Thursday, February 08, 2007

Another day

Mr. Smith, a young man in his twenties, with a wife and small child, came to the doctor about two weeks ago, concerned that his fevers and chills at night, accompanied by some swelling in his neck, were signs of something serious.

He was right.

Further investigation showed swollen lymph nodes in his lungs and axillae (armpits) as well, leading to a presumptive diagnosis of lymphoma. Biopsies were taken of the swollen lymph nodes in his axillae, and blood tests sent.

That’s right about when the seizures started. So he was started on anti-seizure medications while the blood test for lymphoma came back. When they returned as negative, and it was noticed that his kidneys had started to fail, the presumptive diagnosis switched to SLE, causing lupus cerebritis and nephritis. This also explained the faint discoloration of his face as a malar rash.

Because a definitive answer was desired, primarily so effective treatment could be begun, a kidney biopsy was performed. This involves sticking a long hollow needle into someone’s back, removing a core sample of kidney tissue. In a normal person, this causes some bleeding and pain, usually requiring just a stay overnight for observation.

Mr. Smith was no longer much like a normal person, physiologically.

The surgeon who had performed the axillary biopsy had noted that he had to hold direct pressure on the wound site for and abnormally long time to get sufficient coagulation for the patient to be moved from the OR, so some measure of abnormal bleeding was expected. What actually happened was a dramatic amount of abnormal internal bleeding. He bled so much, in fact, that he developed abdominal compartment syndrome, meaning the pool of blood started to pressurize the rest of his abdomen, to the point that his intestines were in danger of dying. He was taken back to the OR to decompress this and returned to the SICU with a vacuum dressing over the hole in his abdomen. He was also on a ventilator now, and it was only with great difficulty that the intensivist was able to keep his oxygen saturation above 80%.

Within an hour, the bleeding had undermined the seal on the wound vac and blood started to pool underneath him. His body temperature, which had not been high enough before, fell to 93 degrees, despite air blankets and stacks upon stacks of regular blankets. He continued to bleed, from the cracks in his lips, from the site where the central line was placed, and from his abdomen.

Transfusion, which had been started when it was noticed that he was losing blood from the vac, despite the dressing and surgical ties, became “aggressive.” In under two hours, he received over a dozen units of blood, multiple units of FFP, of cryoprecipitate, of recombinant factor VII. The resuscitative team began getting desperate. He was given DDAVP, estrogen, anything to encourage coagulation.

None of this, I should add, occurs in a vacuum. While the doctors were having the requisite conversations about the situation described above, the patient’s wife was crying at his bedside, one of the hospital's priests with her, praying comfort to both healthy and insensate. In between passing bag of platelets and blood, I found myself humming silent amens along with them. Outside the room were various family members and friends in addition to the medical students and assorted gawkers. A nurse or tech, I’m not sure which, played with the patient’s young son in another room as his father tried to die next door.
Amongst the vending machines
and year-old magazines
in a place where we only say goodbye

I have yet to actually see a patient die. My first year on the wards I saw a patient crash in the SICU, actually right down the hall from where I stood watching the above, and his abdomen was opened by the surgeons right in front of me. But he was wheeled back to the OR, tenuously clinging to life, and died in that blue-decked room out of my sight. I have had several patients with diagnoses that will kill them, and in some cases, I’ve seen their doctors later and found out about their demise.

Mr. Smith was no different. The estrogen, or the factor VII, or whatever, stabilized him enough to take him back to the OR, the critical care docs giving macabre well wishes and glad I’m not yous to the anesthesiologists taking the case, and life in the SICU continued. Three doors down, another patient with a seriously bad heart and a bad case of Pseudomonas sepsis started to go downhill, and the focus shifted. Mr. Smith couldn’t be considered at present, there were other patients to attend to. But in a small room outside the OR, filled with cheap, easily cleaned furniture and strewn with cast-off magazines, the focus will never shift.

As I walked out of the hospital, I had no idea what was happening with Mr. Smith. I know the anesthesiologists and surgeons were joking in their darkly humorous fashion before wheeling him back. But in a moment of seriousness, the attending surgeon said he didn't favor his chances stopping the bleeding. "Even if the bleeding is stopped," returned the internist, "Smith has been off his steroids to control the lupus for a while now. His kidneys are probably already shot, and his lungs aren't far behind." There isn't really going to be a happy ending here, no matter what.

Though I care about the outcome, I also had to bear in mind the fact that I am on call tomorrow and must get sleep before my 36 hour shift. So it was necessary to leave, to sign out my patients to the on call team, to walk out of the place of grief and go home enjoying my health.

Part of the strain in becoming a doctor is maintaining compassion while bearing in mind the fourth Law of the House of God: the patient is the one with the disease. And so, though I realize when I'm at work that this is indeed where I am supposed to be, I need also to be able to come home and go to sleep, despite all the Mr. Smiths.

I still haven't gotten that last part down.


medstudentitis said...

Wow. Sounds like one of those days that you realize that things just got a bit more complicated than neat pictures in medical textbooks. I hope you find a way to get through this, I don't know how I will when the time comes. I guess we will all find our own coping mechanisms that will allow us to sleep.

Oh, and in response to your post on my blog, I just don't think internal would give me the snowboarding time I need...

thebeloved said...

I am so thankful that there are people like you to whom God has given the grace to deal with these sorts of things. May you continue to rely on Him and may you be borne up moment by moment.

Alice said...

That sounds like a nightmare. One of those patients who get the bad medical equivalent of the jackpot, more complications than any one person should ever meet.

I know what you mean about never having actually been there for a patient's death, although one died overnight (similar story, from trauma though, bleeding out and hypothermic despite all transfusions and surgeries), and another died a few weeks after I left the service. I'm not looking forward to July, because the pattern has to change after a few nights of call. . .

zhoen said...

I have always cried over every patient who died. Always. Not wracking, grieving sobs, but earnest tears. Not a choice on my part, it just always happens. And I am glad it does. And I go on.

A good day is when everyone gets out alive.

erin said...

Nathan, thanks for the link you left on my blog! Your post on Amanda was quite moving. The miscarrying woman I spoke of was actually my mom(weird, huh?), who has since tried to bleed to death in the process. Anyway, a very nice blog. Thanks again.

heidi said...

Nathan, if you don't watch Scrubs, you should. I have a whole new appreciation for it.

The first time my husband saw someone die, it was hard for him. Now, it's part of the life in the hospital.

I love the show Dead Like Me. It has helped me come to some peace with death that I've experienced personally. At one point on the show, the lead character, George, refuses to take a little girl's soul out so that she won't die. Her mentor explains that souls have an expiration date - if you don't let them go when they are supposed to, they wither and decay. Thinking that way has helped me get by sometimes. It's weird but it works for me.

And finally, a little wisdom from Dr. Perry Cox: "'What about our duty as doctors?' [he stops to face J.D.] Look. This has nothing to do with the patient -- it's all about you. You are afraid of death, and you can't be. You're in medicine, you gotta accept the fact that everything we do here -- everything -- is a stall. We're just trying to keep the game going; that's it. But, ultimately, it always ends up the same way. "

Bright blessings and peace to you.

Nathan said...

medstudentitis - it most definitely was. Actually, most days are, but there's always an attending around to remind you of the importance of those textbooks.

thebeloved - thanks. Sometimes I wonder if I have indeed been given that grace, but I appreciate the benediction.

alice - the SICU is full of nightmares, a cruel irony, since it is always so bright the patients rarely sleep well. If we both are still bloggin in the throes of internship, I wonder very much what will happen to our perspective when that finally happens.

zhoen - I think that's healthy, or at the very least, human.

erin - you're very welcome. Do come back again sometime.

heidi - I do watch it. Though it has, in recent episodes, become much more largely about sex, the first season especially was pure genius. One of my teachers knows the medical advisor to the show, as they were classmates at medical school. I tried to get him to finegle me a spot as an extra, but no dice. I'll have to check out Dead Like Me sometime. I don't have TV though, so that will be a rental or a serendipitous circumstance. Thanks for the blessings. Peace be upon you as well.

SnowQueen said...

You might find it interesting to grab this book if you ever have a little time. It'll shed a little light onto what happens when people die.
Raymond Moody MD, PhD, "Life After Life"
I work within a field that deals with death. It's an interesting subject. I don't work in hospice, I could never deal with that.
The human body is fascinating!

Anonymous said...

So whatever happened to Mr. Smith? Did he make it or not?