I don’t think of myself as a proceduralist. I don’t like performing invasive procedures as I don’t like to cause pain if I can avoid it. I will do them when they are necessary but it is not a natural fit for me.
The patient was a 39-year-old mother of a 7-year-old son. She was admitted for pain control and I thought she would not have much time left to live. She had known this herself for the past six months. In preparation, she had purposefully reconnected with her ex-husband the father of her child. She wanted to make sure that they would have a loving relationship after she had died. She had been reluctant to come into hospice as she had wanted to spend as much time as possible with her son and other family members at home.
We wanted to sort out her pain as quickly as possible to get her back home. We managed to sort it out within the first three days. This was good as she had met with our social worker and the final adjustments to her will were being made. Her lawyer had been engaged and would be arriving in three days for her to sign the final papers. It was important to have this sorted out as she wanted her house to be transferred to her ex-husband for him to have a house to raise their son in. She had worked hard to buy her house, it was her pride and joy. She wanted her son to have a stable home environment.
Overnight she went to the toilet but on the way back to her room she heard a loud crack from her right hip, followed by overwhelming pain. She could no longer support her weight and managed to call out for help. The nurses needed to use the lifting hoist to get her back in bed, which made her scream.
I reviewed her the following morning and I recognised a familiar pattern. Shortened leg, twisted at a non-anatomical angle, tender to touch and excruciating pain with the slightest of movements. Fractured hip, likely broken through a metastatic deposit. We talked about going to the hospital but she did not want to go anywhere. She said that she had already been to the hospital too many times in the past. She thought her time was limited and she wanted to spend it in hospice.
We gave her stronger pain relief which relieved her pain but because of her poor overall condition, it made her sleepier. She didn’t want to be sleepy, as she still needed to sign her new will. Her son’s future welfare needed to be sorted out before she died.
I came up with an alternative plan, for which I needed to draw upon my procedural experience from 20 years ago. As a first-year orthopaedic house officer, I developed the skill of performing femoral nerve blocks. A good way of soothing the pain of a broken hip. I hadn’t done one for twenty years but I was willing to give it a go. I called our colleagues at the hospital as I needed equipment and medications we didn’t usually stock in the hospice. Our kind hospital colleagues arranged for local anaesthetic and injection needles. An Emergency Medicine Specialist called me to refresh my memory on the injection technique. I drove to the hospital myself to pick up the equipment that would be needed.
I had to channel my younger self as I performed the procedure. I steadied my hand and plunged the needle in, injecting the advised mixture of medications into the patient’s groin area. I hoped that it would work but was unsure if it would.
I went to check the patient an hour later and her pain was controlled. She didn’t need extra medications for the rest of the night. The next day she was comfortable and lucid when the lawyer came to complete her paperwork. Afterwards, my team offered to redo the procedure but she did not want it repeated. In the next days, she rapidly deteriorated and we kept her comfortable.
She died three days later in the presence of her gathered family.
well done james! a great outcome for your patient & her family.
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