Let Her Sleep!

“Doctor, can you come quickly, my mother is unwell!”

Even after doing thousands of home visits, I dread phone calls like these. If it’s an actual emergency, I can hardly help with the meagre tools I have in my bag, and the family had better call the ambulance and rush the patient to the hospital without waiting for me. On the other hand, there are genuine conditions in which a home visit by a doctor can help much more than transporting an unresponsive elderly to the unfamiliar environs of a hospital ICU. It’s quite tough to decide on the phone, which is which.

I take a deep breath and start triaging. “What”s wrong?” I ask.

“She’s not waking up!” says the panicked voice on the other side.

My heart sinks. Very often, it is quite difficult to convince the family on phone to rush to the hospital. I get responses like ‘Oh, we want you to visit to make sure it’s worth taking her to the hospital or not..’

“Is she breathing?” I fire the next question.

“Yes, she’s breathing fine. She’s just not waking up!” 

With the list of differentials swirling in my mind – hypoglycemia, hypotension, stroke, myocardial infarction, sepsis, trauma, medication overdose – I look at my calendar. Fortunately, I have some leeway to visit them and spend half an hour or so with them. Even more fortunately, they live nearby, so that I won’t have to combat Gurgaon traffic in reaching their house.

As I am climbing out of my car, I make sure to carry my ECG machine along with the home visit bag.

The door is answered by an old lady, who ushers me deep into the house. There’s a gaggle of concerned neighbours surrounding the patient in her room, some sitting, some standing, some rubbing her feet, everyone with a panicked look on the face. It’s not very clear which one’s the daughter who called me, but there’s no time for introductions.

I start collecting vital signs – unresponsive, pulse 76/min, blood pressure 124/86, respiratory rate 20/min – so far so good – and at the same time start enquiring about what else is going on. Fortunately, most of the gaggle is quiet, and only one or two ladies in the room take the lead in answering the questions.

It turns out the daughter had called me from her office, and is on her way home. The neighbours try to help out as much as they can. I look at her past records, I enquire from the maids, I try calling her daughter again.. No significant past medical history, no current medications except for vitamins, no signs of infection on examination. Time is ticking, but there’s no clear cut diagnosis in mind. I feel like I’m missing something, Is it time to give up and call the ambulance?

Finally inspiration strikes and I hit upon the right question. “How much has she been sleeping?”
And the answers start flowing.. She has been continuously awake – taking care of her infant grandchild – for the last one month, getting barely 1 or 2 hours of sleep a day! Her daughter has rejoined her hectic job that keeps her away most of the day. I take a look at the patient’s medicine box – no sleeping pills there, and I breathe a deep sigh of relief. 

“Let her sleep in peace,” is my prescription, “and bring her to the clinic when she wakes up.”

I mentally add ‘Exhaustion due to Insomnia’ to my list of differentials on my way to the next home visit. 

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