Thursday, March 06, 2008

The Ravages of Alcoholism

The patient was 44 years old. By the time I got to see him he was already on the ventilator. He was also on levophed (commonly referred to as "leave em dead") and dopamine, both to support a faltering blood pressure. I stopped to review the labs. What a mess! His bilirubin was 22 (normal around 1.5) and his other liver function tests were off the wall. He was anemic and his blood chemistries were not compatible with mammalian life. His ammonia level was 144 (normal less than 40). Ammonia is normally detoxified by the liver, and high levels seen in liver failure are thought to contribute to a depressed mental status known as hepatic encephalopathy.

The patient was indeed comatose and so my only history came from reading the chart.The patient had reported drinking about a quart of vodka a day, while smoking 2 packs of cigarettes a day. You would think that this was a combustible combination, but apparently he had not exploded and was simply found down on the kitchen floor.

I entered the room only to feel the shifting air pressure, to catch the flitting shadows in my peripheral vision. The Angel was already on the job.

"Hey!" I said, "Give me a chance to examine the guy."

The laughter was unnerving, as usual, and the voice still scared me a little.

"Don't waste time on this one, I am here to collect him."

"How do you know I can't save him? Some times the liver can heal once you stop the booze."

Again, the rasping laugh. "Yes. You could save him so he could live to drink again."

He had a point. I went about my exam, first checking the drips and the monitors. Pretty grim. Max doses of pressors, vitals marginal. He was a deep yellow bronze, jaundiced from his liver failure. His belly was distended and tense, filled wih the fluid of ascites. His feet were quite swollen, when I squeezed, my fingers left deep imprints. At this point the family, sister and mother, came in.

I introduced myself and then reviewed his condition with them. I closed my remarks by stating that his condition was terminal and that he had no chance at all of survival. I braced myself for a hostile argument, but it didn't come. They were both exhausted, undoubtedly by years of cleaning up the mess left by an alcoholic son or brother. What I saw was mostly relief. They asked a few questions and then agreed to withdraw support. We stopped his IV fluids and pressors, and he died within 5 minutes.

I scanned the room for the Angel, but felt nothing. I went outside to write a note. This man was only 44, younger than me by ten years, but he had drank himself to death. It appeared that he had also tortured his family along the way. Now maybe all involved could move on. I tried to picture myself in their situation, one of my beautiful sons dying in an ICU at only 44 years old, but the images wouldn't come, it just didn't compute. I did resolve to appreciate my good fortune, and cherish every minute I had with my children.

I finished my note and left the ICU, already dialing my wife's cell just to say hello.

Saturday, February 23, 2008

When Viruses Attack

One of the occupational risks of being a doctor is exposure to infectious diseases. This can come in the form of accidental needle sticks, of which I've had my share, or exposure to infectious agents through contact. Yes, I wash my hands very frequently, but the risk remains. We have recently had a mini influenza breakout, with two patients ending up in the ICU on ventilators. It may or may not be related, but last Tuesday I began to feel a little sick. Nothing major, just a scratchy throat, cough, some congestion. I figured it for a standard cold (or in doctor speak, viral URI), but by Wednesday morning I knew things very more serious.

I started to spike fevers, developed a headache and started chilling and shaking. Getting out of bed to make the ten step trip to the bathroom took all my concentration and willpower. I actually called in sick.

You might think that a group of doctors would understand that people do get sick and should stay home, but in my group we all pretend that we are invulnerable to the diseases that affect mere humans. We have no system in place to fill in for a sick partner. In eleven years with my current group I had never taken a sick day. Not once. But on Wednesday I had no choice.

I was in bed for 36 hours, miserable with cough, headache, drenching sweats, chills. It finally dawned on me that I most likely had real influenza. I contemplated taking a course of tamiflu but in the end didn't have the energy to phone in a prescription. I talked to my father on the phone and mentioned my illness. Before retiring, he was a pediatrician which is almost like being a doctor (just kidding, Dad). He asked if I had been to see my doctor. I told him no, that would be a sign of weakness. After we finished laughing, his only comment was "Jackass."

On Thursday I attempted to work, but only lasted a few hours. Friday, I was in the whole day, and appear to slowly be getting better. It's a little scary how weak I've gotten. It's like that episode in "Buffy, the Vampire Slayer" when she temporarily loses her super powers. I'm normally a very vigorous, athletic person- someone who thinks of spending an hour on a gigantic thoroughbred horse, jumping fences, as a light workout. Now I was having trouble walking up a flight of stairs. Scary indeed.

Saturday was one of those glorious, sunny days that makes you give Minnesota another chance. After weeks of temperatures below zero it was now in the twenties and the snow sparkled. I took our Labrador for a long walk, letting her run in Kenwood Park. When I got home, a few hours later, I was exhausted.

It has finally sunk in that doctor or not, athlete or not, a virus is a virus. It doesn't care, This one hit me like a steamroller and knocked me flat. I will have to work each day to increase my endurance and strength, just like anyone else. I'm just thankful the Angel of Death didn't see the need to take an interest.

Saturday, February 16, 2008


I was taught in medical school that pneumonia is the friend of the elderly.It helps ease the transition from this life to the next.

She was 94 years old. The family insisted that she was living independently at home. Apparently her independent living did not include eating, as she appeared to be a thin-skinned bag of bones. By the time I got to her in the ICU she had already been put on the ventilator. Why you would put a 94 year old on the vent escapes me. Her respiratory failure would have been a perfect way to die: progressive obtundation, coma, death. The ER doc had talked to the family, who I guess was impaired in some way, and wanted "everything possible done". Of course, the fault is ours. As her doctor of the moment, the ER doc should have said "I'm sorry. There's nothing we can do. It's her time to die."

The ICU room was darkened and I saw no need to turn up the lights as I examined her. Her bones stuck out everywhere. She had very little hair but still had her teeth. She did not respond during the exam. As I leaned in to listen to her heart I felt the now familiar shift in air pressure and heard a rasping laugh.

I pulled one of the earpieces of my stethescope out of my ear and without turning to see what would only be a shadow at the corner of my vision, I said "Yeah, yeah. I know. She's all yours. But not for a little while. Have some respect."

His voice had too much air whistling over ancient, inhuman vocal cords. "Why do they fight it so? Is life in this small, dreary world so precious?"

"It has its moments."

The presence shifted closer for a moment and then seemed to recede to the edges of the room. "Her moment is gone. You work on her body but she has already left it."

I put the earpiece back on and listened to her heart. The rhythym was regular, but the blood flowing over her 90 plus years old, calcified valves made a roaring sound with each beat. A systolic murmur, likely from the aortic valve.Her neck veins were flat, suggesting that she did not have fluid overload and that her respiratory failure was not from congestive heart failure. I shifted to her lungs and heard the whistling, prolonged expirations of inflammed, swollen airways. I made a note to myself that she would need iv steroids and inhaled bronchodilators. When I took off the stethescope and stood up I heard the rustle of robes, the creak of leathery skin.

"You still here? No famine or pestilence somewhere else in the world that requires your attention?"

"I am everywhere.Waiting."

"Yeah, well, fuck that. You'll have to wait a little longer on this one."

The laugh again and then gone.

I sat by the computer and checked her labs. They had swabbed her nose for culture and the rapid antigen for influenza A was positive. So we had an explanation for her lung problems. A classic case of real influenza. People toss the word flu around, most often referring to a viral upper respiratory tract infection or viral gastroenteritis. But this was influenza. The same disease that had allowed the Angel of Death to harvest souls wholesale during the pandemic at the beginning of the 20th century, and intermittently over the decades.

The ER notes said she hadn't been to a doctor in several years and that meant she hadn't had the flu vaccine. Might not have mattered much as it seems that this year's vaccine was an antigenic miss, meaning it didn't prevent the strain of virus currently making the rounds. I wrote orders for tamiflu twice a day down the feeding tube and sat down to dictate a note. It was late and I figured I'd save the inevitable family meeting for the morning. I couldn't imagine the type of dysfunctional psychopathology that would result in tormenting the family matriarch during the final hours of her life.

The car barely started, having been out in the minus 15 degree weather of a Minnesota February night, but eventually fired up after several tense tries. I hunched over the wheel, and drove with muscles clenched, waiting for the engine to generate some heat. And then the Angel was back. The soft laugh, the thickening of the air.

"Fuck you." I ventured half-heartedly.

"You did well tonight." came the rasp. "She lives yet."

"Gee, I'm touched by your compliment, but could you kiss off for awhile. Someone might see me talking to my self."

"I am here. You are not alone. We are two sides of a struggle, two sides of a border. A struggle that you will always lose and I will always win, sooner or later. Sooner or later they are all mine."

I reached down to turn up the radio. "I fight the fight as long as they want me to. I don't decide who lives or who dies, but if they want to hang on to their sorry ass lives a little longer, I try and make it happen."

The Angel's presence faded and my shoulders relaxed. Maybe it was the heat finally coming on, or maybe I get a little tense in the presence of death incarnate.I took the exit off the highway and turned into my street, controlling a small skid with the nonchalance of a northerner driving in February. The tires crunched up the driveway and through the opening garage doors.

Upstairs, bed, sleep.

Sunday, February 03, 2008

The Week Begins

Monday morning I start the week long ICU rotation. I will be on call one week night, Monday this time, and the weekend. Monday morning I start a work day that lasts until Tuesday at 4:30 pm. Saturday morning I start a call weekend that ends Monday at 4:30 pm. We recently recruited a new partner. During the interview process some of the candidates asked if you got the day after being on call off, to which we responded "In your dreams, that's where you have the day after call off."

Non-medical people often think this is crazy. How can you work for 36 to 48 hours, during which time you may or may not get any sleep. My first response is that I have been doing just that since I was in my early twenties, and it's the difference between a doctor and a civilian. Patients don't get sick at convenient times, and if you don't like staying up at night, working holidays, going without sleep for a day or two at a time, then find a different profession.

Residency training programs now have time limits on work periods and require that residents go home by 1 pm after being on call the night before. Basically, instead of doctors, modern residency programs are producing skilled laborers who work shifts. Upon finishing training they will be ready to go to work for health care corporations. We have seen this most clearly in the shift to hospitalists, who are employees of whichever corporation owns the hospital, and cover the inpatients and new admissions, working defined shifts of 6 to 8 hours. Although they are all well rested, patient care responsibilities turn over several times a day as shifts end and none of the doctors really gets to know a given patient well.

My view is that the one big advantage of being a doctor is that you don't have to work for anyone else, ever. As a highly educated and skilled professional, you can open your own practice, run your clinic however you see fit. I love that part of being a partner in a small private practice. I have no boss to impress, no supervisor who can judge me. My patients are the only ones I answer to, and my practice is based on a professional obligation to provide them the best care possible.

Saturday, February 02, 2008

Rat Poison 2

I went about my rounds, eventually leaving the ICU and doing ward follow-ups. In truth, I almost forgot about the case until about 4 in the afternoon when it kind of struck me that I hadn't heard anything about her lately. I wandered down to the ICU and sure enough there was a lot of commotion in her room. The Flying Squad was back and they were getting the patient organized, giving report to the ICU nurses, getting her hooked up to the ventilator and monitors.

I walked in and caught the flutter of a shadow in my peripheral vision, the rustle of robes of heavy cloth. No one else seemed to notice. Not a good sign if the Angel was taking interest. "What happened in IR (Interventional Radiology)?" I asked, as soon as I caught a nurse's eye.

"They found a bleeder, in the splenic artery. They coiled it with a good result and she seemed to stabilize. For a while at least."

I looked at the monitors first. The A-line was reading about 75 systolic with a pulse of 130. Not good. "Labs?"

"Just drawn. Nothing back yet."

I set her up for two more units of blood and some FFP as well on spec and started examining her. Her extremities were cool and she had a purplish mottling of the skin that is called livido reticularis. It's seen in patients with shock from various causes. Her abdomen was still rigid and she was obtunded (doctor speak for totally out of it). The labs began to trickle in: her INR was now 1.25 and her platelets were ok. The hemoglobin was low but not terrible and would improve with transfusion, but her blood pH was markedly decreased implying severe acidosis. I heard the rasping, huffing laugh and turned around only to see a shadow disappear. The Angel would get this one. We had waited to long to intervene.

Maybe it wouldn't have mattered anyway but I felt that we had had a window of opportunity and missed it. Medicine is a team sport. I need the surgeons and the radiologists, and they need me. They each have to make their own decisions and we all live, or die with them. I reluctantly went out to talk to the family. This would be a tough one: relatively young, abrupt onset of a lethal event.

About an hour later we had an order for DNR/DNI, and later in the evening they agreed to withdraw support. She died in the early morning hours the next day without ever waking up.

Thursday, January 31, 2008

Rat Poison

Well. Where, indeed, did that last post come from? Maybe I was channeling Che Guevara or something. I get a little passionate when it comes to exploitation of the proletariat in America.

Back to the ICU.

It was Sunday. Bright and sunny and absolutely freezing in the way of Minnesota in January. I was on call for the weekend, slogging through morning rounds when I got the "5141" page. I thought "So it begins." The ER doc was somewhat frantic. The patient was a 60 year old woman who fell at home and couldn't get up. EMS was called and noted a blood pressure of 60 systolic. They put in an IV, started some saline and transported her to Red Room 1 in the ER.

Once there the ER doc noted a rigid, distended abdomen. The labs showed a hemoglobin of about 5 (normal is around 14), meaning she didn't have much blood perfusing her vessels, probably because most of her blood volume was in her belly. She was also on coumadin.

Coumadin is rat poison. The rats eat it. It thins their blood, preventing the blood from clotting. The poor rodents bleed into their heads, get dizzy and crawl outside to die. Ok, I made up that last part, but you get the point. People are put on coumadin for a variety of problems such as blood clots, cardiac arrhythmias, artificial valves- situations where you need to prevent blood from clotting. The problem lies in the fact that coumadin has what we doctors call a narrow therapuetic window. That's doctor speak for a drug where beneficial treatment levels are very close to lethally toxic levels.

In order to monitor therapy in patients on coumadin we monitor a lab test called the INR, which stands for International Normalized Ratio. Whatever that means. The goal is for the INR to be between 2 and 3. Less than 2 means risk of clotting and when you get greater than 4 or so it means increased risk of bleeding. Monitoring the INR and adjusting the dose of coumadin is a major headache with the dose being adjusted just about every week. This patient had an INR of 7.5. When the ER doc relayed that to me I responded with something really intelligent, on the order of "Yikes!"

She arrived in the ICU and, along with 3 nurses, I set about stablizing her. We basically poured the blood bank into her, to correct her anemia. We also gave her a lot of fresh frozen plasma and vitamin K to try and reverse the coumadin-induced anticoagulation.I put in a femoral arterial line for real time monitoring of blood pressure. Her blood pressure came up and her heart rate came down and we got a chance to sit back and catch our breath.

The first thing I did was have the HUC stat page the surgeon on call. Wherever she was bleeding from she was going to need someone to go in and fix it. The surgeon came by and had a look but felt we should temporize and focus on correcting her high INR and transfusing her. I had to agree that at the moment she looked relatively good, although deep down I wondered if now was the time to operate, when she was indeed quasi-stable.

Well, you fight the Angel of Death with surgeon you have.

Needless to say, about an hour later, when I was just finishing my orders and dictation she crashed. I ordered more blood, but our peripheral IVs weren't up to the task, so I went for the big guns. In a patient who needs massive infusions of blood and fluids you want a central line that's short and fat, and therefore has less resistance to flow. I favor a Cordis introducer in these cases, so I had the nurse set up for the line. Not only was the INR still elevated making line placement risky, but this patient weighed in at 100 kg, meaning no landmarks were available to guide my needle home into the internal jugular vein. Once more I rolled out the Site-Rite portable ultrasound and, fortunately, with only a minimum of flailing about had an introducer in place in short order.

By now the surgeon was back, but he opted to turf the patient to Interventional Radiology. The goal was to have the radiologist do a mesenteric angiogram, locate the bleeding artery and, if possible, embolize or otherwise clot it off. The Flying Squad came and trundled her off to Radiology and I went off to try and see some of my other patients. For the next few hours at least, she would be a SEP (Someone Elses Problem).

Tuesday, January 23, 2007

The Dialysis Patient

I got the call at 3 pm as I was back at the office, feet up on my desk, lightly sleeping. The nurses used to tease me about this activity, but now are protective of my nap time. I can sometimes hear them whispering or moving quietly near my desk so as not to wake me up. The 3 O'clock nap is one of the high points of the day. The rounds are done, but you can't go home yet as you are responsible for any new admissions or consults until 4:30. You're exhausted from the grueling days and nights on call. A twenty minute nap at the desk is pure bliss.

The call came from Interventional Radiology. Hmmm. A call from IR can be routine, a question about a vascular access procedure on a dialysis patient, fro example. Or it can be a disaster. The IR guys do some incredible things, snaking around the arteries and veins, using the blood vessels of the body like a highway. They get to where the trouble is and then dilate arteries with balloons. deploy stents, embolize bleeders. But they can also get into horrendous complications. Sometimes they dilate the vessel a little too much and it bursts. They call the surgeon first and me second.

This call was a complication, but not too bad. They were draining fluid off the lung of a dialysis patient, a procedure called a thoracentesis. During the procedure the initially clear fluid had turned bloody, and the patient had complained of pain and started coughing. This is when the doctor starts to sweat. The follow-up chest xray had showed a partially dropped lung or pneumothorax. Since I was the nephrologist covering I got the call.

The patient was, at best, a trainwreck. He was a former smoker with obstructive lung disease. He had congestive heart failure with a left ventricle that twitched and quivered rather than pumping. He also had end-stage renal disease and was on dialysis. The reason he accumulated fluid around the lungs and in the belly was that he had a bad heart. Whenever we tried to take off fluid with the dialysis machine his heart couldn't compensate and his blood pressure dropped. We never were able to get him to his dry weight and he progressively swelled up with fluid.

He also had the angry wife syndrome. When I began to take the history she jumped right in with a tirade about his last hospitalization and how the doctors had screwed everything up. You see, his problems were not the result of 60 pack years of smoking, coupled with bad diet and lack of exerecise, It was because the doctors had let him sit in the ER for 10 hours before ordering the right xrays, blood tests, blah, blah, blah. Since that hospitalization he had been in a nursing home, being fed through a tube, transported to dialysis three times a week. He didn't walk and it quickly became obvious to me that he was relatively out of it as well.

Ok. So what the hell are we all doing here with the dialysis and invasive procedures in Radiology? I mean here is this poor loxed out guy: laying in bed, can't walk, can't talk, can't eat. I mean really, what the fuck?

I soothed the wife as best a possible, ordered some pain meds so a least the old guy wouldn't suffer, and admitted him to the ward. She asked me if I planned on surgery for his dropped lung. Yeah, lady, totally, I'll call the OR right away, because they love operating on cadavers.

My plan was to make him comfortable and see if the lung re-expands. At most he'll get a chest tube, but even that could be trouble. Hopefully I can get him back to the nursing home and he can live the rest of his days in peace.