From the Editor: ADLS

Pamela Benson, MD, MS, FACEP

It’s 0437 Saturday, and I'm feeling like I used to feel when the last patient was safely bedded in the ICU, the ambulance bay was empty, my car stood in an otherwise deserted parking lot, and the quiet snoring from the stretcher behind me was testament to the beauty of the human ability to sleep through anything.

I’m now 301.5 hours into a never ending shift that will end all too soon. And no one prepared me for this!

I took hours of BLS, ACLS, ATLS, APLS and taught them for years. I coordinated and participated in disaster drills for over half a century and never thought of them when the disasters hit, because I knew what to do. But somehow, I missed the ADLS course. How did that happen? How could I not have studied and passed the skills stations? How can I be so unprepared to care for this one patient, this one most important time?

Thursday a week ago, He had routine pre-“first-visit-with-a-new-physician”-blood work done. The call came in a little after six on Friday evening. The new Dr. G gave me his lab results and laid out a suggested course of action, CT abdomen and pelvis, without contrast due to the CKD4. Easier said than done on the Friday night of a long July 4 weekend. She apologetically explained she was leaving for a week’s vacation in NYC (“who takes a vacation in NYC in July?” thought this Jersey girl). But she said she’d be available by cell, and that she’d contacted Dr. C and filled her in.

The patient was included on this telemedicine call with Dr. G and on speakerphone with us when Dr. C and I discussed how to proceed. We answered his questions honestly but reinforced that we shouldn’t jump to conclusions until we had the CT results.

On Monday, I was able to schedule a CT for three weeks later. Dr. C declared, “why would I even order a CT if I have to wait 21 days for it to be done?”, pulled strings and got it STAT at 4pm.

We had them burn a DVD of his CT and viewed it together while awaiting the call from the radiologist. The news was devastating. His bones were full of lytic lesions, one vertebra seemed only lesions. The 683 PSA had not lied. Why didn’t he have any symptoms? What had we missed?

Tuesday, Dr. C contacted hospice and arranged for the intake interview She directed the purchase of foam bandages and a gel seat (not egg crate) for anticipated skin ulcers.

On my way home from the dentist (I cancelled his next appointment, no need for a dentist now), I stopped at the crematory to ask a simple question, “What do I do when he dies?” The answer was equally short, “Call hospice. They will take care of everything for you.”

I contacted our lawyer to give final verbal approval of the 93 pages of powers of attorney and trusts which had arrived in my email just seven days before and to request they expedite His final copies. The lawyer and paralegal were both on vacation, but the miracle worker (secretary) had them in my email, with extensive instructions how and where to sign, date, and notarize each one, by the following afternoon.

Wednesday was spent on paperwork; making to-do lists; finding titles (who knew his utility trailers had titles) and deeds; printing, reading, and applying ‘sign here’ stickies to pages of documents (only his, mine will be done next week); and talking. We’ve done lots of talking.

Thursday, the wonderful woman at the Division of Motor Vehicles facilitated transfer of his vehicles, trailers and all, to me. We stopped up the street at the dumpster, and I took over his chores for the first time. (I have no idea what other small jobs he has been doing that will now fall to me). He was exhausted when we got home, but we felt satisfied that we were getting things in order.

Friday, we met two friends at the notary and, in a miraculous 33 minutes, signed, dated, and notarized all 93 pages of legal documents. Home again, exhausted, we met with the hospice nurse, who was unbelieving as she toured our “nursing home” house. I had carefully designed the house for accessibility (entrance ramps rather than stairs; roll in showers with grab bars everywhere; vanities that convert for wheelchairs; four foot wide halls; vinyl flooring with no sills). She checked off the walker, bedside commode, shower chair (all clean and stored in the “DME” closet, thanks to bionic knees and hip).

She discussed powers of attorney, advanced directives, and DNR orders. I pointed to the thick file next to me, just back from the notary, and asked if she needed copies.

And so, the waiting and learning began…and, sorry to say, newsletters were forgotten, for the moment.

Join us at our ACEP23 meeting for a panel on caring for loved ones in their (and our) times of need.