Sunday, November 17, 2013

Bedside

                

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?