Posted on 01/18/2007 2:21:14 PM PST by 60Gunner
Recently, I received an elderly patient brought in by the medics who was “found down” (unconscious and unresponsive) by a neighbor who had passed by her apartment and noticed a foul odor. She had fallen for some inexplicable reason, and lay immobilized on her right side for what we estimate to have been about a week. Her entire right side from her knees to her shoulder was burned by the chemicals in her own urine. Her right hip looked like a rotten apple, bruised and mushy, destroyed to the bone under damaged skin. The wasting of her muscles caused a massive dumping of creatinine into her bloodstream, which in turned completely destroyed her kidneys. Nobody knows who the hell she is. She will almost certainly die tonight from Multiple Organ Dysfunction Syndrome (MODS), Acute Respiratory Distress Syndrome (ARDS), and septicemia. This was somebody's daughter, best friend, sister (?), mother (?). She must have been somebody to somebody on this earth at some time. And now it is very likely that she will die alone.
I wrestled with a lot of anger and remorse with this case. I was angry that someone could be left alone for a whole week, and that the only reason that EMS was called was because of the odor coming from the apartment. Had there been no odor, how much longer would she have lain there? It was likely that she would have died that night anyway, since by then she was in full-blown respiratory arrest. She had no paperwork, and when we notified her next of kin (after finally tracking them down due to some brilliant work by our social worker) they were completely shocked that their mother was ill, much less dying. After all, she had just walked around the lake with the daughter a week ago, and she was independent. What happened?
Elderly persons who are able to maintain their independence are generally encouraged to do so for as long as possible by their families, their friends and by their healthcare providers, with certain exceptions. The reason for this encouragement is simply that "if you don't use it, you lose it." It's a quality of life issue. If a person in her 70s or 80s is able to perform the basic activities of daily living as well as remain active in the community, then in my opinion, he or she should be openly encouraged to do so. Our society is all too ready to shunt the elderly, even independent elderly, off into "retirement communities" where the Baby Boomers and Generation X-ers don't have to deal with them. America is unique among nations in our treatment of the elderly. But I'll save the scathing indictment of our society’s treatment of the Greatest Generation for a later date.
My theory is that an independent person of any age becomes just another commonly-perceived thing in our busy world. We, being entertained by the unusual, tend to ignore the normal. We are thus attuned to exceptions rather than norms. So unless one is accustomed to watching the elderly (as a nurse or other provider would be), the independent elderly person simply does not draw one's attention. The person's neighbors, children, and friends become accustomed to the person going about his or her daily life and they do not become worried if the person does not call or is not seen for a few days. The more diligent people call the elderly person regularly. Still, everyone gets distracted by the demands of the world now and then.
But whether independent or not, an elderly person is at higher risk for injury in the home because his or her body, as high-functioning as it may be, is still old. Reflexes are not as quick. The heart loses its resilience. Arteries lose their flexibility and vascular resistance increases, causing hypertension. Bones lose their inherent toughness due to calcium loss (in men as well as women, but more so in women). Depth, contrast, and light perception are diminished. Hearing is not as sharp. Balance deteriorates. So one day, our elderly subject is at home and suffers a transient ischemic attack ("mini-stroke"), or a heart attack, or gets up too fast after taking medication for blood pressure and gets dizzy. Or maybe her bones have become so brittle that the simple act of pivoting shatters her hip. Or maybe she has had a martini or two, or three, with her lunch and is now a little tipsy. But down she goes. And she has no "life-alert" call button around her neck (comparatively few do), and either the phone is out of reach or she is in too much pain to crawl to it. Or she has hit her head on the floor and sustained a concussion, or any number of other factors.
Meanwhile, nobody comes around to see about her, or if somebody calls, when she does not answer they simply assume that she is out and about. She could cry out for help, but may not be heard if she is in a room where her voice will not carry. The days go by, with no help. But then somebody begins to notice that something is amiss. It takes awhile for us to perceive these things when someone is usually so independent...
"I haven't seen Aunt Louise lately. Have you?" "Now that you mention it, I haven't. But you know her; she's always out doing something." "Yeah, you're probably right."
More days go by. But then the neighbors begin to notice something. The mail keeps piling up in front of her door, or in her mailbox, but her car is still parked out front. Her dog has been outside for days. People have come by, but she doesn't answer her door. It was guessed that maybe she had decided to go on a trip. She did that before, and she can afford it.
All the while, the person's body is breaking down under the enormous strain that forced immobility places on it. Skin breaks down and ulcerates as pressure cuts off the blood supply to the surface. The body begins to break down muscle tissue (and not fat) in order to maintain the supply of nutrients and proteins that the body must have to function. The major products of this process are ketones and creatinine kinase- both of which are lethal in high concentrations. The longer a person stays in this predicament, the worse things get for the body as it tries desperately to keep the important functions going. The buildup of ketones makes the blood acidotic. The pH of human blood has a very narrow normal range (7.35 to 7.45), and to go beyond this range in either direction is incompatible with life. The kidneys will secrete bicarbonate in order to buffer the blood, but only for so long before becoming overwhelmed. And when all that creatinine kinase produced from muscle wasting reaches the kidneys, it clogs the glomeruli and the kidneys are no longer able to filter out the sludge. From that point, the downward spiral becomes more precipitous. Since the person has not had anything to drink for days, there is no way to flush out this destructive substance that clogs the nephrons. So the kidneys simply shut down. Lethal toxins begin to build up in the body at a more rapid rate. But that's not all by a long, long way. Our subject has more misery to experience before she intersects with my life.
Human waste excoriates the skin on contact, and after days without being washed away, whole areas of skin are completely gone. Infection sets in, and within days the person becomes septicemic- that is, the infection reaches the bloodstream and is carried throughout the body; from this point, all major organs are affected except for the brain (for awhile), thanks to the blood/brain barrier. Septic shock occurs. Acute respiratory distress develops. The major organs begin to shut down, one by one. The kidneys have already failed, and now the other major organs become utterly ruined.
Finally a concerned neighbor, or the mailman, or a family member who can't stand it anymore, calls the police. They arrive, talk to whoever called, look in the mailbox, look at the outside of the house, and knock on the door. And knock again, and again, and again. At some point, they decide to go into the house or apartment. And the first thing they notice is the smell. The medics are called, and soon the person is lying in our treatment room.
Could this have been avoided? I don't know. I suppose if our lady was in a nursing home or some other facility, it could have been avoided. Putting Aunt Louise into a nursing home or adult family home is a difficult decision, particularly if she appears perfectly healthy for her age. In her case, would it have been appropriate? I don’t think so. But could something have been done to prevent this poor lady from suffering for as long as she did? I certainly think so! But it requires that everyday people- including me- to do something that has fallen out of style in our selfish society. That thing is called being a good neighbor. It involves getting to know the people who live around us. The more we know our neighbors, the more likely we are to notice when something is wrong. Unless we know our neighbors, we will not be able to avert a disaster like this.
But one must come to grips with the fact that sometimes otherwise independent elderly people just go down, and where they go down will make no difference regarding prevention of the event. It’s what happens after the event that serves to indict or uphold us. We must not allow the media, the movies, the magazines, the TV shows, and our own "busy-ness" to blind us to the lovely human beings who live right next door. The price we have paid is that our own neighborhoods turn against us because we decide not to "get involved". And people like this dear old lady show up in my Emergency Room covered in week-old filth to die long, miserable deaths.
So I challenge the dear reader to do something completely opposite what our society and our media tell us that we ought to do. Don't live unto yourself. Make friends with your neighbors. Get involved. You can be a hero!
ER Nursing Stories Ping.
Oh what a sad story. This is why I tried so hard to keep in constant contact w/ my elderly (independent) grandmother.
Yeah. I'll keep "Aunt Louise" in my thoughts. Perhaps she will recover?
Great as usual.
Took care of a woman who stroked in her easy chair. She sat a week. Not pretty. But she survived and healed.
ping
Congressman Billybob
Neighbors do not know each other's names. Decades ago, my father found an elderly neighbor under these circumstances. And that was when there were neighborhoods.
We do not have children* and very likely will die under these circumstances, or whichever one survives the other will.
*If there were a big fat WILL involved, I wonder.....
A terrible story. Thank you for the advice.
I would also suggest that older people who live along should be given one of those gadgets to wear around their necks that can be used to call for help. It's not foolproof, but if someone falls down and breaks a hip, they may not be able to get to a phone. But they may be able to push the button and call for help.
Unfortunately, it isn't. Remember the woman in the UK who died because the ambulance crew was on mandatory break? Remember the scores of elderly who died in the Parisian heat wave and August or two ago?
My wifes calls my mother daily as well as a number of elderly live-alone people in our neighborhood.
I like the last paragraph.
Allow me to add that we the mobile ought to make the effort to keep in touch because the aging reach a point where they cannot do it as easily as we can. Think about it ... even our business will pale when the elderly loved one is incapacitated unexpectedly. Also, put aside the notion that an aging parent or parents have a right to the trade off between being independent and being safe ... we, their loved ones, MUST make the decision and not leave them to make it because they will wait too long and circumstances will make the choice, usually negatively, very negatively.
Even if the elderly person is fine, day after day, a visit with someone can cheer their soul and perhaps make that day a little brighter. Is that too much to ask? I don't think so.
The Palm Beach County Sheriff's Department has a program of civilian volunteers who use a department car and check on people. These people put themselves on a list so that someone comes by every day, knocks on the door, and makes sure the resident is well. Stupid simple program, they need to expand it. Other communities need to adopt it. Churches do it in some areas.
I just read your profile. Never mind the doctor or nurse question. :D
I will make it a point to keep track of one elderly, alone person.
Better go call my mom.
That is one great tagline.
bump
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