Tuesday, June 18, 2013

Google my symptoms, please

In the previous episode of "As the Amyloid Turns" we discussed Mom's elevated blood pressure during the week of June 3, and we ended with a bit of a cliffhanger:

June 8 (Saturday): Mom called me at 9:40 this morning and . . . I should probably end this blog post here. It seems long enough.

Let's see if I can cover the next 12 hours in a single blog post. Here we go . . .

June 8 (Saturday): Mom called me at 9:40 this morning and asked me to Google some symptoms she has. She said she has significant pain just below her ribs, on both sides. She said it’s around the diaphragm level. The discomfort started last night and she had a hard time sleeping, and this morning it’s worse. She also said her blood pressure was still high this morning, something like 195/99. Another interesting thing is that she has gained nine pounds in the last week.

I was wondering if it was peritonitis or maybe a ruptured spleen, so I looked up symptoms for both of those. I knew that a ruptured spleen would cause pain primarily on the left side, so I didn’t really think it was that, especially since her internist had checked for an enlarged spleen at her most recent appointment just over a week ago. The only peritonitis symptom she definitely had was the abdominal pain, but I figured since her blood pressure has been high since Monday afternoon, and it isn’t responding to the increased dosage of clonidine that she started taking Thursday evening, we need to get her to the emergency room. I also knew about the spot on her abdomen that flared up, ruptured and started oozing pus while she was in Hawaii last month, so the possibility of that leading to peritonitis was on my mind as well.

So I called Mom and told her we need to get her to an emergency room. My sister Amy took her to Presbyterian Hospital in Plano and I met them in the waiting room. Just before noon she saw a triage nurse who took some basic information and her vital signs. When asked how she would rate her pain on a scale of 1 to 10 (with 1 being no pain and 10 being the highest), Mom said 8. Given her high tolerance for pain, we knew that meant she was really in some pain. But oddly enough, her blood pressure was down a little to 168/94. I explained to Amy that Mom has the opposite of white coat syndrome, since her blood pressure is often better in the doctor’s office. We then went back to the waiting room and Mom was called back at 12:30 PM to an exam room.

The emergency room doctor (Dr. W) came in not long after that and started asking questions, focusing on where the pain was. Mom also showed her that the spot on her abdomen would still ooze a little if she squeezed it. That got the doctor’s attention and she put on some gloves so she could squeeze some pus out herself and get some on a cotton swab so they could analyze it in the lab. We told the doctor the history of the bump, with the peritoneal dialysis catheter insertion and removal, then noticing the bump, getting a CAT scan, finding out about the surgical felt, and the bump recently flaring up like a pimple and rupturing in Hawaii. The doctor said they needed to do a CAT scan and she left the room at 12:50 PM to write up the orders.

Then a nurse came in to insert an IV line and draw blood. He was trying to get the needle in Mom’s left arm when she let out a little yelp of pain. He tried a few more times without any luck, and then he moved to her left hand. He said the veins were blown, which I guess means when a needle is inserted they start bleeding a lot under the skin, making them useless for an IV line. He moved to her left hand and eventually got a needle inserted the way he liked it, but not before hurting her a few more times. He then had to draw some blood from another location and I suggested he try her right hand. So he moved over there but still had some difficulty drawing blood, and he left a nice size blood stain on the bed.

Around 1:15 PM a nurse came in and said something about drinking a liquid to provide contrast for her CAT scan. In the past they have not given Mom any contrast for imaging procedures like CAT scans because of her kidney problems. I wanted to make sure the doctor was aware of that in case the contrast was optional. Since she’s on dialysis now it might not be such a problem since the dialysis would eventually filter out the contrast. The nurse said she would talk to the doctor about it. The doctor came in a little while later and said she had talked to one or more of Mom’s other doctors about the contrast, and they agreed they needed to do the CAT scan with contrast in order to get a good look at her abdomen, and it will be cleared out at dialysis on Monday. I think it was at this point when the doctor said Mom would likely be admitted. I asked her if peritonitis was a possibility and she said it was.

Mom started getting sleepy while waiting on the nurse to bring the contrast liquid. She probably would have slept better but her pain level was still an 8. The nurse brought in the contrast mixture and Mom finished it at 2:45 PM. Another nurse took her for a CAT scan around 3:15 PM. She was gone for about 30 minutes. While she was gone I had the room to myself and found the movie “The Muppets” from 2011. Unfortunately there are just too many interruptions in the emergency room to be able to enjoy a movie.

Her blood pressure reading at 4:22 PM was 149/65, but the pain was getting worse, probably a 9 or 10. She said it was hurting to breathe. I don't think she had been given any pain medication at this point.

Around 4:45 PM Dr. W came in and said she had good news. It isn't peritonitis. Mom has a small pocket of infection in the abdominal wall muscle (about 11 mm), so it’s not an infection within the abdominal cavity. She may not need surgery but she will likely be admitted. Dr. W said they would get her started on an antibiotic and she mentioned vancomycin. Mom and I both spoke up and said she’s allergic to vancomycin. (It gave her that horrible rash when she was given it last year at dialysis.) Dr. W said that was good to know and she would add that to Mom’s allergy list.

I asked Dr. W if Mom had been given any pain medication because her pain seemed to be getting worse and was now getting higher up in her back. She said she would write up an order for some more pain medication.

Dr. W came in later to present a plan that would not have Mom admitted to the hospital. She had been speaking with the doctor on call at Dr. K’s office, and if Mom goes home with plenty of pain meds and antibiotics they can do the procedure to drain the infection Tuesday morning. If Mom were admitted to the hospital today, she would have the procedure Monday in the hospital. Mom was really hoping to get to MD Anderson in Houston for Ed’s surgery on Tuesday, but it was looking like that was not going to happen. So the options were essentially to stay in the hospital on pain meds until they can do the procedure on Monday, or go home on pain meds until they can do the procedure on Tuesday. We said we were ok with going home. Dr. W said not to hesitate coming back to the ER if this plan was not working for any reason over the weekend.

Another part of this plan was that Mom would need to be given some more antibiotics at dialysis on Monday. Dr. W said she had been talking to a doctor (presumably the doctor on call from Dr. K’s office) who was going to call the dialysis clinic and explain the situation and tell them about the antibiotic she would need at dialysis on Monday. Dr. W said they would also give her a sheet of paper at discharge explaining the situation, and she needed to take that sheet of paper to dialysis on Monday.

Not long after that two nurses came in, presumably to begin the discharge process and remove the IV line. Mom told them they could not stay unless they had some pain medication. One nurse looked on the computer and saw that pain meds had been ordered, so she told the other nurse not to remove the IV line just yet. She came back a little later and gave Mom a dose of morphine in the line attached to her left hand. Within a minute Mom said her arm was really itching and burning. The nurse said that was a normal reaction some people have to morphine, and it should go away in a few minutes. Eventually the itching, burning sensation went away and Mom dozed off and got some good sleep. 

Mom's blood pressure reading at 6:22 PM was 136/61, so that was really good compared to what it had been earlier in the day. However, the discharge nurse came in about 30 minutes after Mom had been given the morphine, looked at the monitor and saw that Mom’s oxygen level was only at 80%. I told her Mom had been sleeping and I could see that she wasn’t breathing well. Mom said something about the morphine doing that and I said it’s more likely the sleep apnea. The nurse asked if Mom was on CPAP. Mom said she was and I said something like, “Well, she has a CPAP machine. Whether or not she uses it consistently is a different question.” The nurse told Mom to be sure and use it tonight. Her oxygen came up after she woke up, and it was above 90% in just a few minutes.

Mom and I left the hospital at 6:50 PM and headed to her pharmacy to drop off her prescription. Unfortunately that pharmacy was closed. We went to a CVS nearby, but that pharmacy was also closed. My wife Cathy went online and found a Walgreens pharmacy in Carrollton that was open until 10 PM. Mom was exhausted and needed to get in bed so I took her home so Laura and I could get her to bed and make sure she used her CPAP machine. We got the CPAP machine hooked up per Mom’s instructions, then Mom went to bed and I went to Walgreens with Mom’s insurance cards and the prescriptions for hydrocodone and an anti-nausea medicine. I dropped off the prescriptions some time after 8 PM, then I ate dinner out in my car until they were ready. I took the prescriptions to Mom’s house, gave them to Laura, and headed home around 9:40 PM, which was 12 hours after Mom had called me to Google her symptoms.

So that was a long day, to be sure. I felt like she was in good hands in the emergency room, and as long as Dr. W's plan regarding the antibiotics and pain medications works, she should be fine until the procedure on Tuesday. In the next post we will find out that plans do not always match reality.

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