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

Influenza

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.