by Atul Kumar
“She pets her dog.”
“Awesome, we’ll spend a quarter million on this hospitalization so she can go pet her dog. I bet she can’t even remember the damn thing’s name. Gotta love medical care in the US. Let’s grab a bite before rounds.”
~~~~
We met the team for rounds, but Adam, Amy, and Kelly were nowhere to be found. Jason and I quizzically looked at each other as Duke rounded the corner and fast approached.
“Jason, I gave the rest of the team the day off. They only got one admission overnight, so I figured you and Raj could handle that.”
We were both cursing up a storm, in our heads, but on the outside we welcomed the opportunity for more work with no reward as Duke gave us the lowdown on our newest patient.
Rounds flew by.
“Strong work Raj, most residents wouldn’t even have thought that Ms. Maude was having a heart attack. You keep this up and I’ll make sure you make honors on this rotation.”
Before I could thank her, Dr. Miley was off to attend to whatever it is that attending doctors do all day. My guess was surf the web.
“Well, looks like you guys have it under control. I’ll be around if you need me,” said Duke.
Ah, the code words that Duke was leaving for the day and all the work for the team was bestowed upon our shoulders. In medicine it’s never appropriate to say one’s leaving, instead one makes a false offer to be available, when in fact they are likely to be unavailable and definitely do not want to be called or bothered. It’s a strange culture.
“Guess it’s just the two of us Raj. Ohhh … check that out.”
Both our heads turned toward the “click click click” of stiletto heels hitting hospital tile. Growing out of those heels were gorgeous legs with a miniskirt that left less to the imagination than a hospital gown, and a body which deserved even less clothing. She walked straight into Duane’s room.
“You were right Raj, she’s definitely hot, now we know where he got his E. coli from. Can’t say I blame him either. Shall we introduce ourselves?” Jason winked while he said it.
I followed Jason into the room where the sultry Mrs. was seated on the side of Duane’s bed gently stroking his head.
“Hi Duane, just came in to check in on you. Is this your wife?”
“Hi Doc. I’m the better half. How’s my darling doing?” She replied.
“Pleasure to meet you, I’m Dr. Bates and this is Raj, our medical student. He’s been working hard on your husband’s case. The good news is that the blood cultures came back positive for E. coli, likely from the urinary tract infection which you were treated for last month per our discussion on the phone. The other piece of good news is that it’s sensitive to the antibiotic we already have Duane on, which explains why he’s doing so much better.”
“Oh, that’s great news. Do you think he’ll go home soon?”
“I think that’s a reasonable possibility in the next day or two. We’ll keep him over night on the IV antibiotics and then transition him to something he can take orally tomorrow. If he does well, he’s all yours.”
“Wonderful!” She kissed him on the cheek.
“Hey Doc, not to rain on the parade, but my arm here kinda hurts. Can you take a look at it?”
I rushed over to Duane’s right arm and it was almost double in size compared to his left arm, and very tender to palpation. I immediately looked up at Jason whose nod conveyed that agreed with the diagnosis without saying a word. His prolonged silence was my cue to speak up.
“Well Duane, it looks like your IV line has infiltrated; instead of pouring the fluid into your vein, it’s basically leaked it into the soft tissues of your arm. Thankfully it’s not a big deal; we’ll just remove this line and start one on your other arm. I’ll let the nurse know on our way out and get his taken care of this right away. The swelling in your arm should subside and normalize in a couple hours.”
“Phew, thanks guys. I thought it was another infection.”
“I’ll turn this IV off for now. The nurse is next door and she’ll be in as soon as she’s done there. I figure that gives the two of you about 15 minutes of alone time before the next interruption.”
Both Duane and his wife were smiling ear to ear with sheepish grins. I have little doubt they thoroughly enjoyed the next 15 minutes. In fact I think I heard a zipper open before I even shut the door to leave. I doubt it was the one to her purse.
“Raj, why don’t you tell his nurse to swap out his IV and place a new one in his other arm, I’ll take care of his orders and morning labs. He’s got the same nurse as Maude; I think I saw her in Maude’s room preparing her for transport to the cath lab.”
“Sure thing.”
The nurse was indeed helping the transport team move Maude into a gurney for transport. She seemed quite frazzled and anxious … the nurse, that is. Maude was still moaning ‘Abigail’ to whoever was listening. I made a mental note to figure out what that meant.
I relayed our orders to the nurse and she agreed. On my way out she hollered after me.
“Hey, on second thought, I’m busy here; can you just start his new IV?” The nurse had the audacity to ask me this even after she’d already agreed to take care of it, not to mention it was her job, for which she got paid over $50 an hour to do.
“Sorry, I was on call last night, and we only start IV’s in emergent situations. I’m sure you can handle it, but if you are unable to start a simple line, please feel free to give me a page after you’ve failed,” I replied with some spice in my voice.
She didn’t respond audibly, but I could swear she mouthed something inappropriate. Nurses were always trying to get out of procedures, and medical students were prime targets to dump the menial tasks onto. But I wasn’t in the mood to deal with any attitude, perhaps it’d have been different if she’d asked me nicely. The last thing I noticed when I left the room was that she was only wearing one glove. Odd.
Fortunately the morning and afternoon went by smoothly, though the nurse did complain to Jason about my lack of enthusiasm for patient care. Jason was very PC in how he dealt with it, telling her he’d talk to me about it. Our talk consisted of us making fun of her cartoon-themed scrubs and how grateful we were we didn’t have to collect urine and stool samples all day.
Sign out rounds, in which the team that was on call quickly presents their patients to the team that is on call for the night, took all of six minutes. Before I knew it, we were exiting the hospital 35 hours after we last entered, only to return in 12 hours.
~~~~
The morning started before I even parked my car. I received a page from Maude’s nurse asking if I wanted to change her heparin, a potent blood thinner, drip. She wasn’t on heparin when I’d left the hospital; something had clearly changed for the worse overnight.
I rushed to the intern to whom I’d signed out the night before to get an update. Apparently Ms. Maude had quite the eventful night. She did not get the cardiac catheterization during the day as planned due to two emergent cases that bumped hers to later in the day. By that time her labs were rechecked her troponin levels had risen. The cardiologists concluded she was having an acute heart attack. While she was undergoing her procedure they found that three of her bypasses had nearly closed off and required stenting. Remarkably, she underwent the procedure without complication.
All five of her major cardiac arteries had already been bypassed surgically, and now all five bypasses had been stented, with one being stented twice. I didn’t even know such a thing was possible.
I later learned that the cardiologists didn’t think it was possible either, but the risk of putting her through open heart surgery was too great so they tried to dodge that bullet with the stents. If the procedure worked it might be a reportable case; that seemed to excite the cardiologists. I can imagine the title of the article, “Living Corpse Undergoes Repeat Stenting and Survives.”
That explained why I was paged about her heparin. She needed it to prevent the new hardware in
her heart from acutely thrombosing, in which a blood clot forms and completely obstructs the now artificially opened arteries.
I swung by her room, the incessant beeps informing me she was still alive. She looked no different from before except now a sandbag was applying pressure on her right groin, the entry site from where they performed her stenting procedure.
“Good morning Doctor,” said Bernard.
I turned to see him in full regalia reading BQ: Butler’s Quarterly. He definitely took his job seriously.
“Morning Alf … uh, Bernard. How has she been?”
“Amazing, actually. Just a few hours after the procedure her energy seemed to have come back and she was asking to eat again. You folks are really magicians in what you can do here.”
“I can’t take credit for it. I’m glad she’s recovering so rapidly.” The only problem was that I failed to see any recovery; in fact if it wasn’t for the monitors informing me she wasn’t dead, I’d have thought her ready for transfer to the morgue.
As I turned to leave I heard her whisper what sounded like, “Abigail.”
I was going to ask Bernard about it, but got distracted when my pager went off. It was the nursing station. Instead of calling, I just walked up and asked for who paged me.
It was a very young nurse, who I wondered if was even old enough to vote. She still had that look of excitement and caring that had not yet been eroded away and transformed into jaded cynicism.
“Hi.” She looked at my nametag, “Rajen, I’m Breanne, I just took over for Duane. Great guy he is, but I wanted to ask you, is it ok to give him something more for his pain?”
“More? He was doing so much better when I left yesterday that we stopped his pain medications. Did anything happen overnight?”
She consulted her little notepad, “Not really. Cynthia changed his IV last afternoon after transferring Ms. Maude to the cath lab for the second time. Duane received all his antibiotics on schedule. He even took a short walk with his wife and daughter.”
“So his kidney pain is back?”
“Oh no, I forgot to tell you. He passed his stone last night; we collected it and sent to the lab for evaluation. The pain is in his arm.”
“Yea, the IV in his right arm infiltrated yesterday, that’s why it was switched over to his other arm. But the pain should have resolved within a couple hours. In fact, he was back to normal when I eyeballed him before leaving.”
“I’m sorry, he’s complaining of pain in his left arm.”
“Fuck. Oh … sorry, you didn’t hear that.” I took off power walking to his room.
Duane was sitting up in bed. A quick glance at his monitors showed that his heart rate was almost 100. Not what I’d expect in a healthy guy like him on the road to recovery. His BP was normal, but his temperature was 99.4°F, a full degree higher than when I’d left yesterday. His respirations were also increased from 12 to 15. I didn’t like what I saw. Something was awry. He was behaving as though his infection was coming back.
“Hi, Duane.”
“Hey, Doc. How you doing?”
“Forget me, what’s going on with you? I heard your arm has been causing you some discomfort?”
“Yeah, it’s not a lot, but it woke me up a couple hours ago and it’s been getting worse since, so I thought I’d ask for some of that pain medication you gave me before, worked really good last time.”
“Is there any pain in your back or elsewhere?”
“No sir, if it wasn’t for this arm thing, I’d say I was back to 90% of normal.”
“Can I take a look at your arm? Where is it bothering you?”
My stomach knotted up, turned cold, and sank before I could even grab some gloves to examine Duane’s arm. I immediately noticed as he raised his left arm that it was swollen, red, and likely warm. There was some erythema and a small amount of discharge around the IV where it penetrated his skin on the dorsal side of his right hand.
His forearm was swollen by about 25%, extending nearly up to his elbow. But the most ominous sign was that I could see tendrils of redness emanating from his IV site and extending about midway up his forearm, like long spider legs, corresponding to his superficial veins.
I gently squeezed his forearm. He cringed in pain. His eyes watered and his arm involuntarily retracted, all from a squeeze so gentle it’d be considered a weak handshake. I bit my tongue to keep from saying anything to scare Duane. It was all I could do to keep my composure and exude confidence.
“Well. Duane, I’ll definitely make sure you get some pain medications ASAP. I’ll also need to culture that discharge and remove your IV. We’ll have to replace it with another one, likely a PICC line. That’s a catheter line that will be located on your other side. Just think of it as a super IV.”
“Sure, Doc. Do you think I’ll be going home soon? You heard the stone came out last night?”
“I think we should wait until the laboratory evaluation of your stone is complete and we know what this discharge on your IV is from.”
“Well, you know where to find me.” He still managed a smile. I’m sure he wouldn’t have smiled if he knew he was about 24 hours from death had this gone unnoticed.
A lot had to be done in the 30 minutes remaining before rounds. I called Jason and gave him a recap on what had transpired. He cut me off and said he’d be right there as he slammed down the phone. I called the pharmacy to get them working on preparing a Vancomycin solution STAT. Meanwhile, I got the culture supplies ready and notified the procedure team of our STAT request for PICC line placement. I took care of all this in 90 seconds flat.
Flesh eating bacteria wasn’t something that allowed for lollygagging.
We entered in Duane’s room together, armed with culture supplies and pain medications. He looked worried when he saw we were garbed in gowns, gloves, and masks.
“Duane, Dr. Bates here behind this mask. Sorry to barge in on you like this, but you have a serious infection in your left arm that is contagious. We’re going to take the cultures that Dr. Raj mentioned and then we’re going to give you some different antibiotics that will make you all better.” Jason attached a syringe to Duane’s IV port and quickly injected the clear liquid. “Here’s some medication for your pain.”
The Toradol afforded Duane some immediate relief.
We set to work culturing the discharge around the IV, the amount of pus had almost doubled since I was last in his room just a few minutes ago.
“You’re starting to worry me guys. Is everything thing ok?”
“It appears you’ve developed a Staph infection in your left arm. The bad news is it’s started to get into your bloodstream. Once we get these cultures we can tailor the therapy to kick this bug’s ass and get you home to your family.”
Twenty minutes later the Vancomycin solution was ready. In that time, Duane’s temperature had escalated to 100.5°F and his arm became even more painful, requiring morphine to alleviate the discomfort.
The PICC team was busy and wouldn’t be able to insert his line for almost 2 hours; thus, we decided to administer the Vancomycin through his infected IV. We didn’t have time to wait. Being aggressive, we set the infusion for 20 minutes instead of the usual 1 hour.
Leaving Duane in a state of morphine induced haze as we rushed off for rounds, both of us worried about his outcome.
“Raj, you realize he’s probably got a fucking MRSA infection? This is not good!”
“Hey, remember yesterday when I asked the nurse to change his IV? I didn’t think anything of it at the time, but when she was transferring Maude, she was only wearing one glove, and no gown. And we know that Maude is colonized with MRSA.”
“SHIT. FUCK. God damn it … that’s where he got it from. He should have been going home today; instead he got one of the worst nosocomial infections out there. And it was introduced right into his blood stream where it’s been reproducing like mad for the past 18 hours. Normally people get this in their lungs or through a skin abscess in which there are so
me barriers before it hits the circulatory system. Those barriers were bypassed in Duane’s case. If you’re religious, pray for him, man.” Jason was getting visibly upset.
“It’s that bad?”
“Well, if he responds to the Vanco over the next 12 hours or so, we might dodge this bullet, but a direct inoculation with MRSA straight into the blood stream can kill a healthy person in less than 36 hours, dude. That’s why we have all these precautions throughout the hospital. That nurse should never have been without a gown or gloves in Maude’s room. All those signs you see for various precautionary measures on patient doors are to prevent this exact scenario.”
“Damn.”
“You go off to rounds, I’m going to be a little late. I’ve got to get him on isolation precautions; luckily he’s already in a negative pressure room. I’ll call the lab to get the Gram stain results before I come over.”
Dr. Miley was very impressed at Maude’s recovery. But she gave us her soapbox about how medical advances are keeping people alive longer and longer, however, quality of life is usually severely diminished, and the costs go through the roof. From a business perspective Dr. Miley said it was atrocious, to keep people alive with such ‘piss poor quality of life.’ She went so far as to claim, in certain instances, prolonging life might even be unethical, just because we have the knowledge, technology, and means does not mandate that we utilize them all on every case. But we must uphold the wishes of the patients and family.
Speaking of family, none of Maude’s grandchildren had bothered to make an appearance since that night in the ER. However, through Josefine and Bernard, they made it clear that everything was to be done for their Grandmother’s survival.
Just as we began to round on Duane, Jason appeared. Miley said we did all the right things. She’d personally notify the infectious diseases committee about this infection since such a definite link was apparent, clearly implying that heads were sure to roll. She didn’t go in to see Duane in an effort to minimize the risk of contaminating others given his active infection.