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.

The Friend of the Elderly

A wise physician once told me that pneumonia was the Friend of the Elderly. Being a young, naive med student, I didn't understand. As a battle-hardened ICU doc I understand perfectly. Pneumonia is the friend of the elderly because it helps ease the transition from this world into the next.

This last two weeks we had a veritable Quaker Meeting of the Friends of the Elderly. In the space of 2 weeks we had four cases of severe pneumococcal pneumonia, the classical pneumonia. The patients ranged from about 60 to 85 and presented with severe fulminant illness requiring ICU management, including mechanical ventilators, central lines, multiple pressor drugs, broad spectrum antibiotics... the whole show.

One recovered well, two died within a couple of days and one lived to transfer out to the medical ward, but has severe complications, will likely lose one or both legs to gangrene (a complication of fulminant sepsis), and at best, will live the remainder of his life in a nursing home. ICU Doc one, Angel of Death 3.

Pneumococcal pneumonia used to be easily treated with simple penicillin, but now resistant bacterial strains have emerged and we have to use new wave antibiotics. Despite our best efforts, some 25 % of these patients die. This sounds bad, after all, why can't we cure a simple bacterial infection? The thing is, everyone dies of something. Overwhelming pneumonia isn't a bad way to go, and is often pretty quick. As I said, the friend of the elderly. If I can help some poor patient leave this world in relative comfort then I feel I have done my job.

Maybe the Angel is my friend.

Physician Heal Thyself

Got back the day before New Year's Eve. Off in Utah skiing for a week. We go to Alta, which is an alternative type ski resort: no snowboards, ancient lifts, limited number of lift-tickets sold each day. When there, we stay at the Alta Peruvian Inn, an alternative type ski lodge. I highly recommend it if your tastes run to mellow funkiness, with a Soviet-era design theme to the rooms. However, the snow is the best in the country and the mountain rocks. Seven days of skiing lift-open to lift-close, great food, great wine, nice company. Life is good.

Got home in time for a New Year's Eve party with the Russian crowd at the St. Petersburg Restaurant (my wife is an immigrant from Kiev, Ukraine), but as I got off the plane I rapidly developed sore throat, nasal congestion, headache, cough and sneezing. It was like somebody smacked me with an axe-handle and I was down for the count. No way could I get out of the celebration, but as long as I was deathly ill, I volunteered to be designated-driver. I am often on call during dinners and parties and so can't drink anything. The other guests took my sobriety in stride. I'm sure half of them think I'm in AA anyway. We went to a neighborhood pre-party and a 2 am post-party, with me barely able to breath, but driving well. The post-party was with a great crowd of friends, but we got there late in the process. Half the guests were in the hot tub naked, and the other half were relatively incoherent, but very affectionate and carrying water bottles.... hmmm.

Finally got home, paid the baby-sitter off and crashed. I woke up feeling like hell. Now can you imagine anything more unfair than not drinking and waking up feeling worse than hung-over? My wife asked me if I should go to see a doctor. As if. What would they say other than "Probably a virus"? I began a regimen of sleep, green tea, multivitamins, light eating, and by the next morning was improved but not yet well. It was off to work anyway.

One problem with our practice is that we are very tightly scheduled in our rotations and we don't really have a mechanism set up to compensate for a sick doctor. In the last ten years of practice I have been out sick on 2 days when I had viral meningitis. Even then I got grief from the other partners. One of our partners once went to the Mayo Clinic to have neurosurgery. Since the surgery was on Friday we told him to feel free to take the weekend off, as long as he was back to work on Monday. None of us takes seriously the idea that we could become ill or incapacitated, even though we see obvious examples every day at work.

Fortunately, tonight I am feeling better. I went to the gym for a light workout this morning at 5 am. Nothing serious, just a wake up call to the body, a shot across the bow, notice that we would be returning to full action mode soon. True to form, when I stepped on the scale I was down four pounds. Every time I get sick, fortunately a rare occurrence, I drop a bunch of weight. It's like the "Virus Diet".

When meeting the Angel of Death on the field of battle you have to be in good health. By tomorrow, I'll be ready to fight the fight.