by Atul Kumar
Maude was on autopilot and the cardiologist said she could go home in 2–3 days if all went well. Given her advanced age, he wanted to keep her for observation a little longer than normal.
Fortunately, Duane was also doing well. That same evening, after his second dose of Vanco, Duane reported his pain had significantly subsided and he was starting to feel better. Hopefully by tomorrow we’d have his infection’s sensitivities and might even be able to transition him to oral—or PO as we say—antibiotics in a couple days.
I went home that night thinking I’d made a difference in someone’s life and that tomorrow would be a good day.
~~~~
Tomorrow arrived and began as ordinary as a day in medicine can. Both Duane and Ms. Maude were doing well.
In fact Duane’s culture results arrived just before rounds. The causative bug was in fact MRSA; fortunately the strain responsible for his infection was sensitive to Bactrim, a very common and generally well tolerated antibiotic that was available in both IV and PO formulations.
“Thus, given the bacteria’s sensitivity to Bactrim and Duane’s positive response to IV Vanco treatment, I think we can transition him to IV Bactrim for a day, and if he responds favorably, send him home in two days on PO Bactrim.” That concluded my presentation on Duane for morning rounds.
“Raj, that is an excellent plan; make it happen. Switch him over so that his a.m. dose is Bactrim instead of Vanco today. How is Matilda doing?” asked Dr. Miley.
“Status quo.” Jason and I both remarked simultaneously.
“Well, I guess we’re still babysitting her until cardiology allows her to go home, so just keep everything the same and hopefully she’ll be off our service by the week’s end. Ok team, good job, get your work done and get out of here. We’re on call tomorrow, so get some rest tonight.”
While Jason wrote the orders for Ms. Maude, I decided to check in on Duane.
“Good news, Duane. The culture results came back and it looks like the bacteria causing your infection are sensitive to a very common antibiotic we use all the time. We’re going to switch you over to the new medication via IV for a day. If you do well we’ll give you the pill version for another day, and if you tolerate that ok you’ll be out of here on the pill version of Bactrim for a couple weeks or so at home.”
“Hey, thanks, Doc, no offense, but I’d be happy if I don’t ever have to see you again.”
“That’s the same thing the girls say. Guess I should hit the gym a little harder,” I deadpanned.
“Oh, no, no, I didn’t mean …”
My smile gave me away.
“Good one, you had me there for a second. You don’t have a girlfriend? I thought Docs had chicks chasing after them like no tomorrow.”
“Ah, my friend, you speak of the old school. Today’s girls know that the title ‘intern’ or ‘resident’ or ‘fellow’ is synonymous with poverty and sleep deprivation. They don’t waste their time on us lowly trainees. Girls only want the fully board certified physicians or ‘attending’ doctors. That’s where the money is, and the girls know it … unfortunately.”
“For real?”
“Yeah, no joke. Used to be that you go to a bar and once word got out you’re a Doc, girls would find you. Nowadays that strategy is a bust; girls not only ask if you’re done with your training, but in which field you specialize.”
“Why would they care about that? A Doc’s a Doc, right?”
“You kidding me? Girls don’t want to date a general or primary care Doc these days; they want a specialist; that’s where the money still exists. My friend’s a fully-fledged single neurosurgeon and he’s got no trouble getting a girl now. BUT, in med school it was a whole different ballgame. He had to beg for a date. However, now that he makes north of $800k a year, he’s a very sought after quantity, despite an extra 20 pounds and some male pattern balding.”
“Geez, man, and I always thought Docs and jocks get the chicks, in that order.”
“Maybe jocks, you’re the soccer coach and you have a gorgeous wife.”
“See, that’s the funny thing, I met her in college at Cornell, and the pickup line I used was that I was studying to get into medical school. She thought I was smart and going to be a doctor one day. After not getting accepted anywhere, I got my master’s in software design, but I already had her by then.”
I patted him on the back as I prepared to leave. “Well, I’m glad that line worked for you, I’ve had no such luck.”
“You’re a nice guy, I bet you’ll meet someone great; and if not, you can just stick to saving lives. You seem to be pretty good at it.”
“Thanks Duane. I’ve gotta get going, I’ll make sure you get your new medication now, and I’ll be back later to check up on you.”
“Thanks, Doc. Once I get home I’m going to put the word out that I know a great eligible bachelor who saves lives in his free time.”
I bet Duane never suspected that within a week he’d be asking me to take his life, not save it.
~~~~
I entered medical school thinking that by becoming a physician my goal would be to save lives and end suffering. What I didn’t know was that the two didn’t necessarily go hand in hand. Duane was about to teach me that sometimes they are mutually exclusive. And that distinction is precisely why my life just got a whole lot more complicated beginning this very morning.
Before I got to Duane’s room I ran into the covering intern for the night. He was shaking his head as he approached.
“Dude, your guy didn’t do so well. Luckily he’s still alive, and the good news is that he’s off your service.”
“Off our service? We were thinking of discharging him home tomorrow.”
“Cancel that plan. He developed TEN early in the evening and it progressed rapidly. At first he just said his eyes were itching badly, but that got worse and worse, so I got an emergent ophthalmology consult. They said he had severe abrasions in both corneas. But it gets worse. As the eye doc was leaving the room your patient coughs up blood all over the place and freaks the eye doc out. Guess they aren’t used to seeing much blood. Anyway, he called a code. Smart thing he did that ‘cause that’s what saved his life.”
I was in shock trying to take it all in. Just yesterday Duane was laughing and talking about setting me up.
“So by the time the code blue team arrives he’s in a full blown seizure, his skin is so excoriated and pustular it looks like he’s got third degrees all over his body. The seizure was so violent that he fell out of bed onto the floor with chunks of skin just sloughing off. When he fell off the bed his PICC line got caught up on something and came out, so we lost IV access. He was seizing, coughing up blood, and vomiting simultaneously, all while his flesh was flying off with each new wave of seizures. Since we didn’t have any IV access we had to give him some serious IM sedation. But that stuff doesn’t act right away and he was literally choking on his vomit. So we had to do an emergent intubation, which was impossible during his grand mal, so we did an emergent tracheostomy. Once things finally calmed down we transfused him with six units of blood. But due to all the areas of missing skin—I’m talking about 50% of his body. He’s needed steady blood and platelet transfusions all night long. The dermatologists actually came in during the middle of the night to help cover all his skin wounds; I’ve never seen them around after 4 p.m. so that’s saying something. Then we transferred him to the ICU once he was a bit more stabilized. Worst thing is that his daughter and wife were in the room when it all happened. Daughter freaked out and was admitted to pediatric psychiatry for monitoring. The wife’s a mess; cute though, I must add. She was asking for you, something about you saying all was going great.”
“Where is he now?”
“Shit, I’m late, here’s his sign out card. He’s in the medical ICU.” The intern ran off already thinking about his next task at hand.
Fuck, FUCK, FUCK … this was not good. I just stood there in a state of semi-shock. Sure I’d read about toxic
epidermal necrolysis, or TEN, and how catastrophic it can be. Most people with a severe case don’t survive, but it’s so rare, only a 100 or so severe cases in the U.S. per year.
Then I realized what caused it. It was the IV Bactrim he received. Sulfa medications are associated with TEN and that’s the only thing that changed in his care yesterday.
My heart turned into a chunk of ice and I felt it sink to my stomach. It was my idea to start him on this new medication! If he’d just stayed on the Vanco for another week he’d have been fine. Or if I’d inserted his IV instead of that wretched contaminated nurse, he’d never have gotten the MRSA infection in the first place.
Just a day ago he was thanking me for saving his life, not realizing I was the one responsible for almost taking it away.
My legs started moving, but my mind was a cloud of confused thoughts, none of which was completely formed. I was still grappling with how this could have happened; he was doing just fine yesterday.
Before I knew it, I exited on the fifth floor and was entering the ICU. There was much commotion two rooms in front of me. The cramped space was filled with five people, four in long coats and a nurse in scrubs. A ventilator with some long tubing and two full bags of RBCs were being rapidly infused.
I couldn’t see who the patient was because he was covered from head to toe in a thick salve with white dressings covering most parts of his body. His eyes were open but doused in thick lubricating ointment. I couldn’t recognize Duane, but the fact that the ventilator tubing was entering in the middle of his neck and his skin was missing clued me in pretty well that it was him.
I was close enough to hear the attending physicians discuss the case and I made out bits of conversation.
“It’s amazing he’s alive, but his clotting factors are quite low. We’re going to have to give him some more platelets. I think after these transfusions are complete, we can dedicate one of the central lines for blood products and the others for medications and fluids.”
“Agreed. The ophthalmologist was here earlier this morning. He said that his corneal abrasions were severe and worse than yesterday. He might lose one or both eyes if we don’t make sure they’re always lubricated.”
“We should start the IVIG sometime today if the steroids don’t make a significant difference by about noon. If he keeps losing skin like he is now he’ll die of dehydration, blood loss, or both, in the next day or two.”
“Not to mention infection. He had MRSA septicemia; if he gets that in these open lesions the game’s over.”
I’d heard enough, and turned to leave. The chipper and improving Duane was now reduced to being mechanically ventilated and nearly blind. Not to mention that he was losing both skin and blood at an alarming rate. IVIG was a treatment of last resort with only a slim chance of success. But if the steroids didn’t do the trick, this was the last option in the armamentarium for treatment of TEN, aside from supportive skin care measures and blood transfusions.
Just when I thought things couldn’t get any worse, they did. I ran into his wife as I exited the ICU and she came running up to me.
She wasn’t doing well, and who could blame her? In the past day her husband went from recovering nicely to knocking on the pearly gates, her daughter was admitted to the hospital for a psychiatric meltdown from witnessing her father losing half his skin and blood during a seizure immediately after having an eye exam indicating he was rapidly going blind, and she was left alone to deal with the fallout. She looked as one would expect: disheveled, confused, eyes and nose raw from crying and sniffling. But she still managed to dress well, likely the only bit of armor she had left against the cruel world suffocating her.
I braced myself for the onslaught I thought was to follow. I just knew she was going to blame me for everything and yell and curse me out. She might even attack me and report me to the medical board and perhaps sue me. My career would end years before it was even to begin.
I took one last deep breath and prepared myself. As she approached me she slowed down and patted down her dress and coat, in an effort to compose herself for the upcoming battle royale.
What happened next caught me off guard.
“Are you ok Dr. Raj?” she managed to ask between sniffles.
My body managed to seize briefly at the question. I took a moment to take myself in. I didn’t look so hot either. I’d managed to splatter hand sanitizer all over myself as I rushed out of the ICU, my hair was a mess due to my fidgeting once I learned about Duane, and I must have given off the vibe that I was somewhere in between constipated and about to vomit as I prepared for her arrival. What happened next came naturally without thinking.
“Me? You poor dear,” I patted her shoulder, “I can’t imagine what you are going through, and I won’t pretend to.” She embraced me and sobbed on my shoulder.
“I think Duane developed a severe reaction to the sulfa antibiotic we placed him on to try and treat his infection. His body is now registering his skin as being a foreign invader and doing all it can to protect itself by firing his whole immune system’s arsenal at his skin. That’s why it was falling off and bleeding. Same with his eyes. The worst seems to have passed. The seizure was because his brain overloaded and needed to reboot itself. The ventilator is breathing for him at present because he is so heavily sedated from the pain medications, but they are keeping him comfortable.”
“Thank you.” I was perplexed at why I was being thanked. Unable to figure out the reason I continued with my report of his condition and treatment plan.
“They are giving him steroids to try and turn off his immune attack. If that doesn’t work the next step is IVIG, which attempts to scavenge molecules and various cellular and protein fragments that are also playing a role in this havoc being wreaked on his body. This couldn’t have happened to a nicer person. He didn’t deserve this and we’re going to do our best to help him recover.”
“Thank you.”
Again I couldn’t for the life of me fathom what she was thanking me for. I was just blabbering on about what was happening in an effort for her to understand. I was almost about to ask what she was thanking me for. She should have been using me for a punching bag if anything. Instead I just remained silent until she broke the ice and answered my unspoken question.
“You’re the first one out of the dozens that have been running around Duane to tell me what’s happened. The scariest part wasn’t thinking he was doing to die, but not knowing why. You’ve given me answers, and now I can start to come to terms with what is happening.”
I hadn’t realized until that moment what power we carry in something so little as an explanation. After all, what people fear most is the unknown. If you can tell someone what to expect he or she can mentally prepare for it; but if you pull the rug out from someone it’s just a huge mess.
“Can I see him?”
“I don’t think this would be a good time. There are a lot of people around him right now. Tell you what, I’ll call you once he’s more situated and walk you into the ICU myself.”
She agreed and gave me her cell number while walking towards the waiting area with a head hung so low that I feared she might topple over. I had no idea what to do next, so I just stood against the wall until gravity pulled me down and I sat catatonic in the hallway. I don’t know how much time passed but Jason eventually came over and helped me up. We discussed the events that had transpired.
“Raj, you can’t blame yourself. It’s not your fault because of your intent, nay our intent. Ultimately it was a team decision that changing medications was in his best interest. Not to mention the actual name behind the order is mine, not yours. The goal was to get him home as soon and as safely as possible. The intention was not to hurt or cause him harm; if we knew this would happen no way in hell would we have given him that medication.”
“Yea, but it was my idea.”
“And a damn good one at that! You assessed all the options and picked the best one. What occurred was an unintended con
sequence, a grave unforeseeable disability in his treatment plan. Man up, Raj, this is the real world, and shit happens. We’re not here to be friends with our patients, we’re here to help them. Unfortunately, nothing in medicine is 100%. The sad truth is that we’re going to have some complications and tragedies such as Duane. The measure of a true doctor is how he handles the situation when things go to shit. It’s easy to give good news; bad news is what this job is all about.”
I listened and knew what he said was true; I just couldn’t detach myself from the events that had occurred.
“Come on, we’ll grab a bite to eat and talk to his wife again after rounds.”
Rounds went well. Ms. Maude was continuing her nonsensical yearning for Abigail, while her grandchildren still remained MIA. Dr. Miley shook her head about Duane and said let that be a lesson to us all that what we do is very real and not a game. We can’t ever take our jobs lightly when human lives are at stake every minute of every day. With that, she wished us a good call night and headed off.
A half hour later, Jason and I headed to Duane’s wife and escorted her into the ICU. I could immediately tell that Duane’s condition had deteriorated; he was on pressors, meds used to maintain one’s BP because it’s too low due to extreme illness, blood loss, or sepsis. Duane had all three. I let Jason lead the conversation. I wasn’t up for anything besides being a passive observer.
“Mrs. Little, looking at his labs I have …”
His voice fell on deaf ears, Mrs. Little was immediately by her husband’s side holding one of his bandaged upper extremities and sobbing by his side.
“I love you, dear, we’re going to get through this and take you home.” Her body was trembling as she spoke; leaving her gasping for air in between fits of sobs as she tried to communicate to her husband. “Jenny is also in the hospital. She went into shock when she saw your seizure last night, but she’s going to be ok by the end of the week. I’m falling apart here honey … I really need you by my side. The last nine years have been the best of my life … I can’t imagine the next 90 without you. You’ve got to pull through. If not for yourself, for me, babe.” She put her forehead against his bandaged arm and just remained in that position.
