“How is he?” I asked him quietly.
“Stable,” Davey replied carefully, as he pushed the speakerphone button with a gloved finger so Chip could join in.
“Sounds like they took good care of him in Germany and during the flight home,” remarked Chip good-naturedly, but I noted that he and Davey avoided making even the slightest prognosis. “What we’re discussing now is how to move forward. That paper you sent me the other day hit the nail on the head. There are basically two paths to choose from, each of which has its pros and cons. The first option is surgery to remove the pseudocyst, which has the advantage of getting rid of the problem. The downside is the risk of septic shock, especially when we have so few antibiotics left in our arsenal.”
Dr. Sharon Reed, head of the UCSD Health microbiology laboratory, was retesting Tom’s bacterial isolate to confirm that it was still partially sensitive to the antibiotics they tested in Germany, Chip continued. “They will also look for synergy between two or more classes of antibiotics—maybe they’ll find a combination that has an effect that no one of them has by itself. But that mix-and-match experimentation is going to take longer.” Chip apologized as he had to ring off, and Davey took up where he left off.
“The alternative is for IR to insert a drain into the pseudocyst to try to siphon off the infected fluid,” said Davey.
“IR?” I asked him.
“Interventional radiology,” Davey said. These are the mechanics of the medical field who use image-guided technology to perform minimally invasive surgical procedures, inserting drains, stents, filters, and such in places where the sun doesn’t shine. Like Tom’s belly.
“Inserting a drain is less likely to cause sepsis, but it doesn’t solve the problem,” Davey continued. “Drains can also get clogged with tissue and dead cells, and if that happens, he could go septic anyway or the infection can spread.”
Neither of these options sounded ideal to me.
“The question is whether he’s even strong enough to handle surgery right now or not,” Davey explained. “The bottom line is that we don’t want his Acinetobacter getting out of that pseudocyst into his bloodstream. That would be game over.”
Sepsis was the game ender everyone wanted to avoid. Beyond the threat that the Acinetobacter itself posed, if the bacteria breached the cyst wall and flooded the bloodstream it would likely trigger this five-alarm response by an overwhelmed immune system. In sepsis, the immune system overreacts to an infection by launching inflammatory responses throughout the body. Then it throws the whole system into reverse with an extreme anti-inflammatory response, which creates the chaos that can trigger organ failure, tissue damage, and a steep drop in blood pressure that can kill you. It doesn’t take a superbug to trigger sepsis. Any infection can cause it. Sepsis is so deadly because it can strike so fast and move so swiftly to a systemic shock and organ shutdown. In the US alone each year, more than 1.5 million people get sepsis, and about 250,000 die from it. One in three patients who die in the hospital have sepsis, though it’s usually just considered a complication of the medical condition that originally brought them in.
Although I didn’t recognize it at the time, Tom had already survived at least two episodes of sepsis, each time brought back from the brink with swift action to right the wild imbalances that the infection had triggered. To do that required spotting the symptoms quickly, Davey told me. I was to watch for fever, intense shivering called rigors, clammy or mottled skin, a spike in the heart rate, shortness of breath, a sharp drop in blood pressure, mental confusion, or sudden changes in urine output.
Suddenly the medical team’s obsessive attention to infection control measures and their constant monitoring of everything—from blood chemistry to bedsores—took on new meaning. A. baumannii was a deadly invader, but Tom’s own immune response could be the thing that killed him. It was easy to imagine but impossible to know precisely what had triggered Tom’s sepsis—pancreatitis, A. baumannii, or other organisms that were present—but the complexity of his illness made the risks of sepsis all the greater. No one wanted to add a full-out, uncontained assault by A. baumannii to the mix.
How permeable were the pseudo walls of this pseudocyst? Unlike the plastic anatomical models that we remember from high school biology class, at the cellular level, nothing is so cleanly compartmentalized. Take the simple act of eating: aided by bacteria in the gut, nutrients move from the food we eat, through digestion, into the bloodstream, then into our cells through all manner of chemical and metabolic processes. Molecular activity is constant, a turbulent exchange in which physics meets chemistry, testing boundaries where barriers are inevitably breached.
“And we can’t forget about the Candida that’s in there, either,” Davey added, referring to the fungus that had been found in Tom’s pseudocyst in Germany. “If Candida escapes and enters Tom’s bloodstream, it, too, can be fatal.”
Tom’s no-nonsense nurse, Meghan, interrupted us to summon me to the reception desk. “Dr. Tom Savides is on the line for you,” she explained.
Like Chip and I, Tom Savides was a division chief in UCSD’s Department of Medicine. Savides was the head of gastrointestinal endoscopy. We were used to seeing each other at faculty meetings, but I had learned over the past few days that he happened to be an expert on pancreatitis and its complications.
“I’m on my way there and will stop by to check on Tom,” he told me, after we traded pleasantries. “I’ve already ordered a new CT and I’m about to review Tom’s case with Bryan Clary, chief of surgery, who specializes in high-risk surgeries.”
After I hung up and briefed Davey, I could tell he was pleased. “At grand rounds last week, Bryan dared the audience by saying, ‘Show me a patient at UCSD that’s too sick for surgery.’” Davey chuckled softly. “If Tom needs surgery, that’s our man.”
What the docs didn’t say outright, but I would learn later, was that there was some tension among the specialists over which course of treatment to pursue, in part because, frankly, Tom’s condition was so iffy and his prognosis so poor. This wasn’t just an excruciating decision for me and our family. It was agonizing for the doctors as well. I would later learn that some thought it more likely that he would die than stage a turnaround, whether treated surgically or with interventional radiology. They didn’t want to subject him to surgery with no hope of it working. And hope was fading fast.
For Chip, Davey, and the other infectious disease doctors, any intervention posed a risk, but given Tom’s worsening condition, leaving the drains in place when they weren’t clearing the infection seemed unacceptable. Tom had once railed when someone quipped that he was a medical guinea pig; now he was, clinically speaking, a hot potato. Maybe the more fitting metaphor was a twisted version of Russian roulette: nobody wanted to be the one who killed him.
For me, the most salient—and sobering—fact was that there was no “right” answer to this dilemma. You could parse the data till the cows came home, and the risk-benefit ratio was a toss-up. It was the devil’s choice. I still held on to the naïve belief that the doctors would agree on what to do, and they’d pull Tom through.
Davey told me he would be back later, which gave me time alone with Tom. But there is no such thing as “alone time” in an ICU. Meghan hovered like a surveillance drone, taking Tom’s temperature, drawing blood, and entering notes into the computer’s electronic medical record. With all the commotion, Tom began to stir.
“Honey, it’s me,” I whispered to him, holding his hand. Tom opened his eyes groggily and gave a half-smile. “Baby,” he said tenderly, and gave my hand a little squeeze. “What’s happening?”
“He’s on a lot of morphine right now, so he’ll be really sleepy,” Meghan warned me. She was twenty-something, and about five-foot-two with long dark hair that fell down her back in a low ponytail. She expertly adjusted the IV lines and checked the stacked bank of monitors, which was taller than she was. Although petite, she loomed large over Tom, who seemed to be shrinking in size and p
resence with each passing day.
I nodded, then turned to Tom. “You’re in the Thornton ICU,” I told him. “Davey was just here, and we discussed the possible types of treatment to get you better. They haven’t made up their minds yet. Tom Savides, the GI chief, and Bryan Clary, the surgery chief, need to weigh in.”
“Surgery?” Tom asked, rubbing sleep out of his eye with his other hand.
“Yeah, I know what you’re thinking,” I told him. “It scares the crap out of me, too.”
“Yeah, but maybe I should get it over with so I can get outta here,” Tom replied. “Enough of this shit.”
“Hey, you just got here!” Meghan teased.
“We started out in Egypt,” I told her. “Long story.” I turned back to Tom, but he had already fallen asleep again. Meghan gave me a quick rundown of the TICU schedule and rules for visitors. Visiting hours were around the clock. Rounds started anywhere from eight a.m. onward, and family members could attend. Shift change was every twelve hours—7:20 a.m. and 7:20 p.m. Nurses were assigned to one or two TICU patients, depending on their needs. I didn’t realize until later that Tom was her only patient that day, which should have told me something about how sick he was.
“You can bring in a few things from home to make him or his room more comfortable,” she told me. “But take this home with you,” she advised, handing me Tom’s wedding ring.
“I doubt we’ll need anything,” I replied, clutching the ring, which was still warm. “He’ll be home by Christmas, right?”
Meghan arched an eyebrow skeptically and pursed her lips. “Don’t ask me,” she said. “But I wouldn’t count on it.”
We were about to learn why.
A few hours later, Dr. Tom Savides donned the usual gown and gloves and stepped in to introduce himself to Tom and to say hello to me. About sixty, Savides was medium height with a lean build. This was a guy who ate his daily recommended fiber equivalent. His brown hair was clipped conservatively, and he had friendly eyes behind rimless glasses. Tom was awake but groggy, and when he raised his hand to shake Savides’s hand, he got tangled in the IV tube attached to it and took advantage of the opportunity to try to yank it out.
“Whoa, there!” Savides said, and grabbed his hand. He explained that, in addition to the nasogastric tube that continued to siphon out infected fluids from his pseudocyst, the doctors had inserted a feeding tube into his nose, this one bypassing the stomach to the jejunum, a part of the small intestine. “Make sure you avoid the temptation to pull that sucker out, or you could hurt your gut. And from the looks of your CT, you have enough going on in your abdomen.”
We’d barely greeted each other before I peppered him with questions. The most pressing one: “Have you decided whether he should have surgery or drains instead?”
Savides cleared his throat. “Well, for now, Bryan Clary and I both think that surgery is too high risk. Sounds like you have a nasty superbug in that pseudocyst of yours. I’ve dealt with some before, but we generally have more antibiotics to treat them. We’ll let the infectious disease folks handle that part. But we talked to IR and they are prepared to insert an external drain into the cyst to help it shrink.” If only as a temporary measure, this strategy of détente and containment—the decision to leave the superbug undisturbed and untreated for the time being, while more aggressively draining the pseudocyst—seemed to be the bottom line. The problem was, containment could become difficult and might prove impossible. No one could predict how strong the membrane wall of that cyst was. If it were to rupture, the Acinetobacter would spill out and spread instantly.
Davey reappeared at the door of the room and gowned up. “Mind if I join in?” he asked each of us. Savides nodded a welcome.
“How long will it take for me to get better?” Tom asked.
Savides was ready for this question. “We have a general rule of thumb,” he replied. “For every week that you are lying in bed, it will take five weeks to recover. So, let’s say by the time we get you stabilized here, that it will have been about a month since you got sick in Egypt. That means about five months’ recovery time.”
“Five months?!” Tom and I yelped in unison. I was hoping I had misheard.
“I know it’s a shock,” Savides went on. “But gallstone pancreatitis—even without complications—is on the same scale as a major car accident. The course of this illness is like a marathon, and you might be at about mile eleven—not quite halfway. With any luck, we can get this infection of yours under control and eventually send you home for outpatient treatment,” he replied.
Davey raised his eyebrows but kept quiet. Savides promised that his team would be following Tom’s case, but at the moment he had to leave for surgery. He was gone in an instant, and Davey filled the stunned silence with a gentle but sobering confirmation of the typical recovery time.
Davey explained that lying in bed with no exercise causes “deconditioning,” a weakening of the muscles that makes it hard to walk. Tom had lost forty pounds in the past twenty-one days. Not exactly the image of a marathoner. Robert, my psychic friend, had warned us in Frankfurt that this would be a marathon and not a sprint. A few years previously, we’d all laughed when Robert had told Tom that that by his sixty-ninth birthday, he would be skinny. “You can get there the easy way or the hard way,” Robert had said, admonishing him to take better care of himself. It didn’t take a psychic now to see that he was doing it the hard way. Cosmic coincidence or not, we were in for a long haul. Tom was going to need a lot of physical therapy once this was over.
“Will I be home for Christmas, Davey?” Tom’s voice was impatient and desperate. He was tired of being sick, tired of the hospital rigmarole. Christmas was only two weeks away. Davey turned to Tom, and his eyes were bloodshot.
“I don’t know. I sure hope so. But I’d be lying to you if I didn’t tell you that you are really, really sick. We are doing all we can to get you better.”
Reality was starting to sink in through Tom’s opiate haze and my own thick fog of wishful thinking. We’d both assumed that somehow, once home, back where the doctors had more experience with Acinetobacter and the resources and state-of-the-art medicine to back them up, Tom’s recovery would be swift and sure.
The look on Davey’s face was unmistakable. He wasn’t even sure Tom would make it.
10
SUPERBUGGED
UCSD Thornton Hospital, La Jolla
December 14–23, 2015
I quickly became a fixture at the TICU, spending every morning there like clockwork. I learned that to find out how Tom had fared each night, I needed to speak to whoever was assigned as his night nurse, and to call well before shift change, when they were busiest. So, my daily routine began every morning at five a.m. Quick breakfast and occasional shower, and I was at the hospital in time for rounds. As a UCSD faculty member, I was treated with an unearned degree of professional respect, despite the fact that I was not a medical doctor. Ordinarily, I would never have even thought to be present for these detailed clinical conversations about labs and meds or the meticulous routines of nursing care. But Davey and Chip had coached me to step it up in Frankfurt, and this was no time to step back. So, I listened carefully, then wheedled, whined, cajoled, and advocated like his life depended on it. For all I knew, it did.
Keeping track of who was on Tom’s care team was a science unto itself. Unlike Egypt or Germany, where the doctors who presided over Tom were relatively small in number, here there were scores of attending doctors who rotated on and off service in the TICU, in part because it was a teaching hospital. The disciplines caring for Tom included pulmonary and critical care, infectious disease, gastroenterology, interventional radiology, and surgery. The critical care docs rotated every week. The other disciplines rotated every two weeks. And the medical residents typically rotated every month. It was enough to make your head spin. And there was no ICU for Dummies pocket guide.
I made a conscious effort to listen carefully at rounds to pick up the lingo
so I could understand whether Tom’s condition was improving or not. It was tough going. The first few days, I could just follow the big picture. There were so many biomarkers of liver, kidney, and cardiac function. His hemoglobin was measured at least twice a day to determine if he needed a blood transfusion. Bili was short for bilirubin, an indicator of gall bladder function. Tom’s bili was off the chart, indicating that his gallbladder was not a happy camper. His blood sugar was monitored closely since he was now full-blown diabetic after losing about a third of his pancreas due to the infection. And his fluids were documented carefully as “ins and outs.” The ins included IV fluids, nutritional supplements, and blood transfusions. The outs included urine, feces, vomit, and the bilious discharge that continued to be siphoned from his stomach and the gunk from a new external pseudocyst drain that interventional radiology had inserted. At least that delicate procedure was a success, and we could see the results as a cloudy yellowish-brown discharge that drained continuously into a bag. The ooze was the enemy we could see. There was so little in this biological battle that was visible to the naked eye. The lab reports, vitals charts, and monitors were our only window into that war zone.
Soon, the language of illness became my second language. At medical rounds each morning, I could follow the conversation now, even contributing to them from time to time, having memorized most of Tom’s lab values. BP: blood pressure. RR or res rate meant respiratory rate. Words like hemodynamics and AKI (acute kidney injury), not previously part of my vocabulary as an epidemiologist, were becoming familiar. I was no longer reluctant to ask questions—or contribute to the discussion, for that matter. “Welcome to wife-led rounds,” the charge nurse, Marilyn, quipped one morning. When Cameron was young, he’d call me “Dr. Mrs. Mommy”—I guess that pretty much summed it up now.
The Perfect Predator Page 9
