected, but soon after hearing the news, his condition began to deteriorate as well. He grew weaker and began to have spiking fevers, accompanied by delerium, despite the fact that his doctors couldn't find any new source of infection; his pneumonia actually had improved on chest x-ray. He was giving up.
It was my mother who brought up the idea of decreasing my grandmother's prednisone dose - a steroid hormone that can be helpful with breathing difficulties.
After all, she pointed out, that medication had always made her jittery. Her doctor agreed, and decreased her dose. When I asked her doctor how much she had been on, he mumbled, and quietly gave me the answer - an answer that astounded me, and explained why my grandmother had become critically ill while in the hospital. The dose was above and beyond anything I had ever seen used. I suspect it would have made an elephant sick, let alone, a frail elderly woman.
It was an error
It was an error. Someone had made an obvious medication error, an overdose, and no one - not her doctors, nurses, hospital pharmacists, nor her granddaughter - had caught it. When I confronted her doctor with the error, he grumbled something under his breath acknowledging his responsibility in the error, but he was quick to say that it really didn't affect the outcome significantly.
That night, I stayed with my grandmother to make sure she was OK, and that there weren't any more screw-ups. I had a little cot right next to my grandmother's hospital bed.
Now, I have spent hundreds of nights in hospitals, but never with the goal of getting any sleep. It is much easier to run around admitting patients all night than it is to get a wink of sleep in a hospital. I tossed and turned, listening to muffled voices squawk on the overhead loudspeaker, a chorus of beeping IV poles, noisy night staff chattering down the hallway and mysterious metal carts wheeling by, seemingly every 10 minutes.
Every time I heard my grandmother stir, I would pop up and ask her if she needed anything - an afghan rearrangement or some ice chips perhaps? Finally, she gently admonished me for being so disruptive.
Go to sleep!
"Do you have a motion detector on you or what?!" she demanded. "Go...to... sleep." Easier said than done, Grandma.
After that, I tried to remain still and quiet on my cot waiting for the morning to come. When it did, my grandmother looked better. Since the prednisone dose had been decreased, she actually slept for the first time in days - despite my disruptions.
When the morning nurse introduced herself, and declared that my grandmother was "her little peanut," my grandmother's defiant glare told me she was going to be OK. Interestingly, after my grandfather heard the good news, he started improving as well
Then the real battle began. As soon as they started improving, the discharge planners had them halfway out the door, en route to various and sundry nursing homes. Thankfully, they were willing to concede to our pushy family's demands and halt the discharge process so that we could find a decent facility that could take them both and provide adequate rehabilitation.
That weekend was an emotional roller-coaster, but it also was a valuable learning experience on several fronts: one that I hope will help to make me a better doctor. When I make an error - which I have, and I will - I want to acknowledge it, to lose sleep over it, so that I will never make the same error twice. I also was reminded of the impact that simple, preventable medication errors can have. I almost lost my grandmother because of one. Finally, like Greta, and her peonies, it is another example of the power of the will -to live or to die. Now my grandmother will have to stay alive for at least another decade - it'll take about that long to get her hospital bills squared away.
Dr. Jessica Rongitsch has been a full-time internist at the Pike Medical Clinic since 2002.
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