Author's Note:
Sorry for the delay in posting. Just wrapped up a project and have a nice window of downtime over the holidays to devote to this story. Malcolm is headed home.
Malcolm approached the door of St. Thomas's hospital in a wheelchair piloted by none other than Mark the orderly. The gaudy floral arrangement from the PM was in Malcolm's lap. Sam, Julia and Jamie formed a protective phalanx around him as they neared the exit. Jamie went ahead and checked to confirm there were no cameramen or reporters present, and then signaled for the car from the service to roll up to the curb.
Overall, it was an uneventful departure. Sam still felt anxious, doing her own unconscious search for media as they pulled away from the hospital and headed toward home. Malcolm looked better this morning than the night before, dressed in the new corduroys, button-down shirt and jumper Sam purchased so that he had at least one thing he could wear that fit. Julia volunteered to help with alterations on his work clothes, and promised to just do simple basting that Sam could easily take out as Malcolm gained weight. That was one of several Saturday priorities, along with the postponed conversation about Colin Clatcher. Julia had a Sunday morning flight home.
Sam held a large package from the hospital chemist with Malcolm's medications and a sheaf of discharge instructions from Doctor Ravi on her lap. Even with the medical technician and home health nurse meeting them at the house this afternoon, Sam worried about making sure Malcolm followed the directions and took all of the medications as directed.
"I suspect you have been operating with insufficient oxygen saturation for quite some time," Doctor Ravi opined during their final meeting with him. "I would like you to continue using the oxygen for the rest of today and all night tonight. Tomorrow, you may begin going without the oxygen for short periods of time.
"When the technician comes to set up the equipment, he will step you through how to do this. Wear the oxygen saturation monitor at all times when not wearing the cannula. If your saturation level falls below ninety percent, you need to go back on oxygen. Stay on the oxygen for at least an hour, and then if your sat is back at 90 percent or above, you can take off the oxygen again. The goal is to gradually wean you off of the oxygen assistance, though I want you to continue to use it at night." Malcolm grunted. Sam knew he was frustrated about having to continue the oxygen.
"What about the breathing treatments?" Sam asked.
"The technician will bring a nebuliser and demonstrate how to use it. There are two medications, albuterol and formoterol. These are the same medications we've been using. They come in pre-measured phials, so it isn't hard to do the treatment at home. You will do two treatments a day, spaced approximately twelve hours apart. If you experience heavy congestion, you may do one additional treatment. If things don't improve after that, please come in as soon as possible, as there may be something else going on." Doctor Ravi turned to the next page in the thick packet of discharge instructions, which were turned toward Malcolm and Sam. Malcolm did not read them, and probably wasn't listening very closely, Sam surmised. He knew that she would.
"And then there are the IV antibiotics. This is your fourth day of a ten-day course. We'll leave the IV port in your arm, and the home nurse will demonstrate how to change out the bags and take care of the port. You will need to cover the IV port when showering. Please don't do anything strenuous that could cause the port to dislodge from your arm. If anything like that happens or if there is any bleeding around the entry site, call or come in right away. No heavy lifting, for obvious reasons."
"Please call this number to schedule your follow-up appointment for the day after your last dose of antibiotics. We'll remove your IV port and take some blood samples, and also do another pulmonary function test at that time. If everything looks good, we'll do your biopsy the following week.
"Please do not drive until after your follow-up appointment. It would be difficult to manage with the oxygen and the IV." Sam knew this wasn't an issue. Malcolm rarely drove, relying on her to get to work and the car service to get around town as needed.
"What about work? When can I go back?" Malcolm asked.
"I know you have a lot going on at work. I would like you to stay out of the office until I see you at your follow-up appointment. That's to minimize the risk of exposure to any viruses or opportunistic infections. Either of those things will delay your biopsy. If there is work you can do from home, that is okay on a part-time basis, as you feel able, but don't push it." Sam couldn't help giving Malcolm a pointed look at that. She would see to it that he didn't over-do it. He looked suitably contrite. Sam knew he felt badly about worrying her. Doctor Ravi turned to the final page of the discharge instructions.
"Now, let's talk about diet." Malcolm rolled his eyes.
"When you came in on Wednesday, you weighed 65 kilograms, or eight and a half stone. While here, you lost five kilograms. Ideal weight for a man of your height, build and age is seventy to eighty-five kilograms. As I mentioned yesterday, we need to get your weight up to at least 65 kilograms before the biopsy. I'd like you to try to get at least 2,500 calories a day. Some nutritious higher calorie options are full-fat dairy, whole grain breads and pastas. Try to get two servings of protein from meat a day, and five fruits and vegetables. Even with all of that, I would recommend picking up a higher calorie nutritional shake, such as one of these three brands. Some taste better than others. Most of my patients like chocolate flavoured ones the best. If you refrigerate it first and then put it in a blender, it tastes like a chocolate frappe." Sam doubted they were all that tasty. From Malcolm's facial expression, she knew the shakes would be a hard sell.
"This page lists things that could happen that would warrant coming back to A&E. Keep an eye out for increased congestion, difficulty breathing, dizziness or nausea. If you experience any of those things, come in immediately. If your oxygen saturation goes below 90 and you can't get it up to ninety with oxygen and a nebuliser treatment, come in immediately.
"You shouldn't have any side effects from the medications, as these are all the same ones you've been on while here. If you experience any of the side effects listed on the medication packaging, call or come in."
Jamie and Julia returned from the cafeteria just as the doctor closed the discharge instructions. Doctor Ravi wrapped up and asked Sam and Malcolm if they had any questions. Sam was sure she'd have some later when she had a chance to read through everything again, but right now was suffering from information overload.
Sam accepted the packet of instructions, noting with a touch of humour that the doctor knew she was more likely to actually use them.
"Thanks, Doctor Ravi, you've been great. We'll call if anything comes up."
"Right, doc. Thanks for everything." Malcolm and Sam both shook the pulmonologist's hand and the entourage headed toward the elevator and the car from the service waiting at the curb.
Julia was in the passenger seat with the floral arrangement balanced on her lap. Jamie, Sam and Malcolm fit a little snugly in the back seat. Jamie kept up a light patter of polite conversation with Julia, focussing on her children, who were a good bit older than his. Malcolm clasped Sam's hand the whole way home. He didn't say much. Sam suspected he was glad to be out of hospital, and perhaps anxious about the impending difficult conversation with Julia.
