“As long as we can keep the Iraqibacter contained in the pseudocyst and maintain adequate drainage,” he said, “Tom’s immune system can hopefully recover enough that it can kick this infection on his own.”
It was the first really good news we had had in weeks. But I was still worried, especially about Tom’s mental state. His delusions were getting more frequent and more bizarre. It was hard to know if they were some part of the illness, the mix of medications, the isolation in the hospital, or the way his mind was attempting to cope with it all. Or maybe the answer to this multiple-choice quiz was E—all of the above. Whatever sense these nightmares might make internally to his psyche, from the outside they looked like a man unhinged. They were taking a toll on me, too. Every time his delusional dramas spiked, I felt we were on two sides of an abyss, with only a shaky bridge between us that Darth Vader was trying to destroy.
Before dawn one morning, my cell phone trilled Tom’s signature ringtone: Thomas Dolby’s “She Blinded Me with Science.” I had to scramble from bed to reach it on the charger.
“What’s going on?” I asked him, shivering, as I crawled back under the comforter.
“Do we have property in a country that doesn’t exist?” he asked me anxiously.
What the hell was he talking about? And how do I deal with this?
“Honey,” I began. “I don’t know what you mean.”
Tom sighed. He was clearly very agitated. “Think back, way back. Down, down… to the beginning, when we first met. Did we buy—did we purchase a house in a country that doesn’t exist anymore? Have we lost everything?”
This is what he was calling me to discuss at four o’clock in the morning? It was loco. I decided to try some logic, keeping my voice calm and quiet so I didn’t wake the girls, and with hopes of calming him down.
“Tom, it’s the middle of the night. I’ll be there in a few hours and before I come, I will check all our financial papers to make sure that everything is accounted for.” Deep, cleansing breath.
We hung up, but there was no way I could get back to sleep. I made a giant pot of Peet’s coffee in the cone drip filter that Tom insisted on as our only means of brewing it, as he was a coffee aficionado. It overflowed onto the countertop and made a giant mess. I swore loudly. The kittens scrambled under the kitchen table. Newt eyed me and kept his distance.
On my drive in to the hospital, I was deciding how to approach the conversation with Tom. We had to talk about his delusions. Nobody else was. But as soon as I entered his room, I could see that Tom had a sheepish look on his face. He immediately recanted his story.
“Sorry, baby,” he said despondently. “I don’t know what I was thinking. I guess there are Trojans in my head, just like the song on the radio.”
To hear Tom apologize was painful; there was nothing he could do about it. And it seemed there was nothing the girls or I could do, either—it wasn’t as if we could avoid saying or doing things that might trigger him. He would go in and out of these psychotic states without any provocation. The evidence of his mental deterioration was hard to overlook. He often lay still and practically lifeless in his “recovering” state. Then the delusional dialogues would erupt, like breakthrough bleeding from some parallel universe.
Some days, he didn’t even recognize me. Once, when this happened, I decided to take matters into my own hands. Making sure the door to his room was shut, I lifted my shirt over my head and flashed him, yelling: “If I wasn’t your wife, would I be doing this?!” Another time, after the psychiatrist asked him if he knew who I was and he shook his head no, I asked him: “You have been married two times in your life. So, here’s the question of the day: Am I the old wife or the young one?” Tom took a guess: “The old one.” Womp womp. Wrong answer.
Somewhere between data and delusions was Tom’s reality. The superbug still lurked inside him, but his lab values suggested he was starting to improve slightly, so, every day now, people would assure him that he was getting better. But Tom was sure he was dying. He showed all the signs of a deep depression, too. Not even the girls’ continued presence, which usually raised his spirits, was breaking through this dark fog. One morning when I came in to see him, he looked at me gravely.
“We need to call a family meeting,” he told me. “To talk about pulling the plug.”
“What?!” I cried. “What are you talking about?”
“I’m dying. Face it. Davey and I had a big talk in the middle of the night, and he told me that it’s over. So we need to talk about ending it all. Euthanasia.”
I was floored. How could this be true? There was no way.
“Tom. Honey. Baby. I just spoke to Davey yesterday and he didn’t say anything of the kind. He, Chip and the other docs think you’re getting better! Is it possible you could have imagined this conversation of yours?”
I grabbed his phone and looked at the recent call history. It showed that Tom had tried to text Davey in the middle of the night, but there was no sign of a call. I showed Tom the phone. He was adamant that he was right. Exasperated, I called Davey.
“What’s up, Buttercup?” Davey replied in his singsong voice. Davey’s supply of Southern terms of endearment seemed endless, but always somehow reassuring, as silly as it seemed.
“Plenty,” I said. “I am here with Tom right now, and he thinks you and he had a talk about euthanasia last night. He says you told him he’s dying, so we need to pull the plug!”
I heard Davey take a sharp intake of breath. “I’ll be right there,” he replied. “Don’t do anything rash.”
When Davey arrived, he confirmed that there had been no such conversation the night before. Again, we showed Tom the call history, which showed no call had taken place. Tom was chagrined and shaken by the growing realization that he could no longer trust his own mind about what was real versus what was imagined.
“Davey,” Tom told him, “I’m losing my mind.”
Davey’s throaty laughter filled the room. “Of course,” he said, with a lopsided grin.
“No, really,” Tom said. “I sometimes see stuff… weird shit…”
Davey nodded. “Tell me about it.” Davey had had his share of medical problems, too. A few years ago, he’d spent a few weeks in the TICU after suffering a series of mysterious strokes. The neurologists ran a bunch of tests but never came up with a diagnosis. The experience had given him a deeper understanding of what it was to be a patient.
Tom sighed. “Where do I start? Just the other night, I thought I was crawling on the floor around the nursing station, and the nurses were poking me with needles and scraps of metal. So, later, when I was taken to IR, I thought all of the little metal pieces inside me were going to be drawn out with a magnet—and that it would kill me.”
Davey sat down on the corner of his bed and took Tom’s hand in his own gloved one. “It’s ICU psychosis. It happens to most people who end up in the ICU, or anywhere in the hospital really, for an extended period. You can’t tell day from night, so your brain gets mixed up. When I was in the hospital, I could have sworn that I was lying on the floor of my childhood tree house, back home in rural Tennessee. You’re not going crazy. I had my doubts before, but it looks like you’re actually going to get out of here.”
One week later, in mid-January, Dr. Gandhi, the hospitalist who was assigned to Tom’s case that week, told us that Tom would be discharged to a long-term acute care facility within the next few days. Tom was elated, but I was immediately nervous. Sure, the lab tests showed that Tom’s immune system was reviving slightly, that his body had managed to wall off the A. baumannii. But no way did he look like a guy on the mend. Most of the time, he “rested” still and pale as a corpse. And it seemed increasingly that although his body had walled off the invader, his mind was walled off, too—from us. There was nothing encouraging about the continuing delusional episodes and periods when he seemed lost in some dark inner world. Where was that being taken into account in the workup for this discharge? Nevertheless, I texted Chip and Davey to give
them a heads-up. Both of them expressed concern that it was still too early, but Tom was angry that I wasn’t more supportive of the transition. He looked at me with pleading eyes. “Can’t I just come home?” But since he was still receiving IV antibiotics, home was not an option.
The next day, an infectious disease doctor who worked with Chip and Davey, Dr. Randy Taplitz, came to see us. I had met her once before, and Chip had told me that she was one of the best infectious disease docs in the department.
She donned a yellow gown at the doorway and stepped in with a firm yet friendly hello.
“It’s great to see you out of the TICU, but we have a hitch,” Dr. Taplitz told us. “We cultured a new bacterium from your pseudocyst drain, Bacteriodes fragilis. B. frag is a common gut bug and not typically associated with resistance. There is a possibility it is a contaminant from the drain and is not in the pseudocyst, but it could be a sign of a lurking infection.”
“Oh no,” I lamented. “Dr. Gandhi told us Tom is getting discharged this week, probably tomorrow.”
Dr. Taplitz turned to look at me and narrowed her eyes. “I heard that,” she said cautiously. “That’s a pretty ambitious timeline. Until we can be sure that this new bug isn’t a problem, I’m going to advise that we hold off on discharge. In fact, I would like to put you back on meropenem, Tom, just as a precaution. Mero is an antibiotic you have been on already, and you tolerated it well. Hopefully you won’t need to be on it for long.” She looked at us for our reaction. Tom sagged back into his bed, but nodded slowly, resigned.
I shrugged. “You know best,” I told her. I was secretly relieved. No way did I want Tom discharged to a step-down facility that couldn’t handle his complex care. Not yet anyway.
“Good,” she said, as she stepped back to the doorway, stripped off her gown and gloves and washed up. “The last thing we need right now is septic shock.”
13
TIPPING POINT: FULLY COLONIZED
January 17–February 14, 2016
Wow, would you look at that!” Dr. Gandhi was surprised and pleased to see Tom grab the rail of his bed and pull himself up to half-propped position, a feat he had managed the day before for the first time since he fell ill, with unrelenting encouragement from me and Amy from the physical therapy team. “You’re much stronger now—that’s great! Let me just take a look at your belly.” Tom scooched to the side of the bed and let his legs dangle over the side while Dr. Gandhi palpated his abdomen and listened to his lungs. He nodded with approval, and Tom inched back to lie back on the bed. Dr. Gandhi had been stopping in each morning to check on Tom, and we’d found some cheerful common ground in conversation about Indian food. A native of Delhi, one of my favorite cities, he and I idly chatted about the experiences I had collaborating on research with heroin users there. Tom chipped in and spoke about the HIV project he had led with sex workers in Nagpur, and his love for South Indian food, dosas with sambal, channa masala, idli, and puri.
On the other side of his bed, the day nurse, Erin, was entering Tom’s vitals into the online medical record system. “So, feeling hungry for lunch?” she quipped. “How about McDonald’s—say, Chicken McNuggets?”
We all laughed. Tom was still on a liquid diet and only kept down about half of his meals. And he wouldn’t be caught dead eating McDonald’s.
“OMG, your ostomy bag is full again,” Erin noted with surprise. “I just emptied it an hour ago.”
I peered around from my location at the end of Tom’s bed. “It’s a weird straw color too,” I remarked. “It’s been brownish-yellow and cloudy up until now.”
Dr. Gandhi’s brow furrowed. “Keep an eye on that,” he said to Erin. And turning to me, he said, “That looks like ascites fluid, which is really strange. I will page the GI resident to get a bigger ostomy bag up here and to take a look.”
“It’s pouring into the bag now,” Erin said quickly with a growing sense of alarm.
“Measure how much you are collecting,” said Dr. Gandhi, even more quickly.
“It’s five hundred milliliters—and that’s just in the last hour,” she replied, holding up the ostomy bag to show him that it was almost half full again.
“Should we keep a sample to test?” I asked him.
“Yes. Good idea,” he replied. “Let’s do that.”
“I’m cold,” said Tom in a quiet voice. “Can I have a warm blanket?”
“Sure,” said Erin. “I’ll call for one—”
Suddenly, Tom started to shake. Violently. “I am so cooooolllld…” he whispered. Beads of perspiration hung at his brow and his cheeks were mottled.
“I don’t like the looks of this,” I told Dr. Gandhi, biting my bottom lip.
“I don’t either,” he replied. In an instant, concern had turned to alarm. “He’s going into shock—hold on.” In seconds, he’d paged the TICU resident on call to come stat, and Erin used her walkie-talkie to page the charge nurse.
Tom’s breathing shifted suddenly to rapid panting. He started to shake so violently, the bed frame rattled. I heard Davey’s voice inside my head. If he shivers so much the bed shakes, that’s rigors: a sign of septic shock. I looked at the cardiac monitor and saw Tom’s blood pressure drop from 110/72 to 90/55 in a matter of minutes. His respiration rate increased to 35, then 40 breaths per minute. By now, I knew that his normal res rate was less than 20 per minute.
“His BP is in freefall!” I cried out. “And look at his res rate. Holy crap!”
Dr. Gandhi was on his cell phone, pacing in the small space between Tom’s bed and the window. “Yes, stat,” I heard him say. “He’s gone into shock.”
The charge nurse, Julie, came barreling in, pulling on gown and gloves as she and Erin approached the bed. “Should I call a code?” she asked Dr. Gandhi, as she piled several warm blankets on top of Tom. The bed was shaking violently, and I could hear Tom’s teeth chatter.
The doctor paused a second to think. “Not yet,” he replied. “But get him on oxygen. The TICU resident should be here any second.” He looked at his watch.
On cue, in rushed a young doctor that I recognized from the ICU by his spiky short brush cut. Having run from the other side of the second floor, he was out of breath, his white coat flapping behind him. As he paused at the doorway to pull a yellow gown over his head, I read the ID tag that hung from his lapel: DR. WANG, PULMONARY AND CRITICAL CARE RESIDENT. He nodded to me in recognition as he raced over to Tom.
Julie had finished taking his temperature. “One-oh-two point seven,” she announced in a curt voice, as she looked to the two doctors for more instructions. I was at a loss what to do, so I ran to the restroom a few yards away to get a cool cloth for Tom’s forehead.
“Hang in there, honey,” I whispered to Tom, as I wiped his face with the cloth seconds later. “We’ll get to the bottom of this. I won’t leave you.” Tom looked at me and blinked slowly, his eyelids heavy. Behind them, I saw fear.
Dr. Wang finished his assessment within three minutes and was on his cell phone. As I looked over at Erin, I could see that she was emptying his ostomy bag again; it was full. Dr. Wang hung up and turned to the rest of us. “We have a bed open in the TICU. Let’s get him over there.”
“Now?!” I was in shock myself. I suddenly remembered the dire statistics that people die from septic shock all the time, even in the US. And to be contemplating a code—hospital slang for an emergency of a specific sort—meant that Tom might become one of those data points. Tom knew it, too. As the team readied him for the transfer, he gave me a knowing look that said, See, I knew I was dying. I swallowed hard over the growing lump in my throat. What a time for him to be right.
Julie, Erin, and an aide started jamming Tom’s toiletries into large plastic bags marked BIOHAZARD. “Help me get his stuff together,” Julie ordered me. “We need everything to go with him.” Within minutes, Tom was wheeled back to the TICU on his bed, with Dr. Wang and Dr. Gandhi flanking him on either side. Dr. Gandhi pushed the IV pole. I ran along behind, carry
ing three bags of his belongings, my purse, and my backpack.
En route, we ran into Dr. Taplitz. She stopped dead in her tracks, her eyebrows raised in surprise. I was so relieved to see her. “What’s going on?” she asked me. She turned around and together we half-walked, half-ran behind Tom’s bed as they wheeled him down the hall, back to the TICU.
I dropped all formalities. “Oh, Randy!” I cried. “One minute he was sitting up in bed, and then… and then his drain started… and still is… pouring out all of this pale yellow liquid, and then he got cold, and now he has a fever…”
Randy’s forehead creased. “That sounds like ascites. And he’s gone into shock. I wonder if it’s the B. frag we cultured from his drain. If it is, we’re covered. I started him on meropenem last night. But they need to rule out an MI too.” I mentally accessed the Wiki page in my brain. Myocardial infarction: heart attack.
The double doors swung open and there we were again. Back in the TICU. Tom was raced to the end of the hall this time: Bed 11. It was a large rectangular room with a window at the end, but Tom was no longer responsive; by the looks of it, he might never see out of it. His eyes were closed and his face was beet red. His breath heaved in short rasps that sounded like a death rattle. A bevy of doctors and nurses started working on him, hooking him up to a new cardiac monitor, repositioning his IV, and taking his vitals. His RR continued to soar to 45, then 50. From the corner of his room, two familiar faces appeared at the door: Marilyn, the charge nurse, and an ex-military nurse, Joe. Both had been with Tom through so much—and now this.
“What happened?!” asked Marilyn. “We just saw you the other day and you told us Tom was getting discharged soon.”
“That’s what we thought, too,” I replied dejectedly, hugging myself. “But not now.”
Joe put his hand on my shoulder. “Hang in there, kid,” he offered lamely. Joe had wise, blue eyes and a short brush cut. He didn’t take any bullshit from Tom on those days that he had been up to dishing it out. But he and Marilyn, both clearly shaken now, retreated back to the nurses’ station to give the critical care team more space.
The Perfect Predator Page 12
