Sunday, November 17, 2013
Today, for an unknown reason, I thought about sitting at the bedside of patients. I wasn’t thinking about sitting down in the consultation room when first meeting new patients that crossed my mind, although this is always a good practice. This type of sitting sends the patient the message that you care about them and are willing to spend the time to listen them. Rather, it was sitting at the bedside of a very sick patient; being right there to tend to their needs should an urgent situation or sudden change develop.
That’s the nurse’s job, one may say, and that would be correct. But, sometimes, it’s a doctor who needs to be present. I never was part of such a scenario while in medical school. I did see sick patients as a medical student, but, as a student, was never allowed to truly get involved in their care. My first experience with a really sick patient was during the first month of surgical internship.
One night on call I was called to the ER for a patient who had been stabbed in the upper abdomen. The patient was unstable, with severe tachycardia,hypotension and a stab wound between the xiphoid process of his sternum and his umbilicus. He was whisked away to the OR in short order, where the Chief resident and second year resident spent the better part of the evening battling to keep the patient, Jose Gonzales, alive. He had suffered injuries to the stomach, colon, superior mesenteric artery and vein and duodenum. I wasn’t with them in surgery, but I did receive a call at about one am to come to the ICU. They had just brought Mr. Gonzales from surgery and it was now my job to sit with him and attend to his needs.
I immediately noted the drains coming out of his abdomen, filling up with bright red blood.
“Just transfuse him as needed,” were all the instructions I was given.
I gave him a quick once over. His pupils were nonreactive, his extremities were cold, there was no urine forthcoming from the Foley and three abdominal drains were already filled with blood. His heart rate was 130 and BP 75/35. I pulled up a chair, but didn’t sit. For the next four hours the nurse and I pumped blood and plasma and platelets and cryoprecipitate and more blood into poor Mr. Gonzales. As fast as we pumped it in, it ran out: through the drains, through his mouth, through his endotracheal tube, from everywhere. It was my first encounter with a severe coagulaopathy. He was cold, he had already received massive volumes of transfusions and his blood would not clot.
Finally, shortly after five am, I called the Chief resident and asked this question:
“How long do you want me to do this?”
I explained the situation and told him that Mr. Gonzales had been transfused over two hundred units of blood products and we were still at square one. I knew I was just a lowly intern, but I gave my opinion anyway.
“I think it’s hopeless.”
My Chief agreed and we stopped. Mr, Gonzales died about one hour later, never having regained consciousness or any signs of life.
Although Mr. Gonzales may have been the most desperate and intense bedside vigil I’ve sat through over my many years in practice, there have been many more.
I’ve written about some in my books, Behind the Mask and Under the Drape. Chapters in those books recount my experience with one unnamed patient who had a stormy immediate post op course after an elective aortic aneurysm repair and with Gerald, who experienced one complication after another and required multiple operations, surviving the worst case of ARDS (Adult Respiratory Distress Syndrome) I’ve ever seen.
These examples demonstrate that a sick patient often requires constant vigilance. It has been my practice to stay with my very sick patients in the immediate postoperative period until I’m sure they are stable. Most of the time this is a short vigil, sometimes only a brief visit in the Recovery Room or ICU, while at other times I will stand at the foot of the bed, staring at the monitors and foley bag, waiting and hoping and praying for the blood pressure to rise or the urine to start flowing or the pulse oximeter to begin displaying a true waveform, while trying to decide if I’ve forgotten something important or if something else needs to be done. Such physiologic indicators all tell me the same thing. When they are good it means that the patient is probably perfusing vital organs adequately, but when they are bad then the whole patient is bad.
Dora was such a patient. She was old, almost ninety. She had lived in the county run nursing home for longer than she could recall. She came one evening with a very distended abdomen, obstipation and vomiting. She told me her belly had been hurting for three days. In the course of my evaluation I asked her how old she was.
She answered, “Old enough to know better.”
Her workup suggested a cecal volvulus with perforation. This means that the right side of her colon had become twisted, then blew up like a balloon and finally popped, causing peritonitis, a very serious, life threatening condition. She arrived in surgery at about ten o’clock at night and underwent a right colon resection and ileostomy. This means the right side of her colon was removed and then the end was brought out to the abdominal wall where it would empty into a bag, like a colostomy except involving the small bowel rather than the large bowel. The reason the surgery is done this way is that in a very sick patient healing is of major concern and reconnecting (anastamosing) the two ends of the bowel may not be successful, which could lead to a similar problem all over again.
Surgery finished around midnight. I stayed around in the ICU while she woke up. Her blood pressure hovered in the 70/30 range and her urine output was minimal. I was in and out of the ICU, ordering fluid boluses, anxiously awaited lab reports, watching the Foley bag, trying to wish a few drops of urine into the tubing.
Dora lay still in her bed, although she did open her eyes after a while. Her post op CBC came back and the hemoglobin was higher than it had been pre-operatively, even though she had not been transfused any blood. I checked again. Sure enough, her preop hemoglobin/hematocrit was 11.1/33.3 and now it was 11.6/35.0. These numbers told me two things. First, it was unlikely that she was bleeding and second, that she was hypovolemic. I drew these conclusions because bleeding will cause the hemoglobin level to fall. This fall may not always be immediately apparent, but in a patient like Dora, who had already received large volumes of IV fluids, bleeding of any significance would almost surely cause the hemoglobin level to fall.
The fact that she was hypovolemic can be concluded because the rise in hemoglobin suggests hemoconcentration, a long word which means she had lost fluid from her blood stream or intravascular space into the surrounding tissues, the extravascular space. Think of the blood vessels as a sieve. Fill the sieve with marbles and water. Before pouring the mixture into the sieve the combined volume of marbles and water may be one quart, with 50% of the volume marbles and 50% water. The marble level can be considered to be 50%. But, when you pour the mixture into the sieve, the water leaks out and the marble level becomes 100%. The hematocrit level is akin to the marbles, that is it is the percentage of blood volume made up by red blood cells. The fact that it has gone up suggests that fluid has been lost from the intravascular space (bloodstream) into the extravascular space. The bottom line was that she needed more intravenous fluid to fill up her tank, that is the intravascular space.
I stayed at her bedside for a bit more than two hours, until I was sure she was stable, then disappeared for a few hours of sleep before the next day’s trials began. Dora, after the first few rocky hours, perked up and sailed through her postoperative period like a twenty year old. I was able to do surgery to reverse her ileostomy about three months later.
Two years later I was called to see and elderly lady with a distended abdomen. Small bowel obstruction was suspected. I went to the ER and found a very old patient with a very distended abdomen.
I asked her how old she was and she answered, “Old enough to know better.”
“Dora, how nice to see you again,” I answered. “I wish we could meet under different circumstances sometime, however.”
She agreed. Her X-Rays suggested she had a small bowel obstruction and lab tests were worrisome for ischemic or gangrenous bowel. Therefore, at about eleven o’clock that night she went back to surgery where I lysed adhesions, resected an ugly segment of gangrenous bowel and settled down at her bedside and repeated the events of two and half years before.
Once again, after a suffering through a few hours where her condition was touch and go, she stabilized and made an uneventful recovery. I didn’t have the pleasure of seeing her again and I don’t know at what age she finally passed away, but I hope I gave a few more years of quality life.
I still make it a habit of staying around until my patients are stable after major surgery, particularly when the patient has a life threatening condition like those suffered by Dora and Jose. I don’t seem to have to do it as often as I used to. I credit this to improved intraoperative care by anesthesia, better preoperative preparation and, maybe a bit of fortune which has allowed me to avoid operating on extremely ill patients in the middle of the night.
One question does remain.
Have I ever sat at a patient’s bedside just to sit with them?
What I mean is have I ever had a patient who I had grown close enough to and who was so ill that I wanted to stay with them just out of concern and worry over their condition? Even if there was nothing I could do?
I actually thought about this before I even began writing this article about being at the bedside and then, ironically, it came to the forefront during a recent conversation, which was held in the operating room while removing a nasty appendix. The anesthesiologist and circulating nurse asked me just that question. Apparently the topic had come up during the day and they wanted my input.
I thought for a while and I couldn’t come to a definite answer.
I have had innumerable patients over the years I in whom I have a taken a personal interest in their care. Most often these were very sick ICU patients who needed very close attention as their condition had the potential to rapidly deteriorate. Patients like Albert who was admitted with a Neurosurgical condition, but developed sepsis from an intraabdominal source, requiring emergency surgery, and Doris, a victim of a motor vehicle accident who had a missed colon injury and came to our ICU with severe sepsis, or John who also came to the ICU after inadequate treatment for a perforated colon.
These and so many other patients have received my utmost, careful attention to help them through the most critical parts of what were often very complicated illnesses. I never, however, developed a truly personal relationship with any of these patients. I only saw them in a professional sense during their illness and once or twice after they had recovered. I never went out with them for a drink or to play golf. I guess I have taken the medical school teaching to heart: Maintain a detached concern.
The acute nature of surgical diseases, particularly general surgical conditions, rarely allows the development of a close relationship prior to a surgical intervention. Even those patients with cancer who are scheduled to undergo surgery are seen only once or twice before their operations. I care a great deal about my patients from a professional perspective. But, I see my task as one of helping them through the most serious part of an illness or injury; to get them healthy enough to return to their lives apart from being sick. That is the job of a surgeon.
Perhaps, however, I am missing something?
Sunday, November 10, 2013
“I’m here again, ready for another adventure into Never Never Land,” I announced as I blasted through the door which led to the clinic work station.
“You have some nerve showing up here,” Miss James remarked. “I waited for two hours outside the concert hall. It’s too bad, you missed a great show.” There was a touch of venom in her voice.
“Didn’t you get my message? I’m sure I sent one. Dr. Mercal sent over a sick lady from his office. It was too much for the intern to handle. So I was stuck.”
“No, I didn’t get any message. And then I expected you to at least show up at my apartment afterwards.”
“I didn’t finish with that patient until two am. She turned out to have Legionella and a perforated ulcer. Couldn’t find the surgery attending for two hours. It was Bastrock, of course, probably off with one of his floozies. I wouldn’t mind so much if he was a better surgeon, but his patients always have problems. I wish they would take him off the call roster. I’m sorry. Love. I’ll make it up to you, I promise.”
“And, one more thing. Have you made a decision yet? My lease is up in six weeks, you know. They’re pestering me to renew.”
“You know I wouldn’t stay in that apartment any longer, no matter what. It’s too small and drafty and all the appliances are pretty much on their last legs.”
“True, true, but the price sure is right. Anyway, it’s time to get to work. Caleb, the artist is in two, severe headache.”
“Caleb the artist? Should I know him?”
“Probably not personally, although you probably know his work. He’s a street artist around here; he’s done murals and such on the sides of most of the buildings. I think he’s quite talented. He did this sketch for me while he was waiting.”
Miss James held up a drawing in pencil of our clinic, the light over the door, the neon word “Clinic” in the window along with the red cross symbol for hospital. Our storefront clinic stood out from the buildings around the neighborhood. Even in that sketch there was something that shouted “Come here and be made whole.” I looked forward to meeting this Caleb.
I knocked on the door and went into exam room two and announced my presence in the usual way.
“Good evening, Mr….” I glanced at his chart. The only name was Caleb, no address, no phone number, just a single name.
I stumbled a bit, “Uh, Caleb, I’m Dr. Barnes. What brought you in here today?”
He didn’t reply immediately. The room was darker than usual. The only light was from the X-ray box, which provided a soft illumination. Caleb was facing the far wall, his arm dancing back and forth. I noticed a long pony tail, leather jacket and blue jeans. He ignored me and kept on working, creating a mural on our blank exam room wall. After about a minute he turned around.
“Hello, Dr. Barnes. I’m Caleb. I hope you can help me.”
“I will certainly do my best,” I responded, doing my best to put some concern in my voice, while trying to get a glimpse at the newly created art work which now adorned are previously sparse exam room. Caleb wore dark glasses and a white bandana around his head. He put out his hand which I took, receiving a strong handshake. I glanced down at his fingers which were long and smooth.
“What is the problem you are having?” I asked.
“I’ve had this headache for about two weeks. I assumed it was nothing, but it hasn’t gone away.”
“Where do you feel it most?”
“Right in front, like someone is boring into my brain. The light makes it worse.”
“Have you tried taking anything? Tylenol, Motrin?”
“I’ve taken some expired Ibuprofen which helps a little bit, maybe for about an hour, but then it comes back. It seems better in the mornings when I first get up, but by afternoon I can barely move, it’s so bad sometimes.”
“Any other medical problems? Heart, kidney, abdominal pain, nausea, vomiting, fever, weight loss?”
“Take any medications, any allergies, rash, blurred vision, or any visual changes?”
“No, except the light bothers me.”
“OK, OK. Let me check you. I need to turn on the light.”
“Go ahead, I’ll be OK.”
“Let me check a few things with the lights off first.”
I took out my flashlight and shined it in his eyes. His pupils reacted briskly.
“I’m no Opthamologist and I haven’t done this since fourth year, but I’ll give it a try. I picked up the opthalmoscope and aimed it towards his eyes. I was greeted by the red reflex and was able to get a clear look at his retina.
Still have the old touch. But, what am I looking for?
I could see blood vessels and the optic nerve, but had no idea if any of it was pathologic.
Where’s the CT Scanner when you need it?
“I’m going to turn the lights on now.”
“OK,” he answered, but there was a sense of apprehension, almost doom as I flicked the switch.
Caleb winced and squinted when the light came on, then put his hands to his temples and rubbed them vigorously as if he was trying to vanquish the demons that were pounding on his head.
“I’ll try to be quick,” I assured him as I auscultated, palpated and inspected form head to toe. Everything was normal. I turned the light off as Miss James stuck her head in the room.
“I need you in three. An elderly man just came in, wheezing, blue lips, doesn’t look too good. I put him on a hundred per cent oxygen.”
“Did you call for an ambulance?”
“Started to, but the man said he wouldn’t go to the hospital.”
“I’ll be back in few minutes, Caleb. Just lay here with the lights off, that’ll probably help.”
I glanced at the chart outside exam room three.
“Heinrich Dietrich, ninety three,” I murmured as I quickly knocked and opened the door.
“Good evening, Mr. Dietrich, I’m Dr. Barnes,” I started with my usual bedside banter.
I was greeted by the raspy sound of labored breathing. Mr. Dietrich was sitting upright, his chest heaving as each breath came with herculean effort. His lips were blue, his eyes sunken deep into their sockets. His skin was a grayish yellow with superficial scratches and healing sores. I understood immediately why he didn’t want to go to the hospital.
“Terminal?” I asked.
He nodded in the affirmative.
“What can I do for you?”
He handed me a piece of paper and gestured for me to read it.
“Chaim Fiesel, 3233 Elm, #11”
“Send for him…Please,” he requested, his voice, with a bit of an accent, a barely audible rasp.
“But, I can’t…”
“PLEASE,” this time almost a command.
I looked at the paper and then at my dying patient.
“OK,” I answered.
I left the room and found Miss James at the nurse’s station.
“Anything else waiting?” I asked, sort of nonchalantly.
“Quiet as a mouse. What’s going on in three?”
“Mr. Deitrich has terminal cancer. He’s dying and he knows it. He asked me to find this man, a Chaim Fiesel. He’s supposed to be in an apartment over on Elm, only about five minutes away. I thought, maybe, one of us could run over and fetch him. You know, grant the dying man his last request.”
“I’ll go,” she replied. “that way if anything bad comes in you can take care of it.”
“I hate to let you go by yourself. It may not be safe.”
“I’ll be OK. I know that apartment building. It has a big, mean, watchdog and is pretty secure. It should only take a few minutes, assuming Mr. Fiesel is there and will come with me.”
She was out the door in thirty seconds and I manned the front desk. A woman came in with her child suffering from an earache. They were quickly examined, diagnosed, treated and out the door. I went back to check on Caleb. He was up on a chair, creating a new masterpiece on the wall. All I could make out in the dim light were shades of black, gray and white.
I heard the door open and saw Miss James and a short, bent, elderly man come in. He was dressed in a dark gray suit, wore thick glasses and had a dark gray moustache. His eyes however, were alive, a vibrant blue. I hurried to meet them.
“Dr. Barnes, this is Mr. Fiesel,” she reported as the man put out his hand. I noticed the fingers were bent and twisted.
“Nice to meet you,” I said, taking his hand in mine, giving him a strong greeting. “Did the lovely Miss James explain the situation?”
“She did, she did,” he answered, his voice marked by an Eastern European accent, not much different from Mr. Dietrich’s. “I do not know this Heinrich Dietrich and I do not know why he would ask for me. Perhaps, you can find out more?”
“I’ll go ask,” I replied. “Maybe he’s a long lost relative and wants to leave you some money. He is dying, you know.”
“Yes, yes, Miss James did tell me that.”
I returned to room three. Mr. Dietrich seemed a bit more comfortable.
“Mr. Fiesel is here, but he is wondering why you asked for him. He says he does not know you.”
“It’s true, he does not, but in a way he does. Tell him I must see him. I must tell him I’m sorry.”
“Sorry? Sorry for what,” I had to ask. “I ask you because I know that he will ask me.”
“Sorry for what I did, to him, to his people, during the war at Dachau.”
Now it was clear to me. Mr. Dietrich, with his clearly German accent. Mr. Fiesel, a Jew, also German, perhaps a survivor of one of the camps, all adding up to a search for peace on one’s deathbed.
“I’ll carry your message to him,” I whispered in Mr. Dietrich’s ear.
I hope Fiesel understands.
I went back to the lobby where Mr. Fiesel was waiting and explained the situation. Fiesel’s face turned red as he heard my report.
“I was in Dachau; my whole family, mother father, two sisters, died at Dachau. He may have been their executioner, for all I know,” his voice was growing louder. “I should hear the confession of a murderer, a man who served in a place that took my whole life from me? No, I will not. I cannot.”
“But surely you can find it within yourself to forgive, to give this man some peace before he goes?” Miss James asked.
But Fiesel said nothing. He sat down and stared at his gnarled hands.
“I was a violinist,” he said softly. “I started playing at the age of two. I was the youngest performer ever with the Munich Symphony. But, they took that from me.” His voice started to rise and tremble. “Look at these hands, look at what they did to my hands. First they smashed my violin into a million splinters, then they smashed my hands.”
And I saw his broken hands, reflections of a broken soul. I left him and returned to the dying Dietrich, but first I saw a light coming from exam one. I had almost forgotten about Caleb. I opened the door and saw him sitting up in the chair. And, I saw his finished mural. It was a scene of horror. A death camp surrounded by barbed wire, emaciated bodies withering away and dying while soldiers brandishing rifles watched, laughed and did nothing. The sky was filled with black clouds which matched the blackness of death in that camp. Except, at the end of the mural there was a bit of yellow, a sliver of sunlight which illuminated a corner of the camp where one soldier was stooping down, giving a red apple to a boy. The boy was like the rest of the prison, wasted, dying, dressed in a ragged striped uniform.
I felt a body brush up against me. I turned, expecting to see Miss James, and was a bit surprised to see Mr. Fiesel. Tears were streaming down his face. He looked up at me and then left me and went into exam room three.
I continued to stare at that mural adorning the room’s previously empty wall. It was a masterpiece of death and hope. The blacks and grays, the ominous clouds, the pall of death which hung over that camp were all overshadowed by the small expression of kindness set off to one side. In the midst of all that despair, one glimmer of hope shined through. I turned to offer my critique to Caleb, but he was gone.
Mr. Fiesel emerged from room three shaking his head, but also smiling.
“You see,” I began to comment, “a bit of forgiveness…”
He held up his hand to stop me. Miss James stood at my side to hear his story.
“You don’t understand, Dr. Barnes, neither of you do. This picture, this vision of death with its small ray of light illuminating a solitary act of human decency is not just an abstract artist’s interpretation. All that death, all those guards and barbed wire is exactly as it was. And, that soldier giving the apple to that little boy is real. That little boy is me. Look at the date on the picture. September 13, 1943. I remember that day, it was my birthday. I turned ten on that day. I was so hungry, I thought I wouldn’t live for another minute if I didn’t get something to eat. One of the guards took pity on me. He was about to eat an apple and must have seen me staring at him. He smiled at me and then got up and came to me. He bent over and gave me that apple and, along with it, gave me the hope and will to survive. You see, I was all alone, my family was gone, murdered by the Nazis; all I could hope for was death, disease and despair. But, he gave me hope and I did survive. I never became the musician I should have been, the Nazi’s made sure of that, but I did come to this country and became an art dealer. This picture reminded me that in the midst of hatred and chaos and evil, human kindness still may exist.”
“Is that why you changed your mind? To pass on this human kindness?” I asked.
“Maybe,” he answered, “but there is even more. Look at the image closely, look at the helmet.”
We bent over and stared at the soldier and saw, clearly on the brim of the helmet the letters HD.
“Heinrich Dietrich, the dead man in your exam room is the soldier in this mural. He gave me his apple and a second chance at life and I had to thank him. You know, Dr. Barnes, he lived only two blocks from me for over thirty years but I never realized it and he could never gather the courage to come to me. He told me now he would walk past my art gallery; he did this hundreds of times. He even found the courage to come inside once. He asked for me, but when I came out he had left. When I saw him today I knew him immediately. He asked my forgiveness. He offered no explanations or rationalizations. He knew what was done, what he had done, how he had helped it all happen and how he had done nothing to stop it. Yet through all that evil, there still existed this one tiny shred of humanity.”
We three stared at the painting for a bit longer.
“Where is the artist?” Fiesel asked. “I would like to meet him and thank him personally.”
“Caleb; he must have left. He lives somewhere in this neighborhood, I’m not sure exactly where. I’m sure you’ve seen his work all around. He has created murals, like this one, all over the city.”
“I have seen them, it is truly remarkable work, a wonderful talent, but, perhaps in need of a little guidance,” Fiesel murmured. “I will have to search for him. After all, I am an art dealer.”
He shook my hand and gave Miss James a light peck on her cheek and went away.
It was coming up on seven when he left, almost the end of our shift.
“What should we do with this mural?” I wondered. “I don’t think it is quite right for a medical clinic.”
“Death, despair and hope?” Miss James said out loud. “Isn’t that what we deal in here?”
“Perhaps…but not in that order,” I observed.
“I’ll tell you what,” she replied. “I’ll call up Fiesel later today and ask him if he wants it for his gallery. I’m sure he can figure out a way to get it from here to there.”
I snapped photo of the mural, just in case it was somehow lost, and then we went back to the nursing station and found a final gift from Caleb.
On the desk was another picture, bright and colorful. It was my apartment. Seated on the couch were two people, myself and Miss James. There was an open door which showed the bedroom and the bathroom, with two towels on the rack and two toothbrushes hanging by the sink. Next to the drawing was a note.
“My headache is gone. Thank you so much, Dr. Barnes.”
Miss James and I stared at each other and then, almost simultaneously asked.
“How does he know?”
We didn’t have an answer.