A TYPICAL TEN MINUTES IN THE OTHER HALF OF MY LIFE
Another day at work.
7:50 A.M. I'm the backup physician this morning. A nurse pages me.
NURSE: "Yeah, the surgical resident wanted me to call you to look at the patient in room 9698's ABGs (arterial blood gases, a blood test)."
ME: "To look at what? How's the patient?"
NURSE: "She's awake but she looks kind of gray and confused."
That's half of the hospital population. More than half if you also include our elderly volunteer service.
CONNECTING DOTS
At her bedside, the old lady is just as the nurse described. Skin is a pale grey. A little out of it. Vitals are okay, slightly lower than yesterday though.
"Do you have any pain anywhere?" I ask as I feel her wrist pulse.
"I'm ... okayy..." She barely registers.
"Where are you?" I interrogate her mental status as my hands interrogate her abdomen.
"I'm ... home …," she says blankly.
"You are? Then what am I doing in your home?" I ask feeling her ankles and pulses.
I finish my examination before she can come up with an answer. It's a trick question.
(Another confused patient actually answered that question once. She said, "Because doctors go wherever they're needed." I almost split my splenic artery laughing at that. But then I asked what year she thought it was.)
I put my badge key in the computer at the nursing station and look at the old lady's blood tests on the archaic gray computer screen. For such a high-tech successful hospital, The Empire has just about the ugliest computer interface possible.
But that ugly gray screen can be comforting as well. Some days it's a roulette wheel. Checking in to see how your numbers are doing today. I can see your kidneys are doing better. Your infection is clearing. Your heart is strong.
Her numbers tell me she is severely acidotic, though. Normal blood pH is around 7.40 for a healthy person. Hers is 7.10. A little lower pH would mean you're probably in the last few minutes of your final CPR, or on your way to the ICU at best. Any thing more acidotic than that would mean you're probably the title character in the movie Alien. Or probably just dead.
The rest of her previous labs from last night are most unimpressive though. But those same numbers can, like a poisoned gift apple, be fatally deceptive as well.
TOXIC SHIT
Somewhere in the laboratory wing of the hospital's second floor, samples of her stool and blood sit on agar plates designed to nurture specific bacteria. She had some diarrhea yesterday though, and her stool sample came up positive for a bacterial toxin (Clostridium dificile). Now that is some toxic shit.
(… Could you imagine having to grow shit in sugar dishes as your day job?)
"So what do you think?" the orthopedic intern asks me. He's the one who called.
"I think she looks a lot worse on the inside than she does on the outside. I'm worried about infarcted (dying) bowel from C.dif. colitis. I'm calling General Sir Jury ('general surgery') now."
I'd seen this before, two or three times. I know that right now her numbers would show renal failure through the roof, and a bicarbonate level in the basement. She's one of those ittle old ladies who for one reason or another can experience necrotic death in their bowels and barely register any symptoms, until its too late. Maybe it's Nature's way of being merciful on old folks, but Nature isn't what we practice in the Church of Medea Sin ('medicine' for the newbies). Nature can stay in the parks, and the woods, and the hospices.
"But … she didn't have any rebound tenderness and her white count isn't that high," the ortho intern pondered.
Rebound tenderness. The name for what it feels like when you have a hot potato (or exploded gallbladder/appendix) in your belly. When even the bumps in the road on the way to the hospital hurt (a popular ER question). Or when the doctor accidentally bumps your gurney and elicits abdominal pain. (Secret: It wasn't an accident. It's a test.)
It's not the surgical intern's fault for doubting me. The classic definition of a "surgical abdomen" (i.e. needing surgery NOW) should have more pain on abdominal examination. But old people sometimes just don't register normal stress symptoms. Old age itself is a form of immunosuppression. (And most surgical patients are younger.)
I try to explain my suspicions to the senior surgery resident on the phone.
ME: "... I think she might have dead bowel from her C.dif. at this point."
SENIOR SURGICAL RESIDENT (sounds bored, but then again they've seen it all): "Any films?"
ME: "From yesterday, they were negative. But all this is new since then."
SSR: "Sigh … let's get an ABG."
ME (I already told him but I tell him again): "Already got it. Her pH is 7.10 … an hour and a half ago."
SSR: " … that's … pretty low."
ME: "So, do you think you can see her pretty soon?"
SSR: "As soon as I can."
How many minutes is "as soon as I can," I want to ask, but I don't.
I do the only thing I can do at that point and write orders. She's already on the two antibiotics she needs to be on, but I change one from I.V. to oral, and the other from oral to I.V. for better effect, for whatever good it can do. My pen may be my sword, but sometimes I'd really just rather have a sword.
I have to leave to see one of my own sick patients at that point.
Ten minutes later I walk by her room again and see the broad-backed senior resident on the phone booking an O.R. time.
ME: "So what do you think?"
SSR: "Oh, she's going to the O.R. now."
ME: "Thanks."
50-50
This all happened several days ago actually. And I had realized by the end of the day that I had no idea what the old lady's name was. I could barely recall her room number, which already had another patient in it.
I knew the chances of her surviving emergent abdominal surgery though. 50% is the usual number, probably less for her. But if it's you, or someone you know, or your patient even, it's either 100% or zero. Life is an all or nothing thing. To paraphrase that saying, a group of people is a statistic. One person is a life.
I was only involved in her case, in her life, for ten minutes. I didn't really want to know if she survived or not. Sometimes that gray area between 0 and 100 is a lot more comfortable. That gray area allows me to believe I did a worthwhile thing as opposed to yet another futile thing. It allows me to think my experience had a positive impact as opposed to zero effect.
Whether it's a spirit-containing box in Shintoism, Schrodinger's cat, Pandora's Box, or just your curiosity about the light in your refrigerator, sometimes its best not to look into the contents. That way the gray area doesn't turn soulless and black. And there's still room for light.
I think hope is gray.
CURIOSITY AND THE CAT
Ah, I'm so full of shit.
Just thinking about not thinking about it, made me want to check and see anyways, against prior experience and judgment. So I logged into the ugly gray computer system again and looked up the senior's name (he's Korean too, but that's irrelevant).
The old lady was still on his patient list, days later. Sedated and unconscious in the SICU. Going for another surgery that day even for more bowel resection. The surgical princes with their blades were going to take another swing at that ugly black dragon rising in her gut.
That was all I needed to know. I know better than to chance looking again.
I don't want to rename this sleeping Snow White into a Pandora anyways.
