Life and Death Decisions

It’s 4:45 am on a Monday. I wake up five minutes before my alarm, as usual. Since residency began, I have never overslept it. I lie still for another five minutes, checking the clock in between to assure my mind that I have a few minutes of luxury left. And then I surrender my bed to the inevitable day. I arrive to the ICU, bracing myself for the day’s admissions. There is a Whipple, a thoracotomy, and a craniectomy on the OR schedule. They will all come to the SICU after surgery. Since it's Monday, there will also almost certainly be at least one emergent admission from the floor, perhaps a gastrectomy with CHF whose fluid status was mismanaged or neglected over the weekend. I get a quick signout from night float on last night’s events. I meet the new trauma patients: a drunk head bleed from a pistol whipping, a gunshot to the abdomen with a liver lac and a bowel injury. They are both totally stable, and I plan to move them out as soon as possible. After seeing all the patients, I check all their boxes—make sure their electrolytes are balanced, sugars are controlled, and fluid status is appropriate. I lower their ventilatory support to work their respiratory muscles and make a mental list of who can be extubated. I round with my attending, trying to keep my presentations crisp. We discuss a sea of numbers, CT scans and xrays. Satisfied that every patient has a plan to advance their care, I turn my attention to the only really sick patient in the unit. Everyone in the unit is sick, of course, but Mrs. Riley is DNR after the family meeting over the weekend, and there is nothing to do for Mr. Ellis after his catastrophic intraparenchymal hemorrhage but schedule a tracheostomy and PEG. Mr. Turner, however, is actively dying—he has a chance, but his window is closing. I first met Mr Turner a week ago, after a routine sigmoid colectomy. He had suffered repeated episodes of bleeding per rectum and after a colonoscopy tattooed an oozing mass, was offered a partial colectomy to remove the offending lesion. The surgery was uncomplicated, but because of his COPD, recent heart attack and renal failure, the patient was admitted to the ICU for postoperative resuscitation. He was moved to the general floor after two days to make room in the unit. He was almost ready for discharge until his nurse found him collapsed on the bathroom floor in a small pool of dark blood. He was confused, combative, and diaphoretic. The overnight team pumped him with fluids and blood, intubated him, took him to the operating room to remove the bleeding colon, and brought him to the ICU. He had a rising lactate, a pH incompatible with bodily protein function, and multiorgan dysfunction. He was actively dying. I’m only in my second year of surgical residency, but I can already see where this is going. I put him on a bicarbonate drip to counteract his body’s acidity. I’d like to use a different drug but we are “out of stock” of the proton scavenger that works better than bicarb. He is difficult to ventilate, with oxygen levels barely compatible with life despite maximizing his ventilator settings, putting him at high risk for barotrauma. I’m working his lungs hard, trying to blow off carbon dioxide to reduce his acidity, but I’m running into myself because the bicarb I’m using for the same reason creates more CO2 to blow off. It starts to look futile. I try him on bilevel, thinking he’s in ARDS, but he is already on CRRT because his kidneys shut down and his potassium shot up—his T waves on the monitor are like tall spikes. The bilevel causes his pressure to drop more, because the extra pressure in his lungs prevents the vena cava from filling. Again, running into myself. I add another pressor. We are maxed on three. Options are running out. He has no gag or corneal reflex. I call his wife and have a candid discussion. She says she's on her way. His belly continues to blow up, with all the fluids we’ve pumped into him. It’s tight as a drum, so we check an abdominal pressure. 30: intraabdominal hypertension. Another reason for hypotension and difficult ventilation. The only option becomes surgery—his abdomen needs to be cut open to relieve the pressure. We rush him to the operating room and cut him stem to sternum. We examine his bowels and organs. Everything looks dusky but there is no evidence of bleeding, necrosis or infection. I almost hope there is something catastrophic to explain his dire clinical status, something to fix so we don’t return to the hopeless 3-pressor, hypoxemic, acidotic state of the morning. We place a plastic bag over the belly and attach it to a specialized vacuum to maintain sterility and drain extra fluid, We now know how this will end. Wheeling him back to the ICU, I pass several family members gathered outside the ICU door. There are at least fifteen people in the waiting room. A tearful young woman, an elderly lady in a wheelchair. Probably his sister and mother. I get Mr. Turner settled and return to the family, gathering them into the family meeting room. I stare directly at his wife and inform her that her husband is dying, his organs are shutting down, and there's very little chance he will survive for more than 24 hours. This is not the first time I have had this discussion but my mind cringes, expecting a horrific reaction to such unspeakable news. My professional stare does not waver as I move on to discuss options, including withdrawal of care. We offer them time to think, but they don’t need it—-they want everything done. They want him to fight, and they want us to fight for him. We tell them there are limits, that we are out of options, that we are prolonging his suffering. This seems to pain them, but it does not change their minds. They hover by his door as we discuss how to proceed. There is no sense adding another pressor, as there are only so many receptors in the body to constrict to increase blood pressure. We get a bedside echocardiogram to see if we can improve his heart function, but unfortunately his heart function is adequate. We draw labs to see if his hemoglobin is low—maybe we can give him blood—but his blood levels are sufficient from all the products he has already received. My attending goes home and tells me to call the on-call surgeon for future updates on Mr. Turner—he knows this is a futile case. The patient hangs on for several hours. Late in the evening, his pressure continues to dip, and then his heart rate. I have no choice but to code him. We drop the bed down and press on his chest. Abdominal fluid seeps through the plastic bag covering his organs—the vacuum seal has been violated. We give boluses of epinephrine, atropine, bicarbonate, calcium and magnesium. We do three rounds because the family refuses to leave his room. If they were not present, we would do less. I call time of death. We clean the patient and finally allow the family to attend to him. I text my attending that he has passed, and receive no answer. The rest of the night passes uneventfully. Mrs. Riley dies peacefully in the early hours of the next morning, with her four children at bedside, on a dilaudid drip.

Having heart

It was 5:45 in the morning on a Monday after a full weekend of call. Thoroughly exhausted, I shuffled into the elevator and was met by the stench of stale clothing mixed with cigarette smoke. A painfully thin teenager exited, looking lost. I allowed him to wander out, grateful to be spared his odor. I was apathetic, overtaken by a weariness I vowed as a medical student never to have.

Morning rounds passed without incident. All our CABG patients were more or less stable. I collected each patient’s overnight events, vital signs, laboratory values, daily chest xray, ekg, fluid balance and wound status. With my attending’s blessings, I titrated their blood pressure drips to protect their blood vessels, kept them sedated and paralyzed if they were mechanically ventilated, fed them benzodiazepines if they were alcoholics, and added or subtracted tubes and lines as needed. Eager for a post-rounds lull, I sank into a chair in the cardiac care unit and opened my email. Because I was still around, a nurse asked me to renew some orders for electronic housekeeping. Then the pager rang with a consult, and my lull was over.

The consult was for Roy, a gentleman with a history of a recent 4-vessel CABG who needed to be on anticoagulation. He was being followed regularly at his coumadin clinic, where his INR was checked biweekly and blood thinner dose adjusted accordingly. According to the primary team, the lab called him at home and instructed him to come to the hospital immediately for an INR level of 17. On questioning him, they found that he had been taking twice the prescribed dose of coumadin.

I went to the patient’s room to do a full history and physical exam. Roy was an 78-year-old gentleman with scraggly hair and pockmarked skin. He was probably about 5 foot 7 but his stoop cut him 3 inches. The only part of his body that suggested any reserve was a small round belly. He was the kind of person I would pass on Broad Street without noticing. But just like the CABG patients I looked over so meticulously each morning in the unit, this man was once equally carefully looked after in his immediate postoperative period. Now he was back at home with a chronic pericardial effusion, failed kidneys, and an INR that could cause him to spontaneously bleed from any vessel or orifice at any moment. I asked him why he doubled up on his coumadin dose. The question made him suddenly energized, and he angrily replied that he takes all his medications twice daily, so why should coumadin be any different?

After my assessment, I called my attending and we reviewed his echocardiogram. He had a loculated pericardial effusion, stable in size over the past few months. The fluid around his heart was sticky, which meant that effective drainage would be extremely risky. We revisited him at dialysis that same afternoon to complete the consult. He was sleeping restfully in the corner, paying no attention to the whir of the dialysis machine or the Married…With Children rerun playing on his mini television.

My attending put his hand gently on Roy’s shoulder to say hello. After several nudges the patient awoke, grunting. His breathing was labored. His blood pressure and oxygen saturation were borderline acceptable—his heart could barely tolerate the fluid being drawn off. My attending knew the patient well, and other than the INR, was not fathomed by his current state. “Doc, I can’t go on like this,” Roy said. “My lady, she’s 70, she can’t keep running after me. She’s tired. I can’t put her through this. And we got a 6-year-old to get to school every morning. You gotta do something.”

In that moment, Roy was transformed in my eyes from an old man on the street to some kind of selfless hero. With all his health problems, he wasn’t thinking of himself. In his mind, he was running on empty not because the sticky fluid in his heart bag was preventing it from pumping, but because he was a burden on his family. He was sick of tiring his wife, not sick of his heart or his kidneys tiring him. In that moment, the senselessness of his coumadin overdose melted away, and he was wise and kind. Ignorant of things that I knew all about—coumadin dosing, target INR, how to correct a supratherapeutic INR, simple and loculated effusions—but far beyond me in things that matter in life's bigger picture. Nurturing relationships, fulfilling duties, making personal sacrifices, and that too in the face of extreme physical limitations—those are things I knew very little about.

Life as a doctor is selfless and selfish at the same time. You are selfless for your patients and your surgical team, but you are selfish in the face of life outside the hospital. Every effort requires a sacrifice, and by definition, the act of giving to one cause means taking away from another. The taking away is always from outside the hospital, including sleep, sunshine, recreation, and, most importantly, loved ones.

What gives me hope in the face of sacrifice is the knowledge that even when we think our hearts cannot possibly expand to encompass everyone and everything in front of us, it can. Yes, there may be fluid around it. The fluid might even be sticky, too sticky to get rid of. The heart can accept this and make room to expand.

It can make room, if we let it.

In memory of Gai Anyuon

I just received an email from John Alier, the pharmacist at Malek Clinic , that Gai Anyuon, former UU student and nursing school graduate, passed away from tuberculosis. We had hired him to be the nurse at the clinic, but when he discovered he was suffering from TB he left to Kampala for treatment. We were all hoping he would eventually return in good health. He is second from the right in the above photo, which was taken in a truck lot right before he escorted all our cllnic building materials from Kampala to Sudan last May.

Like most Sudanese, Gai was reserved and quiet. But he had an inner strength in him I will likely never fully understand. We met up with Gai in Kampala after landing in Nairobi, our home base. He helped us with our shopping for building materials and participated in our endless evening meetings to discuss how the clinic would be run. He was painfully thin and frail, and had a hacking cough that in retrospect I should have considered might be TB. I thought he had pneumonia but he vehemently denied being sick. He probably desperately needed the job.

We sent frail Gai with all of our wares in a 20 ton truck on the 10 hour drive from Kampala to Malek. He didn't complain once about his health or comfort. He asked for a reasonable sum of money to eat food on the way. He went without basic needs for 2 days while the rest of us traveled far more comfortably to Sudan. He dealt with treacherous border officials, keeping the goods safe and fending off thieves and bandits. He didn't have an inch of flesh on his bones, but he never complained.

Gai was a knowledgeable nurse. I never saw him in action but through our conversations about how to provide health services to the people of Malek, it was clear that he was an intelligent clinician. He anticipated challenges that we would face and brought them up early, so that we could conquer potential roadblocks. My mom and I were definitely outside our element providing health care in a Sudanese village, so Gai's practicality was important (of course, along with Deng and John Alier, too). But again, even though Gai often brought up needs that we could not address due to the rural setting or financial constraints, he was accepting of the limitations and ready to improvise.

I don't know much about his personal life, but I know he was a husband to an "educated" wife, as he described her. I pray his family is safe and well. His quiet perseverance in the face of significant personal and professional challenges is a humbling example to me that I won't forget.