I had a patient from another story called "My Redemption" I think its posted on June 28, 2015
I had an admission waiting in the Emergency room. It was a dying patient who had bladder cancer. He was at the stage where he was so weak his family had to do everything for him and they were just too overwhelmed. The hospice services in our area don't have facilities to admit patients into a "hospice house" so I admitted him to our hospital for "comfort measures"The complication was that his bladder cancer was a large mass that obstructed his urethra (the tube that empties the bladder through the penis. So he had just stopped urinating.
His bladder kept getting larger and larger.
I had tried to put a catheter into his bladder through his penis (called a foley catheter) and no matter what size it was the cancer mass kept blocking it.
So the only other choice was for him to have a special tube put directly from his back into his kidneys called "percutaneous nephrostomy tubes" placed. This would collect the urine and it would run out the tubes into a bag. Therefore skipping the bladder and urethra (the tube that empties the urine out of the bladder into the toilet).
That is NOT a hard or complicated procedure. Usually a radiologist does this. Unfortunately at our small hospital we have NO specialists (just me and the ER doctor). So I asked my head nurse to arrange a transport ambulance to come and take my patient to the nearby hospital with specialists. then wait there while he gets the tubes placed (no more than 45 minutes including all the paperwork) and then they would bring him back to me so that I could make him comfortable in his last days - dying from cancer.
Sounds so perfect.
So I call the Radiologist - his answer - "I'm so sorry man, its Sunday, I'm not in the hospital and I'd have to come in specially to do this. Anyway, I never do these things unless a urologist is around to advise me"
"Thank you so much for your time" I respond
So I hang up and page the Urologist on call - here we go again - another hot potato [see my first post entitled What Is Wrong With You]
This specialist sounds horrified at my story "You should be transferring this patient to the university hospital who has been treating his cancer" he says, "he shouldn't be here" Oh yeah and its Sunday, I finished rounding on my patients and I'm at home lounging at my pool.
"I respond - this man is dying - if he doesn't get the perc neph tubes his bladder could burst, the University Hospital is 2 hours away and you guys are 45 minutes away. I'm not asking to transfer him. I just want him to get the tubes placed."
"No there's too much risk in that" he answers. Don't you see I could be held responsible if something goes wrong"
REALLY - like my patient might die? He is dying!
So I was met with a brick wall. I couldn't let him die in agony like that. I just couldn't
So after a long discussion with the family, we agreed with my plan and I transferred him to the Urologist in charge of him at the university hospital 2 hours away. All 8 of the family had to go down there and be with him during the days that followed.
- being a university hospital they misunderstood my plan and thought that they should be more aggressive - yeah that meant trying to treat a metastatic bladder cancer that had no chance of saving a 86 year old man in poor health. Finally the surgeries they did didn't help and they gave up and guess what - they put in Percutaneous Nephrostomy Tubes - and sent him back to me weeks later to die with dignity. Which he did. But after countless days of agony when their fruitless procedrures were performed.
This was a Geriatricians nightmare. But I was helpless to do what was right for my patient.