by Atul Kumar
Hearing her heartfelt conversation brought moisture even to Jason’s eyes, but he would never admit it. We slipped out of the room and brought down the curtains to give them some privacy. We planted ourselves at the workstation and waited.
“The fact he’s on pressors isn’t a good sign?” I asked, but noticed Jason was in deep conversation with the ICU attending who was doing a lot of gesticulating and brushing his hand through his thinning head of hair. At the end of their conversation the attending wrote some orders and spoke to the nurse.
“What was that all about?”
“I was just getting an update from Dr. Benson. Bad news. In addition to the TEN and MRSA, Duane’s going into SIRS, a precursor to DIC. Basically, his clotting factors are all out of whack and he’s getting a unit of blood every hour and a ten pack of platelets every four to six hours. He said the steroids aren’t working despite the mega doses he’s getting.”
“IVIG time?”
“Yep, that was what he was telling the nurse to get prepped. The infusion should start in the next couple hours.”
“Isn’t that like $10k per treatment cycle?”
“Dude, it’s like $10k per dose, and he’s slated for 2 before nightfall. It’s a last ditch effort. This isn’t looking favorable.” Something caught his attention, it was Mrs. Little exiting from Duane’s room. “Oh, she’s coming out; follow my lead.”
We walked up to Mrs. Little and gave her some fresh tissues to dab the rivulets of tears streaking down her face.
“Mrs. Little, unfortunately Duane is not responding to all our efforts, we’re going to begin IVIG infusions within the hour to try and clear the offending molecules from his body. It’s only a 50/50 chance that it’ll help, but this is our only option. There’s a 100% chance he’ll continue to deteriorate without out it.”
“I understand, thank you for your honesty. You and Dr. Raj were well liked by Duane, he spoke very highly of you both. I know you’ll do your best to help him. Besides it can’t get much worse, right?”
Wrong. But we didn’t actually tell her that. The problem wasn’t so much that he’d die; it was what would happen if he survived.
Duane did well after his first IVIG infusion and was off the pressors by dinnertime. There was even talk of taking him off the ventilator and lightening up his sedation. Everybody was optimistic.
During his second infusion is when all hell broke loose. He developed thrombosis, a rare complication from IVIG. But being Duane, he didn’t just develop the local version, he developed the systemic variety and began to throw little emboli everywhere in his body. By the time it was recognized, he was not responding to pain and was unable to move the left side of his body.
The infusion was immediately stopped and he was sent for a STAT CT scan of his head which demonstrated a right-sided cerebral hemorrhage, or in other words, a stroke. The list of Duane’s problems continued to grow.
“Shit, Raj, I wish he never came to the bloody ER.”
“It’s like what you said about nice guys. They don’t do well in the hospital.”
“Ha ha,” Jason tried to laugh. It came out more like a cough. “You remember me saying that?”
“Yeah, I thought it was all BS.”
“Here’s living proof it’s not. He came in with a simple kidney infection, and now he has sepsis, TEN, DIC, a stroke, and he’s ventilator dependent with a tracheostomy. Not to mention he’s legally blind. I just spoke to Dr. Sun, the ophthalmologist, a couple minutes ago. He said 50% of both of his corneas have eroded away and the likelihood of recovery without scarring is slim. If he ever hopes to see again he’ll need bilateral corneal transplants.”
“He must be going through hell.”
“I’m sure he’d take hell over this. I spoke to his wife. I was completely honest. I told her he had about a 5% chance of making it through the night. So in an hour we’re going to take him off all sedation and perhaps he might communicate a little bit. If he wakes up enough, maybe he can nod or blink his eyes to answer some questions.”
I finished up my other work and entered the ICU just as Jason and the attending were reducing Duane’s pain medications. He was starting to move the right side of his body and tried to blink his eyes.
“Duane darling, can you hear me?” His wife cried into his right ear. No response. She tried again. Then she switched to his left ear and he moved his right arm.
“Can you hear me, baby?”
A slight nod.
“Are you in pain?”
Affirmative.
“I love you …”
And she hit the floor, sobs writhing through her body with convulsive force. Her screams of agony tore through the entire ICU. Everyone heard but tried to look away and ignore them. Jason and the attending picked her up and carried her to the conference room. I was alone with Duane.
“Hey, Duane, can you hear me?”
A nod. He tried to speak, but the breathing tube going into his neck thwarted any possibility of verbal communication on his part.
“Can you see?”
Negative.
“Can I do anything for you?”
An emphatic nodding and right hand shaking.
“What? You name it and it’s done!”
More hand shaking, but I got the sense that neither of us knew sign language. Even if we did, his hand was so bandaged up his fingers couldn’t move individually. He was wrapped up like a mitten.
This was going nowhere fast. Then I had an idea.
“Tell you what, I’ll unwrap your hand a bit and put a pencil in it. Do you think you can write a little?”
Nodding and a forced grunt.
I ran off to get a big pencil and some paper. I unwrapped the mummy like dressing off his right hand and just stared. It was half raw pink flesh and half black eschar, as though it had been laid on a barbeque for too long. The black eschars didn’t look much different from what a mummy’s tissue looked like, as least the ones I’d seen in museums.
“I’m placing a pencil in your hand now. The notepad is just under it, ok?”
He tapped on the pad and tried to write, but his hand movements were clumsy at best, and he succeeded in only making some undecipherable streaks akin to an elephant painting
“I can’t read that Duane, can you try again?”
He tried again.
Same result.
He started banging the pencil now, clearly agitated. But I couldn’t tell if it was from frustration or pain. The pencil was slipping from his grasp, so I wrapped it in many layers of tape to increase its girth allowing for Duane to grip it easier.
“Still can’t read it, are you in pain?”
Affirmative.
“Do you want some pain meds?”
Emphatic negative.
“Do you want to try and write something down again?”
Affirmative.
I again placed the pencil, now enhanced in circumference with surgical tape, in his hand, and he tried once more. Much more slowly and deliberately this time, he succeeded in writing a couple letters before the monitors started to beep and a nurse ran in notifying me his BP was dangerously low. She ran off to get the attending. I hit the silence button.
Duane kept at it with deliberate focus. His whole being was focused into what he was scribbling with his right hand. He finished the first word and started the second as the attending entered.
Chaos ensued. His BP crashed and every alarm in his room went off.
I dropped the pad when somebody bumped into me while hanging a new IV bag. Soon pain meds coursed through Duane’s system and pressors were reinitiated. Within seconds he was again unresponsive.
I bent down to pick up the paper and stood in horror as I read his note, barely legible yet startlingly clear in what he was trying to convey. I saw two words I never believed would come from Duane. He wrote ‘kill me’ on this third attempt to answer what he wanted me to do for him.
Jason was headed over. I hid the paper in my pocket.
; ~~~~
Despite a quiet call night, I didn’t do any sleeping. I was up all night thinking about Duane. I kept thinking about how I’d entered medicine to save lives, but now it seemed that the answer wasn’t so clear cut. Could it be that to ease one’s suffering our role might actually be to assist in their death? After all, if that’s what Duane wanted, was it our right to refuse it?
Technically suicide is illegal. Something I always found amusing because if one succeeded, how were they to get prosecuted? I guess where it really comes into play is that if one commits suicide; their beneficiaries lose any benefits such as life insurance, pensions, and various other inheritances and such. That’s why many people who end their lives make it look like an accident so their heirs can at least reap the rewards of what they had amassed when alive.
A very common way of doing this is death by cop—speeding and then pretending to draw a weapon of some sort when the officer is approaching the vehicle. The officer will discharge his firearm in defense and the investigation will find that the traffic offender only had his phone nearby. In this scenario the family gets all insurance and other benefits and the individual winds up dead in a rapid and painless fashion without actually committing suicide.
The problem with this scenario is that Duane will never be able to drive a car again.
I hadn’t yet told Jason about the message Duane had written to me in his last seconds of consciousness. I was debating if it was even real. I mean can somebody in his state of duress be capable of making such a serious decision? And if so, should his wish be carried out?
After all, once he was intubated and could no longer communicate, his wife became his legal guardian. Thus, she is officially in control of any medical decisions concerning Duane. The problem being, when does she relinquish her power over her husband? Every time he is able to communicate or only once he is fully recovered? And what the hell is ‘recovered’ in his case anyway?
My head started to hurt. These were all very complex questions to which I had absolutely no answers. Medical school never touched on these topics. If they were covered, I must have skipped that lecture.
I lay in bed tossing and turning. When sleep finally arrived it was promptly interrupted by my pager. It was Jason, but he was calling from the ICU. That could only mean it was related to Duane. Any page during pre-dawn hours from another physician is never good news.
Instead of calling back, I hightailed it to the ICU. As expected, Jason was at Duane’s bedside talking to the ICU resident on call for the night.
“Bad news Raj, I was paged about Ms. Maude. Her heart rhythm had a few irregular beats an hour ago, so I got a troponin level. It just came back elevated. Cardiology thinks she might be having another MI and is rushing her to the cath lab yet again. They’re worried she might have had an acute thrombosis in one of her stents. Hopefully it’s nothing. We should know in the next hour or so.”
“Oh, I thought something was wrong with Duane.”
“Since I was up here, I thought I’d check up on him. He’s starting to respond to treatment, how I don’t know, given he’s only on supportive care and antibiotics. In either case, he’s been waking up over the past few hours and I know you have a soft spot for him, so I thought I’d page you. Didn’t mean for you to rush up here.”
I was touched by Jason’s thoughtfulness. Most people would be pissed at being woken up at 4 a.m. to deal with heart problems in a 90+ year old GOMER. But Jason managed to find the positive in the situation and share it with me, namely, Duane’s progress.
I went over to Duane as Jason tried to salvage another hour of sleep before starting the day.
“Duane, can you hear me?”
Affirmative.
“You feeling better?”
Negative.
“Are you in pain?”
No response.
“Do you want me to get your wife?”
Negative.
His head movements were minimal, but definite and brisk. He was clearly hearing me and responding in a coherent manner.
“Is there something I can do for you?”
Affirmative.
“Do you want me to do what was on your note?”
Definitely affirmative.
“I want to do a bit of an examination on you if that’s ok?”
Affirmative.
“I am going to open up both your eyes. I want you to tell me if you can see anything?”
Negative. I tried twice more, same response.
“Can you move the left side of your body?”
He moved his right arm and leg, but his left side remained unchanged, immobile. I assumed he had tried to move all his extremities, but only had luck on the right side.
With that I left and headed outside to clear my head. As I passed the waiting area I saw his wife cuddled up in a chair with a blanket trying to rest. Since she wasn’t allowed in the ICU at night, she waited as close to her husband as possible. She hadn’t even gone home. For as much as Duane was going through, she was going through quite an ordeal herself. The last few days had aged her ten years and completely changed the course of life, not only for her but her daughter as well.
I sat down next to her, I’m still not sure why I did it, but it just seemed like the right thing to do. I gently patted her shoulder and she startled awake.
“Oh no, Duane, he isn’t … is he?” She said in a voice laden with sleep and fatigue. But her face had that look of horror in which she was expecting the worst news.
“He’s actually better.” Her relief was palpable as she readjusted herself to face me.
“Oh, thank you, Dr. Raj. I could use some good news. It’s been miserable, but I still hope he’s going to make it. I can deal with a lot, but Duane’s more valuable to me than my own life. His death would be worse than if I died. I’d gladly give my life for his. I’d take all his pain just to see him smile once again.”
I was touched at her love for her husband and in that instant I knew I’d renege on my promise to do anything Duane asked of me. Killing him might be an act of compassion, but it would be worse than murder for his wife. I knew he’d hate me for that.
“Dr. Raj, do you think he’ll make it? Nobody talks to me about him. It’s like everybody’s trying to avoid me to protect me, but even bad news is appreciated. It helps just to be informed.”
“Well, you know he’s sick. But I was just in there and he could hear me and nod. Definitely seems like he’s turning the corner. If he keeps this up he might survive, though the recovery process is going to take months. And he’s going to require multiple skin grafts in addition to possibly being paralyzed and even blind.”
“But he’d eventually go home?” The look in her eyes was one of such pure hope. It was all she had. To say no would have been criminal. Now I realized why many docs avoided too much patient/family contact. It really was much more art than science, far more subjective and uncertain than the precise and predictable nature of numerical lab values.
“Yes.”
She clutched my sleeves and buried her head on my shoulder, sighing in relief. Hugging me, she kept repeating, “Oh thankyouthankyouthankyou!”
I patted her back, and she eventually let go.
“You realize life will be hard once he returns home. And likely expensive with his care requirements and inability to work.”
“That can all be worked out. I can take a second job. Our parents can move in and help. Jenny loves her grandparents. We might be an extended family under one roof, but at least we’ll be a family.”
Well, I had my answer. I wouldn’t keep my promise and assist Duane in his request. I didn’t like being stuck between upholding the wishes of my patient and those of his wife.
In the back of my mind I still had a nagging thought; I still wasn’t sure who held the actual power of medical decision making. In either case, assisting suicide in the state of California was the same as committing murder. BUT, I knew that … I could easily make it look like an accident or due
to natural causes, in which case his family would inherit at least a million or more tax free dollars from his life insurance. And I’m sure I wouldn’t even be on the list of suspects. However, by allowing him to live, his wife would be much happier, or so she claimed.
“I applaud your attitude. Duane is one lucky man to have a wife so dedicated and caring.”
“I’m the lucky one to have him.”
I shrugged, uncertain of what else to do, “I’ll be back later and make sure you can visit him before the chaos of morning rounds begins.”
I left her with renewed hope, but deep down inside knowing that Duane did not want to continue his life as a mere shell of the vivacious person he was just a week ago. He would be going form breadwinner to bed wetter. From head of household to blind, incontinent, paralyzed parasite in need of constant assistance with everything from eating to bathing. He’d likely need both urinary catheters and rectal tubes to relieve him of his bodily wastes. Not to mention his appearance would be a haphazard quilt of numerous skin grafts, and that’s with the best efforts of highly skilled plastic surgeons and numerous operations.
And that’s the best case scenario.
~~~~
It turned out that Ms. Maude did in fact have an acute thrombosis, or blood clot, of one of her stents. But thanks to the efforts of the stalwart interventional cardiologist on call, he was able to perform a minimally invasive lysis of the clot. In a couple days Mr. Maude would be as new as a fossil again.
Duane also did well overnight and in another day he was extubated and breathing on his own with the assistance of some supplemental oxygen. However, his voice sounded like that lady from one of those ‘dangers of smoking’ television commercials in which her voice is raspy and guttural. That’s because his voice is emanating from the hole in his neck instead of his mouth. At least he was making progress.
His daughter was discharged home, where she joined her mother and grandparents.
Two days later Duane was transferred to the burn unit where they would tend to his third degree burns as well as start his rehabilitation process now that he was off most medications except antibiotics, morphine, and his myriad eye drops and salves for his macerated corneas. The same day Duane was transferred from the ICU to the burn unit, Ms. Maude was picked up in her Bentley to be chauffeured home.
