But the startling sludge in the bulging ostomy bags reminded me of something Félix had described one hundred years ago. The intensity of the bacteria’s reaction to phages “is of such violence that it must have been observed by many bacteriologists but had not been understood,” he wrote. He’d referred directly to a lab in India, where a scientist had seen his bacterial cultures turn clear after twenty-four hours and referred to these as “suicide cultures.” That, of course, depended on whose side you were on. One organism’s suicide is another organism’s victory party. Complete with exploding piñatas when the phages break through the bacterial cell wall and the virions come pouring out.
Chip texted back in record time, saying he would get dressed and head over to the TICU right away. His note said that he still thought the phages were doing their job. “I suspect this is something else,” he texted. The question was, what? He arrived at the hospital within the hour, took one look at Tom, then looked at me. A sheen of perspiration glistened on his forehead. Other than this telltale sign, Chip appeared calm and collected. I later learned that he wrote Davey a note saying, “I think I may have killed Tom.”
That made two of us.
Chip shifted into his own version of hyperfocus mode. He verified that the doctor on call had placed an order to change all of Tom’s lines. This meant changing each of the thin catheter lines that had been inserted into Tom’s blood vessels to deliver antibiotics or allow easy access for taking blood samples. Any could be the source of a new infection. Chip also confirmed that samples had been drawn from Tom’s body fluids—blood, urine, sputum—as well as his drains, to culture any new organism that might explain his precipitous decline. Chip called the research pharmacy and asked them to send samples of the phage preparations to the micro lab to ensure that they had not become contaminated with bacteria from handling. Samples of feces and sludge from the drains were to be tested for blood. A blood sample was taken to test for cardiac enzymes to rule out a heart attack, since its early signs can include shock. The doctor on call had already ordered a CT to determine whether Tom had experienced a GI bleed—all stat. No time to spare. After all of the cultures had been obtained, Chip also increased Tom’s traditional antibiotics. Patients in the ICU who are as sick as Tom have many places through which bacteria can invade, he explained, so they are always at risk for new infections that could be unrelated. When they take sudden turns for the worse, Chip said, it is prudent to look for new and different infections and to change antibiotics while waiting to see how the patient does clinically and while the cultures grow.
I paced the floor by Bed 11, which suddenly felt as oppressive as a prison cell. I could feel adrenaline coursing through my veins, but I had nowhere to direct it. I took a closer look at Tom’s face. It looked like a death mask.
“I am really worried, Chip. Did you see that crap draining from the pseudocyst? It must be World War III in Tom’s gut.”
“I know. I am worried, too.” Chip admitted ruefully. “The critical care team suspects that the phages are the culprit, but that’s because they have no experience with it. I’m guessing that there’s another microbial offender to blame here. We will get to the bottom of it, but in the meantime, are you okay if we put the phage therapy on hold for a day or two until we can determine the cause of the problem?”
“Yeah, I guess so,” I replied, clenching and unclenching my blue-gloved hand. Maybe the endotoxin levels had been too high, after all, and this was where the whole thing would end. But what if it wasn’t the phages or the endotoxin? Stopping the phage therapy was the logical thing to do under the circumstances, but I knew that this carried its own risk. Chip waited, seeing that I was torn.
“By reducing the selective pressure exerted by the phages,” I finally asked him, “aren’t we giving Tom’s Acinetobacter more opportunity to develop resistance?”
Chip had already considered this. “That is definitely possible,” he replied thoughtfully. “But we have the benefit of having two phage cocktails in our arsenal; that is a total of eight phages. No one really knows how much time we have, but I don’t think the Acinetobacter has generated resistance to all of them within a few days. That said, the longer we wait to reinitiate the phage therapy, we do increase the risk that mutant bacteria will start to grow. That’s exactly what happens when we stop antibiotics prematurely.”
“But in the case of phages, things are a little different,” he continued. “In theory, if they are behaving as we hope, they’ll already have reached their Acinetobacter targets and will continue to replicate at the sites of infection—whether or not we continue to administer them through the drainage catheters and intravenously.”
The hours ticked by while we waited for the battery of tests to be completed. His cardiac enzymes were normal, suggesting no evidence of an MI. But the CT revealed that Tom had had a recent GI bleed. That explained the coffee-ground appearance of the stuff oozing from his drains. Although another bout of septic shock had occurred, to find out what organism had caused it meant waiting for the report back on the cultures, which takes twenty-four to forty-eight hours. No quick mug shots.
Dr. Mims was on rounds again. He warned me that even if Tom awoke from his coma, I needed to prepare myself. He had been bedridden for so long that he could have permanent damage to his nerves or his muscles—neuropathy or myopathy—or both. How much more bad news could there be?
But there was more. A man Tom’s size should contain nearly two gallons of blood, and the normal hemoglobin level should be at least 13.0. Each day in the TICU, his hemoglobin level was monitored to ensure that it hadn’t fallen below the critical level, which was 7.0. When that happened, which it had on several previous occasions, there wouldn’t be enough hemoglobin to carry oxygen to the body’s vital organs, and a transfusion would be needed. Tom’s hemoglobin was 5.5, meaning that he had lost almost half of the blood in his body. This was mostly due to his GI bleed, but for months now, his bone marrow had been busy making white blood cells instead of red ones. That also explained his zombie face. Dr. Mims had sent an urgent request to the Red Cross for three units of blood, but they hadn’t arrived yet. Tom had received more than sixty units of blood since he’d fallen ill. Nearly eight gallons. His blood was becoming harder and harder for the Red Cross to match. I made a mental note to donate blood more regularly. One of the many reasons Tom was still alive was thanks to scores of anonymous blood donors.
The mood around the TICU had become somber, the hope for their miracle patient fading. No one would meet my gaze, which only made me feel worse. How was I going to tell Tom’s girls that their dad had septic shock again? I was to blame because I had insisted on an unproven experimental treatment that was alive and multiplying inside him. My only consolation was that Tom still kept producing enough urine that the nephrologists were not pressing for dialysis. Just when I was feeling like I was coming apart at the seams, Davey appeared at the doorway to Bed 11.
“Hi, Sunshine,” Davey said softly with a smile, and gave me a warm hug.
“Davey,” I cried. “Am I glad to see you! What’s your take on what is going on with Tom? How bad is this bleed, and what does it mean for his prognosis?”
Davey pulled up the CT scans on the computer and pointed at the black and white images on the screen. As he adjusted the view, a bolus of blobs morphed into various sizes before us, like time-lapse photography of a lava lamp.
“Chip and I went over the CT with the radiologist, so I will tell you what I know,” Davey said, as he sat down backward on a swivel chair. “So, we are looking at a cross-section of Tom’s abdomen. See that? That’s his liver. And that small spongy glob? That’s what is left of his pancreas. He’s lost about one third of it, but what’s left does not look necrotic. Not dead—that’s a plus.”
“Okay.” I nodded. “Those blobs could be Pluto and Jupiter as far as I am concerned. What’s that cloudy stuff?” I pointed to an area around the pancreas.
“That’s inflammation,” Davey replied
. “There’s a lot of it, which is why he has so much ascites fluid in his abdomen. The fluid is putting a lot of pressure on his lungs, which is why he is still having problems breathing. Those cloudy regions around his lungs are pleural effusions. More fluid. But what I really wanted to show you is his gall bladder.” Davey pointed on the screen to a melted hockey puck. Not what I’d imagined.
“Isn’t the gall bladder supposed to look more like a sphere?”
“Yep,” Davey replied, waiting for me to go on.
“So where did it go?” I asked, confused.
“Here,” said Davey, holding up one of Tom’s ostomy bags that was still collecting a steady stream of thick brown fluid peppered with coffee-ground flecks. “Some of it was probably excreted in his feces too, since it showed signs of old blood.”
Yuck. I shuddered. I might never drink Peet’s again. “So basically, the Acinetobacter infection eroded his gall bladder tissue so it just disintegrated and seeped out of him?”
“For lack of a better way to explain it, yeah,” Davey grimaced. “But it’s not the end of the world. You can live without a gall bladder. Lots of people do. Let’s just see what grows from his blood culture and hope that it isn’t the Acinetobacter again.” What he didn’t say was that if the superbug was isolated in his blood again, that would probably mean that the phage therapy wasn’t working. And if Nature’s ninjas weren’t wielding their nunchucks by now, they never would.
But Mother Nature, Darwin, or both were on our side. By the next day, Tom’s fever started to break and his WBC count decreased markedly. Chip dropped by Bed 11 in the early morning to check in.
“I thought I would find you here,” he greeted me. “Looks like things are headed in the right direction again. We should get the results of the culture by this afternoon, but I am betting my white coat that the culprit isn’t Acinetobacter.”
Early that afternoon, Chip reappeared.
“Okay, let’s have it,” I demanded, trying to invoke some decorum or politeness, and failing.
Chip chuckled and his freckles stood out more than usual.
“The micro lab finished the cultures, and as I suspected, the phages are not implicated in Tom’s latest episode of sepsis,” he said. “His blood culture grew Bacteroides thetaiodomicron, a common gut bacteria, but a problem when it sneaks into the bloodstream like this.”
Considering the possibilities, this was great news.
“Leave it to Tom to acquire yet another organism that no one can pronounce,” I replied sarcastically. “This one sounds like it has been to a few frat parties. Now please tell me that this bug is susceptible to antibiotics.”
Chip was equally gleeful. “Yup. It’s sensitive to meropenem, and he’s already on that, so we are covered,” he responded. “That is likely why this latest episode of sepsis has already started to resolve. What’s more, Monika, the fellow in Victor’s lab, did some further sensitivity analysis on one of the isolates from Tom’s drains that was taken right before the phage therapy. It was sensitive to minocycline. So, we are adding that to his regimen today. I have a feeling he is going to be back on track soon. With your permission, I would like to reinitiate phage therapy ASAP.”
I agreed. We didn’t want the A. baumannii to have an opportunity to start to grow again.
There was a driving-blind sensation and a hurry-up-and-wait rhythm to this whole thing that Chip seemed at ease with; me, not so much. There was no way in real time to monitor phage activity: Were they taking down huge satisfying swaths of A. baumannii? Making it to the obscure pockets of infection? Getting siphoned off and recycled by the liver? Languishing in some dead-end crevice where their bump-and-sniff style was stymied? You couldn’t know. And the specimen they sent off every few days to the Navy lab took time to culture and analyze. Chip seemed to have a special gear—some sixth sense—he shifted into for complicated cases that called for him to work with the fits and starts inherent in data, the delays and the human factor. I marveled at this capacity.
“The reason I’m loath to stop now,” Chip said, “is that we haven’t yet measured the phage at the sites of infection and we don’t know for certain that what we think should happen will actually happen in a patient like Tom.”
His expression softened a bit, and he delivered his clinical decision with his down-home doc warmth.
“If a boat ain’t rocking, don’t sink it. Tom was clearly improving on phage therapy until twelve hours ago. Changing course suddenly by stopping phage therapy altogether is something that I want to avoid because his boat has not only not been rocking, it has been rising.”
My bet was on Chip.
At the moment, he said, Tom needed to have a few of his drains upsized by interventional radiology. The glop oozing from his drains was so viscous, they were worried the tubes would get clogged, which could aggravate the infection. I left a voice mail for Carly, who was scheduled to replace Frances on the afternoon shift with her dad. I didn’t want her to be blindsided when the phage therapy resumed. She texted me back a few minutes later:
I hope y’all know what you’re doing. He’s barely recovered from this last bout of septic shock.
She was right. Tom was not out of the woods yet, and there was no telling if plowing ahead again was going to be the biggest mistake of my life. Much later, I learned that this was the day when my nephrology colleague, Joe Ix, had asked his resident how Tom was doing. She told him, “Well, Chip thinks he’s getting better, but nobody else does.”
25
NO MUD, NO LOTUS
March 22–31, 2016
The next morning, I lay in bed and hit speed dial an hour earlier than usual, at four a.m. Despite the pitch-black, I could feel the button as if it were Braille. By chance, TICU was lucky number 7. I would take whatever luck came my way these days.
“Thornton ICU…” a female voice answered, which I suspected was Mary, the charge nurse on night shift.
“Hi, I am calling to see how my husband, Tom Patterson, slept through the night.” I continued to lie in bed in the dark, stroking Paradita’s furry stomach with my free hand. The whole herd was with me: Bonita was perched on my hip, and Newt was curled behind my legs, lightly snoring. At least one of us was getting a good night’s sleep. I knew that with these four-legged alarms, there was no chance of me getting any more Zs.
“It’s still happening,” said Mary. I could hear her typing on a computer keyboard while she spoke.
“What is?!!” I exclaimed, jumping out of bed. Upended, Bonita, Paradita, and Newt scattered in all directions. If Tom’s interventional radiology procedure had lasted all night, something had gone terribly wrong. Why hadn’t they called me?
“The night,” she replied calmly. “The night is still happening. It’s four a.m.”
“Oh, yeah,” I replied, trying to dial down the edge in my voice. It was a time when most people were sleeping. “So is he?”
“Is he what?” Mary asked benignly. Was she joking? I couldn’t tell.
“Sleeping through the night!!” I snapped. It felt like we were caught in the Twilight Zone version of “Who’s on First?”
“Like a baby,” Mary replied. “Now go back to sleep—and that’s an order!”
A few hours later, I shook off my snarly attitude and drove to the hospital. The earlier call had left my nerves jangly, which seemed irrational, but I was still reacting to the day before, when I’d assumed Tom was fine, based on all reports, and arrived to find all hell had broken loose. Now, although I wanted to hear good news, it was hard to trust it. The radio was playing Louis Armstrong’s “It’s a Wonderful World,” one of my old-time faves. I sang along, reflecting that Tom would have been six feet under by now if it weren’t for the phage community and all the doctors and nurses who worked so hard every day to keep him alive. People like Mary, who’d kept her calm when I’d snapped at her. It was a wonderful world, or had been anyway. Maybe it would be again. If only Tom could pull through.
Through the atrium, past the
line of towering palms standing at attention, and with just enough time to say a little prayer in the elevator—Please, God, give me the strength to get through whatever this day brings me—the doors opened on the new day, a new shift in the TICU. And day 115 since Tom had gotten sick in Egypt. I checked the whiteboard behind the nurses’ station and saw that Chris was assigned as Tom’s sole nurse today. It had been a week since he had stood by Tom’s side as the phage therapy had begun with the Texas cocktail. I gowned up and stepped in, and Chris greeted me with a hug.
“I just finished catching up on Tom’s chart. I know you’ve gone through hell these last few days,” he said kindly. “But things are already looking better today.”
Tom’s blood pressure was stable, so they were able to lower the pressors, and his heart rate was down below 100 for the first time in days, Chris said. “And,” he added, “he seems to be stirring.”
I almost shrieked but managed not to.
“Are you serious, Chris?! No—really? Are you sure?” I said. “Tell me you’re not shitting me.”
Chris smiled. “I shit you not. Watch this.” Chris approached Tom’s figure on the bed, and leaned down toward his ear. “Tom, it’s Chris again. I just need to ask you a few more questions. Can you use your left hand to squeeze mine?” A few seconds passed, then I saw Tom’s hand move almost imperceptibly and give Chris’s a faint squeeze. I gasped.
I breathed into Tom’s face. “Honey, honey, it’s me. It’s Steff. Can you open your eyes? I have missed you so much!” Please, God, please let him wake up.
The Perfect Predator Page 25