Thursday, August 24, 2006

An Answer for Pennsylvania Progressive About the "Found Down" Patient

In my post on August 22 ("A Rough Day in the Sandbox"), I described an elderly female patient who was brought in after being "found down" after spending 8 days on the floor of her home.

One visitor, "Pennsylvania Progressive," responded to my post with this:

"The question I would ask is who the hell would let someone sit in that condition for eight days? Unless she lived alone or no one visited her I don't see how someone could let someone else suffer like that."

First of all, I want to tip my hat to Pennsylvania Progressive for prodding me to answer this difficult question. It must to be addressed. I will try to do so now, as succinctly as possible.

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 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 poor treatment of the elderly. But I'll save the scathing indictment of our selfish society for a later date.

My theory is that an independent person of any age becomes just another commonly-perceived thing in our busy world. That's not really a bad thing; human beings are attuned to exceptions, not norms. So unless one is attuned 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 of the person does not call or is not seen for a few days.

But 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 moreso in women). Depth, contrast, and light perception are diminished. Hearing is not as sharp.

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. Or she is in too much pain to drag herself to the phone. Or she has hit her head on the floor and sustained a concussion; or any number of other precipitating 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 so-and-so 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."

So 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 calling, but she doesn't answer her door.

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 if human blood has a very narrow range (7.35 to 7.45), and to go beyond this range can be fatal. The kidneys will secrete bicarbonate in order to buffer the blood, but 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 mess. 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.

Urine and feces excoriate 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, 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 are 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.

Could something be done to prevent this from happening to this poor lady? I certainly think so! But it requires you and everyone else 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 you. The more you know your neighbors, the more likely you are to notice when something is wrong. Unless you know your neighbors, you will never be able to avert a disaster like this.

Who can be blamed for this? Us. You and me. Why us? What did we do? We allowed the media, the movies, the magazines, the TV shows, and our own selfish "busy-ness" to blind us to the lovely human beings who live right next door. And so our 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 and die long, miserable deaths with tubes shoved into every orifice and even in some that were cut into her.

But that does not mean that it has to stay this way. If you want to change something badly enough, the odds are that you will succeed if you just try to change it.

So I charge you, dear reader, to do something completely opposite to 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!