Seven Patients

by Atul Kumar

  As the water cleansed away the salty residues of his night sweats, J looked down at his abdomen and realized it was redder than yesterday and a whitish discharge was present in the lower right quadrant. His abdomen also seemed to be bloated and quite tense when he pressed his finger against it.

  The coke certainly augmented his ability to deny that anything serious was occurring; deciding that it was just gas from what he ate yesterday, he donned his attire.

  Bending down to put on his slacks was wrought with agony. His stomach felt like it was going to explode and his belt required two fewer notches than normal. Promptly deciding the best remedy was more inhaled confidence, J helped himself to another line and rushed out the door, but not before ensuring the contents of his valise were in exact order.

  Arriving at his car, he found it covered with trash and debris all over his hood and some thick brown syrup streaked his windshield. Apparently, somebody didn’t realize the trash canister was now in the alley and used his car to rid themselves of their refuse.

  J made a mental note to get the lock on the door changed, cursing as he picked the trash off his baby. The wipers made easy work of the syrup, or whatever the hell it was. The fact that the trash contained baby diapers was not encouraging.

  Driving today was not as easy as yesterday. His abdomen throbbed at every bump on the road, and that was with his upgraded suspension set to luxury, where one could traverse a speed bump without noticing.

  At a stop light J felt something damp on his stomach. Looking down he realized that he had soaked through part of his shirt. His face felt hot and his eyelids burned when he closed his eyes. J kept driving, but soon he became nauseated and almost vomited. Only fear of ruining his leather upholstery prevented the bilious fluid from escaping his mouth. Fortitude won and he held it back, burning on its way back to his stomach.

  Immediately after arriving in Beverly Hills, J knew he had to do something. Inhaling another dollop of coke, the obvious answer was that he should look for real estate that he could buy to move out of his shithole. He likely got some stomach bug from one of his skanky neighbors.

  While exiting his sedan and retrieving his laptop from the trunk, J realized his shirt was soaked through in the lower right quadrant with a milky white fluid. It couldn’t just be from sweat. He stripped off his shirt and redressed himself from his valise, donning a new piece with those stupid cuffs his clients favored.

  Tightening his buckle sent a pain so severe though his body he involuntarily convulsed and dropped to his knees. This time the bile exited and splattered all over the sidewalk. His vision was double and he was shaking as though plunged in a freezer.

  All J could do was pull out his cell phone and dial emergency before another wave of pain took hold of him so violently that all his nerve endings fired at once and sent him flat on his back. His head hit the ground with a dull thud, and blood began to flow freely from his scalp. But J didn’t notice, having already lost consciousness moments before.

  ~~~~

  The hot tub’s temperature was perfect and the jets just right. Even better was the ice cold beer that never seemed to end. The only annoyance was the bloody ambulances or fire trucks screaming by every five minutes, seemingly louder every time. Great! As if on cue, another one went screaming by. What the hell! It didn’t just pass by, it got louder and louder and then just stayed; it must be right outside my apartment.

  Damn it! It was my alarm clock and I was a good four snoozes past my 4:30 a.m. wake up time. I had to forego my shower this morning just to get my ass to the ICU in time to figure out what happened with my patients overnight.

  I hoped a couple died; that way I might be able to get my work done on time without having to admit I was late.

  Switching rotations and giving up my easy radiology month for another month of ICU was not the most brilliant move on my part. At this point I’m not even sure why I did it. I’m sure some deep-seeded part of my id or ego, or whichever part is responsible for prudent decision making, thought it’d be better to take on another “real” rotation so I could be a better doctor, instead of having hours of free time to go drinking in some of L.A.’s hottest bars.

  Seven straight days on ICU, from 5:30 a.m. to about 9:00 p.m. and what did I have to look forward to? Another six days of the same before this rotation finally ended.

  “Hey, Raj! Dude, did you have a rough call last night?” Asked the amazingly effervescent and always smiling Jenny as we passed each other in the hallway. Thank God she was going in the other direction and I didn’t have to endure any further questioning about how my night in bed at home was nor explain why I still looked like crap.

  “Something like that.” I muttered in reply and I half walked/half ran down the endless corridor to the infamous ICU looming ahead with its two sets of behemoth doors and myriad of precautions, clearly letting all know something wicked this way comes.

  Rushing to the census board I was instantly greeted with bad news; there was only one death overnight and it wasn’t one of mine. All six of my patients still occupied ICU beds.

  Grabbing a stack of progress note paper I quickly began rummaging through labs and overnight events, trying frantically to mentally recreate what happened overnight so I could present it cohesively to the team. After that, I’d be asked questions I couldn’t answer, and we’d come up with a plan for the day. Same old.

  It’d be great if I had anything remotely interesting; instead I had four patients whose average age was 96, all circling the drain. The fifth was an uninsured, non-English speaking AIDS bomb who was so infected with every pathogen known to humanity that he had a negative pressure isolation room requiring full blood, fluid, and respiratory precautions every time anybody went into the room.

  To round out my docket, I had a 22 year-old attractive Princeton graduate who was applying to medical school but was hit by a drunk driver while she was walking to her car after her volunteer shift at the hospital. Now she lay on a ventilator with a tracheostomy, completely paralyzed, unresponsive, with a shaved head from the placement of her ventricular shunt last week. The pain I saw every time I looked at her was gut wrenching; it was such a sad story, and I had already seen too many of such.

  Somehow I managed to finish all my notes and infuse myself with a dozen ounces of Pepsi before rounds began.

  “Since we’re on call today, I’ll try to make rounds brief so we can handle the new admissions. Hopefully we get a few during the day today so the medical students can be actively involved.” These were the first words uttered from Dr. Clyde, our ICU attending.

  Damn it, I’d forgotten it was our call day. Things just kept getting better.

  Clyde was one of those remnants from days long gone. He was the consummate physician, tall with grayed hair, always punctual with a starched white coat, slacks, tie, stethoscope, and a highly professional demeanor. His wrinkles didn’t make him look old, only more distinguished. And his eyes held that kind of warmth which put families at ease even when he was delivering catastrophic news.

  “Dr. Mok, why don’t you present Mr. Martinez to the team?” It wasn’t a question, though; being the Director of the ICU, Dr. Clyde always got what he wanted. But it was nice of him to ask.

  Great, I was the first to present, and I was the only one in scrubs. Everybody else was well dressed, while my coat was wrinkled with a few odd stains on it. I was so over being in the ICU for two months straight. Shuffling through my notes, I got started.

  “I’ll just briefly recap for the team, as we’re all well acquainted with Mr. Martinez. He’s a 42 year old male with AIDS who was admitted to the ICU 27 days ago. He has a viral load of 250K, CD4 count of three, an ANC of 15, profound anemia, cryptococcal meningitis, CMV retinitis, oral thrush, Pneumocystis jirovecii pneumonia, a multi-drug resistant strain of Tuberculosis, Kaposi’s Sarcoma on his chest and back, microsporidial diarrhea, severe cachexia from AIDS wasting syndrome, and florid onychomycosis.” Wow, I managed that all in one breath and sounded so
mewhat organized.

  “He continues to do poorly, failing to thrive and barely communicating. His PICC line was recently infected and required replacement by radiology due to poor vascular access. He cannot take in oral food or liquids; thus, he is being given total parenteral nutrition, this being day number 22. He has stage 2 decubitis ulcers over his sacrum.

  “Overnight there were no acute events. His oxygen saturation is only running at 89% even on 12L/minute of oxygen with a non-rebreather mask. It appears as though he will likely require intubation and artificial ventilation soon. His hematocrit remains at 18 despite nearly daily blood transfusions.

  “Ophthalmology reports that he has lost almost all vision in his right eye, but they are starting to make progress on his left eye with twice weekly intravitreal injections. He might be able to retain some useful vision if he stabilizes.

  “Renal reports that poor perfusion and toxic medications have overwhelmed his kidneys and he will likely begin dialysis in the next couple days. Other services should provide their recommendations later today.”

  Phew! I survived that presentation. I wiped the sweat off my brow preparing to be slaughtered with questions. Instead everybody just stared at me contentedly.

  “Well done, Dr. Mok. What is your plan for Mr. Martinez today?” Clyde actually inflected his statement, indicating it was a question. He only did that when he was impressed or teaching somebody a lesson by being rhetorical. I hoped it was the former.

  “Well, I think we should essentially maintain the status quo and continue with all his current medications despite the nephrotoxicity. We should plan to intubate him in the next day or two before he completely crashes. We should also discuss his situation with the family. Given his grave prognosis we should strongly pursue a possible DNR order, if the family is reasonable and willing.”

  “Any other information, or should we proceed with Dr. Mok’s plan?”

  The chief resident, Jack, piped up, “I spoke with the family yesterday and they wish to continue at 100% efforts for as long as it takes. They still seem to hope that he might recover and one day return home and possibly go back to work. They got quite upset when I insinuated neither of those were reasonable, or even feasible, goals.”

  “And so it shall be; he might occupy that room for many weeks before something overcomes the miracles of modern medicine.” All the while Clyde was shaking his head, clearly in disagreement of the family’s wishes. “Dr. Mok, please see that we continue to do all we can. Ok, let’s move on.”

  And so went rounding for the next four hours.

  Alas, it was finally time to get some food. Just as we regrouped to grab a team lunch, the Chief’s pager went off, followed by a team groan.

  “Hey Rajen, why don’t you take this hit. It’s some dude found down, next to his car. He’s in the ER, bed 3. Call me once you get a handle on the situation,” instructed Jack as he returned from answering the page.

  “You got it, boss, hopefully it’s something interesting.” I replied with feigned enthusiasm, all the while cussing out the son of a bitch in my head for no good reason other than it made me feel better. Nobody had replaced Cindy, who was still on medical leave; and the work seemed to have increased with a commensurate decrease in morale.

  Forgoing food, I headed straight to the ER, soon to learn that interesting doesn’t always mean good.

  ~~~~

  Walking into the ER, I was happy to see that it was relatively quiet except for some commotion in one of the trauma bays. Heading in that direction, I bumped into Dr. Peters.

  “Rajen, good to see you. I’m guessing you’re up here for bed 3, right? I’m glad it’s you; I’m a bit tied up with this trauma. We might have to do a cardiac massage in a minute here. Please go ahead and get things started. Just order whatever you think is appropriate, here’s my badge. You can use it to access the computer for the orders and …”

  “Dr. Peters, we need you now!”

  She tossed me her badge and rushed into the ruckus as the wall of people opened to let her in. All I glimpsed was a squirt of blood that hit the ceiling before the gap was closed and the team returned to their frenzied work.

  It was quite trusting of Peters to give me her badge. Hopefully it meant she liked my performance over the past year. I felt quite empowered knowing I could order any test in the whole hospital’s armamentarium for this guy, from simple blood tests to highly specialized MRI scans. My mood lifting, I searched for his chart to get started.

  The chart didn’t contain much information beyond the paramedics’ report. A 34 year-old Caucasian male was found down next to his car, I found it odd that the report mentioned the car next to which he was found down, a heavily modified black Mercedes Benz CLS 63 AMG. I figured they’d be busier, I don’t know, say saving his life and trying to get him here, instead of taking note of his car.

  I shuffled through the chart and was able to learn that his name was James Downs, and apparently he was in the process of dialing 911 for assistance when he lost consciousness not far from here in one of the nicer neighborhoods. EMS was able to use GPS to locate him because his phone remained connected with their switchboard despite his consciousness being disconnected.

  James was profoundly hypotensive on scene with a blood pressure of 64/42, heart rate of 148, and short, rapid breaths at 40/minute. He had sustained a scalp laceration which was oozing heavily, and he was very febrile at 103.9°F. Nothing else noteworthy was found during the primary survey.

  The paramedics placed him in a rigid cervical collar, placed an occlusive pressure dressing over his scalp laceration, started 2 large bore IV lines though which he got a liter of fluid on scene and another en route, and placed him on oxygen via face mask. They closed his car’s trunk, reporting it was empty, and brought his briefcase with him. The contents remained unknown because it was locked. The car was also locked, and they didn’t have time to search for a key.

  Not bad given their total time on scene was just over four minutes. Travel time to the hospital added another five minutes. Since arriving here he had a quick examination by Dr. Peters, if you can call it an exam. She cleared his C-spine, allowing his collar to be removed, and, well, that’s all.

  Guess the rest was up to me.

  I walked up to James’ bed and found what I’d expected, a very fit and well-dressed man who was barely conscious, with a couple empty bags of saline and a head dressing that was beginning to soak through with blood. Laying on a gurney with the head elevated a bit, he had some blood splatter on his shirt, and his face was glistening with sweat.

  Something wasn’t quite right; healthy guys don’t just pass out for no reason. I scanned him again from head to toe while standing at the foot of his gurney, carefully looking for anything amiss.

  This time I noticed bags under his eyes indicating he might be fatigued, not uncommon for a hardworking professional. There was some whitish debris on his face and nose, either dust from his face-plant on the roadside or cocaine; the latter was not uncommon amongst the rich yuppie crowd seen here.

  His shirt was nearly soaked through from his copious perspiration. Looking at it more closely is when I noticed there was an odd bulge underneath the lower right portion of his shirt. His lower extremities appeared fine except for some tears in his slacks by his knees, presumably from his fall.

  While I did have Dr. Peters’ badge, I did not have her presence or garner any interest from the nearby staff to assist me with my evaluation of James. Besides, everybody was still busy helping out with the exsanguinating trauma case.

  “James, can you hear me?” I asked. He didn’t respond. I tried again louder, still no response. I tried yet again almost yelling.

  “Yes, I can hear you! But my name ain’t James,” came a smart aleck response from the bed next door.

  Ignoring the comment, I donned some gloves and gently shook James’ shoulder. No response. A firm sternal rub didn’t arouse him either. Given that no ribs cracked, I pushed even harder, digging my kn
uckles into his flesh while I rubbed forcefully up and down on the center of his chest. He grunted and tried to brush away my hand. His eyelids fluttered for a second and he turned his head to the side and was again unresponsive.

  Well, at least I established he was alive and responded to pain.

  I hooked James to a blood pressure cuff and oxygen sensor. While the cuff was inflating I checked his temperature. Shit, he was burning up, 104.1°F! At least his BP was a little better at 90/64, his heart was a healthy 124 beats/minute, and his oxygen saturation was 99% on 10L oxygen.

  I bolused him another liter of normal saline and took a step back to decide what to do next. He must have an infection somewhere giving him this incredible fever. If he was sweating this much and working long hours, he could easily have passed out from hypovolemia.

  I’m guessing the powder on his face was from cocaine. The problem (besides the fact that it was cocaine) was that it’s one of the most powerful stimulants known to man; thus, whatever was making James so somnolent had to be pretty damn severe. I had better hurry the hell up and figure out this mystery before Peters realizes the idiot I am, or James dies.

  Interesting how my motivation was to impress Peters, above all else. Sometime over the year I’d transformed into caring more for my evaluations than my patients, but in either case the goal was saving lives. Snapping back to reality instead of introspection, I decided I needed to draw some blood for some basic labs and cultures.

  I also wanted to check him for any illicit substances. There were two ways to do that: either by blood or urine. Given he wasn’t awake enough to give me a voluntary piss sample, and there wasn’t a nurse around to catheterize him, I’d send off for the blood version of that test. Sure I could catheterize him myself, but shoving a tube into a sleeping dude’s penis, through his entire urethra, and all the way to his bladder wasn’t something I was keen on doing.

  Grabbing blood Vacutainers and culture vials I got ready to draw blood, when I realized I knew nothing about this guy. What if he had AIDS, Hepatitis C, Kuru, or some other strange infection?