Life has a funny way of making sure we're exactly where we need to be. Tonight, for example, I was supposed to be off, but Shane (one of my assistants) is really sick, so I came in to man the pharmacy overnight. Funny how the compounding pharmacist happens to be here when the nurse comes looking for some concoction to make albendazole taste better (good luck with that!) and alternate dosing forms for a
hospice patient.
The albendazole "taste-testing" can wait for later - when I have more than just myself to do the tasting - plus, hospice care has always been one of my soft spots.
It's about 4am, I'm listening to Tracy Chapman sing about "Fast Cars," and waiting for Lauren to come pick up the "hospice kit" I spent half the night making for Peter. We can't save them all, no matter how hard we try. With Peter (also known as Peterson), we have tried and tried - even flew him to the states for treatment. But sadly, the humongous cancer tumor on his neck (about the size of his head) didn't respond to chemotherapy, and neither did the metastatic tumors that cropped up in his lungs and other areas. When it became clear that he would not get better, the hospital staff at Broward General (the hospital in South Florida that was covering the treatment) asked him and his mother about their wishes. Peter wanted to come back to Haiti, to see his brothers and sisters, and to die at home.
So Lauren brought him back, and tomorrow they will spend about 6 hours driving the 25 miles to take Peter and his mother home. (Did I mention that roads here SUCK?)
I made the usual suspects for the "hospice kit"; morphine in several strengths (both injectable and oral) to help with pain control, injectable lorazepam as well as a liquid lorazepam "with a chaser of haldol" for fear and anxiety, zofran (for the nausea on the bad roads), atropine drops for under the tongue (helps stop secretions)... And a custom ketamine/baclofen/diclofenac/lidocaine gel...
There is a very good chance that today will be Peter's last day on this planet. Without going into all the gory details, the plan is to keep him alive long enough to return home to see his family one last time. I took Lynden to translate for me - he used to teach kindergarden through 6th grade, so he's good with kids. I had Peter explain where it hurt, and describe the type of pain, and explained what I was going to try to do. The pain Peter is experiencing is excruciating, but not diffuse; it's specific to his neck (under the mass and up the back of it) and the area surrounding his chest tube.
I'd read an article a while back about topical ketamine for hospice patients, and we often compound baclofen/ketoprofen/lidocaine at Broadway (my job back in the states), so I did some research (in 4-point font, on my blackberry), and made a gel to ease his pain.
This was one of the few times in Haiti I've worn gloves... A gel designed to absorb through HIS skin would also absorb through mine. I warned him that the application process might hurt a little - I had to rub the gel into the places that hurt. He was a trooper, not even a tear. When I came back to check on him, he said the pain in his neck was gone. He was a little light headed, but able to carry on a conversation and play with the paints and play dough I brought him. He said he felt more "clear headed" than when he was on all the morphine - goal accomplished.
On my way back to the pharm Sam asked me what I had done. Sam is a Haitian medical student who will be starting his third year this fall. He had never heard of the concept of "hospice" or end of life care - it doesn't really exist in Haiti. Sam doesn't know it yet, but as of this week he will be an employee, not a volunteer. He'll be my "intern," and will have projects and presentations just like an intern in the states... Sounds like I've already found his first project...
~PJ
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