Examining the Deceased Person

Two weeks into my medicine rotation, and I’m really starting to enjoy it. It’s a refreshing change from the mundane stuff I was doing in orthopaedics anyway.

Finding out that I would start medicine as the night ward call RMO on the last week of orthopaedics made me a tad bit apprehensive though. My apprehension was unfounded however, as the nights had seemed to be going well. I’ve got a very friendly and reliable registrar, and the tasks I’m asked to deal with are manageable at my current level of knowledge.

Perhaps one of the amusing things I’ve done so far, had been examining a deceased person. Prior to this, in the one and a half years of working, I’ve only come across one deceased person as an intern. And that wasn’t the greatest experience. But that’s another story for another day.

Anyway, I got phoned by one of the nurses asking me to confirm the death of one of the patients.It was an expected death with the daughter present there. I made my way to the ward, and carefully read the patient’s history. I looked at my watch. 12:40 am. As I got to the patient’s room, it was illuminated by a very dim light, throwing sharp menancing shadows over the patient’s face. Her lips were sunken in, and she had an open mouth, with eyes closed. Protruding cheek bones, and a pale face alerted me to the fact this woman would have been very frail and in poor health prior to presentation.

I introduce myself to the daughter, and explain that I’m going to be examining her mother. I call out the patient’s name, and start giving some tactile stimulation over the sternum. No response. I feel her radial pulse. No pulse. I try the carotid pulses. No pulse. I listen over her chest for breath sounds and heart sounds. Neither of those are present after 30 seconds of auscultation. Finally, I open her eyes to find big dilated pupils that don’t react to a torch light. The eyes looked out, almost as if they were made of glass. I contemplated doing the “rag doll eyes” test, but given the way the patient’s head was angled, and how the daughter was there, I decided against it. I calmly turn around to the daughter and say “I’m sorry to inform you, but your mother has died.” I glance at my watch; 1.04 am. The daughter sobs quietly. I ask her if there is anything I can offer her for the time being, like a cup of water. She politely declines.

I walk out of the room to document my findings. I am surprised that I wasn’t freaked out this time by a deceased person. I know I shouldn’t be saying this, but it felt different in a way (in my mind, kind of cool), seeing and examining someone who’s life ceases to exist. I felt detached in a way examining the patient. I felt emotionless, felt like I was just going about doing my job. I think what helped was that I hadn’t been involved in this patient’s care. Perhaps that’s why I didn’t feel so emotional. But then, I’m not so sure how I am supposed to feel after something so sad like this. Was I supposed to feel this detached, or was I supposed to feel at least a little something about a person passing away?

I’m certain that there are many more deaths I’ll be asked to confirm. So far, I have confirmed 3 deaths, which for my stage of training is probably considered quite low (thanks to me being in a more regional hospital with less patients). I am lucky so far in that the deaths of all the patients I have had to confirm have been expected deaths. I fear the unexpected death, and having to explain and answer difficult questions they may have, as well as dealing with reactions of family members like anger and denial. I hope I’ll have the experience and skills to deal with that in the future.

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Drug Seekers

“Oh, but I just ran out of my oxycontin medications the day before coming into hospital. Could you write me a script for when I go? I won’t see my GP until 4 days time”.

Sigh. This man was on 90mg of oxycontin a day for back injury sustained years ago. The pharmacist thought his story was dodgy, as did the nursing staff. Bells and whistles were going off, and I couldn’t help but think that this is one of drug seekers that I’ll be facing for the rest of my career.

The nurses had found syringes in his belongings. Not only that, but his story was extremely sketchy. There was an unaccounted period of 3 months of which he hadn’t obtained any oxycontin from his last GP. He must have been doctor shopping in that period of 3 months. In addition to all this, the man was demanding. He told the nursing staff that he wouldn’t leave hospital until he got some scripts.

I didn’t know what to do. I had a feeling that I could perhaps tell him that it is not one of my policies to discharge people home on strong pain relief when I am not familiar with their medical history especially in regards to his pain and his scripts. Being like any junior doctor who is stuck about what to do, I phoned my registrar. She told me to just give the scripts. So, I wrote the scripts (only for 8 tablets however – to last him till his supposed appointment with his GP in 4 days time) The man took off shortly after being given the scripts. I felt defeated.

Reflecting in hindsight, I don’t really see why I didn’t just decide to not write the scripts in the first place. There were 3 months of unaccounted scripts of oxycontin that he wasn’t getting from his regular GP, his story of running out of medications was extremely suspicious, and the nurses found syringes in his belongings. My biggest fear at the time however, was always the thought that what if I don’t write the scripts and he definitely had no medications? I thought about not writing the scripts and telling him to see ED if there were any issues with pain, but it felt irresponsible. Also, I was afraid of what would happen with his threats of not leaving until he got a script. These patients sure are scary (he looked scary too – missing a few teeth, menacing eyes that glared at you).

I recently read an article (http://www.racgp.org.au/afp/2010/august/prescription-drug-misuse/) that deals with the very issue of drug seekers. They’re a challenging group of patients to cater for. They may use tactics of intimidation, and guilt tripping to get what they want; more pain medications. In Australia, oxycontin and alprazolam are the most abused drugs. What’s more, there are an estimated 20,000 prescription drug shoppers in any 3 month period.

The article goes on highlighting some strategies to deal with the drug seeker, something like saying “it’s my choice” or saying “it’s our policy that we don’t prescribe strong opiods/benzodiazepines for new patients” effectively giving no room for negotiation from the patient. The second strategy is really good, but I feel the first one could still give room for a drug seeker to negotiate and manipulate. One thing the article really highlights however, is the fact that role plays with such scenarios have shown that doctors are initially embarrassed or too shy to say no to drug seekers.

Would I write another script for a suspected drug seeker? Probably. But I’ve learnt something from this encounter. I learned that it’s quite hard saying no to a drug seeker. But with this experience in mind, I’m in a better standing for that next encounter with the drug seeker.