The Perfect Predator

by Steffanie Strathdee

  Randy stayed with me in the corner of the room as the TICU team completed their assessment, thank God. I was so grateful for the support. Chip and Davey had told her that I didn’t have any other family living in San Diego. I felt like I was having an out-of-body experience, looking down at Tom, the doctors and a woman with dirty blond hair who looked like a shell of a human being: me.

  One of the critical care doctors, Dr. Mims, barked an order I did not immediately understand. “Page anesthesia, stat!”

  I turned to Randy. “Why are they paging anesthesia?” I whispered to her.

  “They need to intubate him,” she explained calmly.

  “Oh no, not the ventilator! Oh God…” My voice started to escalate. It didn’t sound like me. It sounded like someone who was becoming hysterical. My inner voice whispered: life support. Translation: death.

  “It’s gonna be okay,” she reassured me. “Trust me. He needs the support to breathe right now. Hopefully it will just be for a few days.”

  Within minutes, a new team of doctors arrived. There were now more than ten in Tom’s room. They gathered around his bed in a swarm, so many that I couldn’t even see him anymore. Tears slipped down my cheek one by one, then in steady rivulets. Someone handed me a Kleenex. I heard someone else say that three liters of fluid had now poured into Tom’s ostomy bag.

  A trim blond woman that I didn’t recognize emerged from the swarm and approached me. “Mrs. Patterson?” she asked me.

  I looked at her blankly. Honestly, in the moment the name didn’t register. “Uh, yeah. Steffanie Strathdee, actually. But yes, I’m Tom’s wife.”

  She handed me a piece of paper in her gloved hand. “I’m Dr. Meier, the anesthesiologist. We need to intubate your husband immediately to help him breathe. He probably won’t remember anything about this and we hope he doesn’t, since the memories can be… unpleasant. Can you provide us with consent please?”

  I nodded and signed the form. She thanked me and returned to the swarm, directing the activities of the hive. Within another five minutes, they all withdrew from the bed, their job done. I gave a sharp intake of breath. Before me, my husband had a face-hugger strapped on, through which a giant tube entered his mouth, like the man who had died in Bed 9. It was connected to a contraption the size of a small child that took up all the space to the right of his bed. It had several gauges and dials that I later learned were set to max. The dreaded ventilator. The vent. With a start, I realized that Tom could no longer talk. And that I couldn’t even remember the last thing we talked about. Would I ever hear his voice again? How did this happen, and so quickly? I felt totally disoriented.

  Randy looked at me and her eyes narrowed. “Are you okay?” she asked me.

  “Yes. No. I don’t know, actually.” I looked at her and tried to smile. And failed miserably.

  She handed me another Kleenex. “Do you have anyone around that you can call on, that can help give you some support?” she asked me gently.

  Both the girls had been down in San Diego for half of December and January, and Carly had just left a few days ago to deal with, among other things, the burglary of her house during the holidays. We were all making decisions day by day and doing the best we could.

  “Tom’s girls just went back to the Bay Area,” I told her vacantly, hardly able to focus. My good friend Liz was out of the question. Although she only lived a few doors up the street, her husband had just been diagnosed with end-stage pancreatic cancer. This was no time to add to her burden. So many other people were supporting us in so many ways, but…

  “Call the girls,” Randy said. “I can talk to them if they need more information,” she offered kindly. I confessed that I hesitated to call them because I knew I was getting a reputation for crying wolf—overreacting to the point that they had a hard time determining how serious the situation was at times. I didn’t blame them. I had a hard time gauging the gravity of these dips and dives myself. I was not naturally an alarmist. But how was I supposed to tell that a crisis would resolve, as, somehow, remarkably, they kept doing with Tom?

  Randy assured me that I couldn’t possibly overreact under the circumstances. Not this time.

  The next twenty-four hours were touch and go. Tom was placed in a medically induced coma while the docs worked to get his sepsis under control. He was given extra fluid to replace what he lost and sent for a CT to determine what was going on in his abdomen. His hemoglobin dropped precipitously, and he got a transfusion. Three pints of blood. He had lost at least one quarter of the blood in his body. While I waited for the results of the CT, Davey arrived. I ran to him and he gave me a big bear hug, and I buried my face in his neck.

  “Hi, Buttercup,” he said quietly. “I’m up to speed. I stopped by radiology to look at the CT.”

  “And?” I asked him anxiously.

  Davey looked grave. “Tom’s pseudocyst drain slipped and dumped all of the crap inside it into his abdominal cavity. This is what I was afraid of,” he said. “The Acinetobacter is now everywhere in his body. He is now fully colonized.”

  “Oh my God,” I whispered. It was the worst possible news. “And we have nothing except Victor’s cocktail of antibiotics to treat it, right?”

  Davey shook his head and tried to meet my gaze, but couldn’t. “That cocktail is bacteriostatic, keeping the infection from advancing, but it isn’t bactericidal—”

  “Meaning it can’t kill it,” I interjected.

  “Right,” Davey replied softly. “It’s no match for the Acinetobacter, especially now that it’s spread everywhere. We took samples of his blood and his sputum, but I bet my white coat it’s going to confirm Acinetobacter.”

  My eyes filled with tears. “Is there any good news at all?”

  Davey thought for a moment. “Well, there’s no sign of an MI. And Randy probably saved his life by putting him on meropenem yesterday. The B. frag was definitely growing in his blood first. Without the mero, he probably wouldn’t have made it this far.”

  Four days. That’s how long Tom “slept,” kept under with propofol, the “Michael Jackson drug” that its creator called “milk of amnesia.” Each day, he was wakened briefly to make sure that he was still able to hear and follow commands by giving a thumbs-up or nodding his head. The day finally came when it was time to turn the propofol off to try to wake him up for good. He emerged from that netherworld slowly over the next few hours. Wiping four days of crud from his eyes, I could feel the warm blood rush to his cheeks as I touched his face with my blue-gloved hands. He finally looked… alive.

  “Hey, Rumpelstiltskin,” I whispered. “Welcome back to the land of the living!”

  Earlier, when I’d posted an update to Facebook, sharing with friends that Tom was in a medically induced coma, I’d invited any suggestions to add to our improvisational music therapy. They poured in with an eclectic mix: Leonard Cohen, David Bowie, Lucinda Williams, Timber Timbre. The girls and I made playlists on Pandora that Tom could listen to around the clock, assuming he could hear. I Skyped daily with Robert, my spiritual rock, and the girls and I stayed in touch with Martin, a holistic healer in San Diego who shared a special place in the family and often came to sit bedside and lay his hands on Tom. We received messages from around the globe that friends and colleagues were lighting candles and saying prayers; the outpouring was overwhelming. I had no idea if any of these things would work, but I figured they couldn’t hurt. In a struggle that was so isolating in so many ways—we still couldn’t touch Tom without protective gear—it seemed that he and we were at a vortex of caring, loving, healing energy and presence. It was like nothing I’d ever experienced before. Tom, still on the vent and unable to speak, seemed oblivious to most of it, but at times, someone’s presence roused him from the deep or coincided with a positive shift in some of the monitors tracking his heart and other vital signs. But only sometimes.

  I never knew what a day in the TICU was going to hold. My routine call at five a.m. to get the report from the night nurse was
my feeble attempt to get a handle on a situation that I could never have control over. Each day that I made the half hour drive to the hospital, I asked myself, Will Tom be conscious or unconscious? If he is awake, will he even recognize me? The days that he didn’t were the hardest; it made me feel like my presence was totally useless. Deep inside, I knew that wasn’t true, but it was getting harder to keep my chin up.

  Finally, after several days, Tom spent more time conscious than unconscious and was weaned off the vent. A speech pathologist worked with him so he could start to relearn how to speak. One morning I approached his bed just as he was waking up.

  “Good morning,” I said to him with a smile. “Do you know who I am today?”

  Tom looked at me thoughtfully and croaked, “Me… me…”

  I got ready to be disappointed. Note to self: don’t ask a question when you are not prepared for the answer.

  “Me, what?” I asked him anyway.

  “Mi amor…” Tom croaked, and blew me a little kiss. My heart melted. I wished every morning began like that. More often, his fragile grasp on life and his thin defenses against the deadly Acinetobacter within dictated darker moods and more startling turns.

  One morning, after Tom’s physical therapy session, he had a surprise visitor. Bob Kaplan was his childhood friend, a fellow surfer, and lifelong conspirator in manly mischief. Bob had shifted careers from academia to government work some time back and lived in DC, a big shot now, but was in town, had heard about Tom, and stopped by to see him.

  “Some people will do anything for a little sympathy, huh, Leroy?” Bob teased him, calling him, as he always did, by his middle name. Tom tried to respond, but couldn’t catch his breath.

  I lamely reminded him of the tip the nurses used to help him remember to breathe in through the nose and out through the mouth: “Smell the rose, blow out the candle.”

  “Fuck that,” Tom snapped irritably. “Easy… easy for you to say.” I stopped hovering and the two resumed their mostly one-way conversation. Bob reeled off one-liners, a little worried when Tom seemed unable to parry in his usual way. Any pretense of conversation ended abruptly when Tom’s cardiac monitor alarm went off. His res rate had spiked over 30. Will, the respiratory technician, tried every option to stabilize it and clear the goo from Tom’s airway, but finally shook his head as the alarm sounded again.

  “Sorry, man,” Will said, shaking his head. “Gotta call Ghostbusters.” And just like that, Tom was back on the vent. This time, they did a tracheostomy—cut a hole in his neck to attach the breathing tube directly to his windpipe—and when they were done, the metamorphosis was complete. He now looked more like a space alien than anything human.

  Every skirmish threatened to be Tom’s last. He’d already survived three bouts of septic shock, and one was enough to kill many people. With every success, the good news was that he survived to fight another day. But despite each battle won, it felt like we were losing the war. And for good reason: we were.

  In recent years, more and more medical journals and media headlines had been reporting on cases in which people were getting sick or injured and developing infections that once would have been treatable with antibiotics but were now fully antibiotic-resistant. While doctors were struggling to treat the casualties case by case, the battle had spread far beyond them.

  Left unchecked, an estimated 10 million people were going to die from superbug infections each year by 2050. The former director-general of the World Health Organization, Margaret Chan, had recently stated that we were on the cusp of a post-antibiotic era, where a simple scrape could lead to limb amputation or death. It sounded extreme until you looked at Tom, who was, in fact, dying little by little each day. My husband could soon become one of the more than 150,000 people who die of a superbug infection in the US each year.

  The pharmaceutical industry’s rote assurances that new antibiotics were on the way ignored the reality that millions of people could die in the years needed to develop new drugs and move them from lab experiments to clinical trials. This speedy antibiotic pipeline was a pipe dream. The truth is more complicated.

  Colistin, the last-resort antibiotic that Tom’s A. baumannii was now resistant to, has been around since World War II, and the last new class of antibiotics was discovered in 1984. Within those classes of antibiotics, a certain amount of tweaking could create new generations of a drug, but bacteria eventually developed resistance to them. Colistin, specifically, was increasingly proving ineffective against bacteria it used to snuff out, not only in the US but globally.

  To make matters worse, powerful antibiotics like colistin wipe out the friendly bacteria that help keep our internal microbiome in balance. The temporary loss of these good bacteria is considered part of the routine collateral damage of antibiotic treatment. It’s not a critical loss for most healthy people under ordinary circumstances because the normal balance of protective flora typically returns. But if friendly bacteria are annihilated in someone whose immune system is already severely weakened, like Tom’s, a superbug like A. baumannii can more easily move in for the kill. And each new wave of the aggressive bacteria is more likely to have genetically adapted to tailor resistance for survival.

  In increasing numbers of cases, a serious underlying illness brings patients to the hospital for treatment, but what kills them is an unrelated infection they acquire there. These so-called nosocomial or healthcare-associated infections are a growing problem, with governmental estimates that on any given day, about one in twenty-five hospital patients has at least one such infection.

  Sick people are also especially vulnerable to the side effects of the antibiotics on other organs and systems. Colistin is considered a last-resort or “salvage” therapy because it can be toxic to the kidneys and nervous system. In its favor, colistin has a high cure rate if the treatment duration is short and the patient isn’t already suffering from shock or severe malnutrition. But Tom was suffering from both. And he had already been taking colistin for a month. He was also still receiving meropenem and tigecycline, two other big-gun antibiotics. Tom’s A. baumannii was resistant to them, too, but taking him off all antibiotics would feel like we were giving up. If there was even a slim possibility that one of them might kick in, we wanted to give it a chance.

  Antibiotics or no antibiotics, it was also increasingly clear that this was now much more than a battle against this superbug alone. It was just as much a struggle to survive the cascade of complications—a euphemism, really, for the many ways that the embattled body becomes overwhelmed and begins to fail. One complication and a medical intervention to fix it often lead to another. In Tom’s case, as in many, CT scans were essential for an accurate view of a problem area, yet with every scan came the risk that the imaging dye would further damage the kidneys and lead to kidney failure. And although the nurses flushed the catheter tubing from his abdominal abscess regularly, the tubing kept getting clogged and the infection kept spreading. Their solution was for interventional radiology to keep adding more drains; surgery was still considered out of the question. Every procedure added new risks of complications and more sepsis.

  Lungs, heart, kidneys, brain. As they falter, it’s like watching an expanse of city lights against the night sky, block by block flickering off until all that’s left is the dark. Some days Tom could follow the nurses’ commands to move a foot or squeeze his hand. Other days he could barely open his eyes. Tom was quickly becoming the poster child for the dystopian future of the post-antibiotic age.

  On Valentine’s Day, I decided to shake things up a bit. I put some lace undies on under my sundress and made a sign that said VALENTINE’S INTERVENTION IN PROGRESS: ENTER AT YOUR OWN RISK. I drew a large heart around the words. It wouldn’t compete with the other sign on the sliding door to Bed 11, which was bright green and read STOP! CONTACT PRECAUTIONS. Looking in the mirror above the sink, I applied bright red lipstick and puckered, giving the paper a big kiss right in the middle. “Ha,” I whispered to no one in partic
ular, “that ought to do it.”

  I’d borrowed tape from the nurses’ station to put up the sign and had told the day’s charge nurse, Marilyn, that I was about to give Tom his Valentine’s Day present. When I told her what I planned to do, I’d promised it would be all-look, no-touch to adhere to infection control procedures.

  “This is a first for the TICU,” she chortled, as she tucked a lock of her Doris Day hairdo behind one ear.

  In Tom’s room, I shook the mouse on the computer and clicked on YouTube. In the search box, I entered the words “Marcy Playground” and found what I was looking for: “Sex and Candy” was one of Tom’s favorites. I laughed out loud. He loved to sing this—or had.

  “This one’s for you, babe,” I crooned. Curtains pulled, standing bedside, I pushed the Play arrow with my blue-gloved finger, then carefully pulled my protective gown, and dress, aside for a black lace reveal. No response. Dress and gown back in place, I flipped to our Pandora playlist and took a brush and combed his hair, thinking that I saw him grimace as I pulled at a few knots of matted hair near the tubes that hooked over his ears. Later that morning, little had changed but our place on the playlist. The haunting familiar lyrics to “Hotel California” wafted through the room.

  I closed my eyes. How old had I been when I had learned to play this song on my acoustic guitar as a teenager? I hummed along with Don Henley, who sang about trying to kill the Beast with a steely knife. Tom’s eyebrows furrowed slightly, or was it my imagination? Whatever he might be hearing, including his favorite music, it was hard to know what his brain might be making of it. Even ordinarily, a quirk in his sensory wiring mixed sound with colors—a condition called synesthesia—so that everything, from Beethoven to the beeps and hums of the bedside monitors, brought a shock of color with it.