tyranny of distance, part 2

the diabetes educator had left her the previous day after a 2 hour "catch-up", apparently well except for ongoing unstable bsl (which had been going on for years). she found her in the same position 24 hours later, unconscious, gcs 11 and febrile. with no obvious explanation for her temperature of 39.5 (impressive for a 82 year old), mild neutrophilia and a surprisingly normal crp, i asked the ed resident to do a lumbar puncture. id just done a question on herpes encephalitis and aciclovir was on my mind. sure enough, the csf came back with high proteins, relatively normal glucose and (drum roll please...) 100% mononuclear cells. and so the aciclovir went in. the next day we noticed she was having seizures and added phenytoin. her gcs fluctuated between 6 and 8. things looked bad.

her closest family was her dead husbands nephew 110kms away. he was the only one that seemed to care (i will try to come up doc but it wont be until the weekend cause im working) but didnt feel comfortable making medical decisions for her. there was a son in wa, he said, and gave me a number that didnt exist. apparently there were three more sons in holland, and i left a message on an answering machine after a (what i presumed to be) dutch "please leave your name and number..." routine.

later, the son from wa rang me. i guess the nephew had better luck getting on to him. he was angry that switchboard had made him wait (on long-distance) while i was in a family meeting (rapid deterioration in a woman with extensive stage small cell lung cancer). but he quickly got the picture. no he couldn't come, he said, because he didn't have the money. and he didn't want to be stuck here if she died. did he wanted mum to go down to adelaide or melbourne for further investigations? no doc what's the point? shes in her eighties and shes had a good life. i promised him id let him know how things went. later on i overheard some nurses talking: apparently my patient is loaded. ahh...

i shut my ears and quickly moved on to the next patient.