The man should have been in his prime, but lay in his 30s in his ICU bed when I returned back in the morning. I was on my medical intensive care unit rotation during residency. We were rounding with the attending ICU doctor, describing each patient’s illness and plan, when I heard the patient’s story.
“Mr. Terry is a 35 year old male with a history of alcoholism here with massive blood loss and anemia secondary to a bleeding gastric ulcer,” one of the other residents informed us. We were huddled around in a circle, speaking in hushed voices. We learned that his blood content was about one quarter of what it should have been—Hemoglobin of three —which is usually incompatible for life for longer than a few hours. So when I peered in his room and he was looking up, weak but smiling, I couldn’t believe it and did a double take. He seemed pale and translucent through his dark skin, but seemed happy that his family was nearby. I returned my attention back to the resident who was presenting the patient to us.
“…his heart rate has been hovering around the 160s overnight, but his blood pressure has been holding relatively fine in the 110s/60s with aggressive fluid resuscitation. Exam shows no focal abnormalities except for pale conjunctivae (skin underneath your eyelids) and slow capillary refill, along with his heart rate…”
“How many units of blood did he get overnight?” asked the attending physician, the bald and laid back Dr. Zain. He was only a few years beyond our training.
“That’s just the thing,” responded the resident. “He has declined blood because he is a Jehovah’s Witness.” Long sigh. Then the attending doctor finally responded.
“Then what are we doing for him aside from maintaining his volume status with fluids?”
“Nothing,” added the resident. “We’re checking his blood counts every 12 hours.”
“No, stop checking. His blood will be so thin you’ll only be depleting him further; he needs every last bit. Have you contacted the GI team for upper endoscopy and colonoscopy to find the source of bleeding?” asked Dr. Zain.
“We have,” responded the resident, “but he is too unstable for sedation and they won’t do it. We need to fix his vitals before they can consider it.”
The attending responded, “Have you tried to explain to the patient he will likely die if he doesn’t get blood?”
“Yes,” answered the resident, “But he refuses. Not sure if he’s caving into family pressure or he truly doesn’t want it, but he’s still declining any blood.” Apparently the gentleman was devout enough to refuse blood but not devout enough to avoid eroding a hole in his stomach from the alcohol.
“His code status?” asked Zain.
“Full code,” responded the resident.
“OK, since we can’t give him the only life-saving medicine we have—that is, blood—keep giving him saline for fluid expansion and we’ll continue to monitor him. Then we moved on to the next patient to finish our rounds.
Three days later we returned to Mr. Terry, like we did every day. He was doing worse. His heart rate was 180, he was getting weaker, confused. His liver enzymes were elevated, his kidney function was worse. His organs were in failure–dying slowly–from not getting enough blood.
I was scheduled to be on call that night, so I interrupted the rounds when the resident in charge of him was presenting overnight events.
“So,” I began, “He’s a “FULL CODE” but won’t take blood…So if he codes and his heart goes into V-fib overnight, I am supposed to defibrillate him to re-start it?”
“He’s a full code, so yes,” said Dr. Zain, shrugging his shoulders.
I remarked, “So a couple of units of blood could save this guy, and it would probably cost peanuts, and he could go home stabilized and arrange to get his outpatient endoscopies.”
“Yes,” responded Zain, “But instead, this is day four in the ICU and he is in multi-organ failure.” We finished rounds and attended the Grand rounds (i.e. a a lunchtime lecture attended by doctors), and returned to the ICU. The residents began in earnest to clear the ICU of improved patients and transfer them to the floor, to make room for the new patients that would likely arrive overnight while I was scheduled to be on call. After that they began to assemble a list of patients to sign out to me. We had twelve in the ICU that night. The ICU had room for eight more. At least it would be less than the eleven new patients like the last night I was on call, I thought to myself.
I sat down with each resident as they summarized their patient’s condition and plan in about three sentences each. Then I headed to the cafeteria to get a quick early dinner before the admissions would start. My pager started beeping. I went to the grimy beige phone at the front of the sitting area and dialed back. 75262. I recognized that to be the ER.
“Hey, Amir, it’s Chibuike,” said one of my fellow ER residents. “You’re in the MICU, right? I’ve got one for you!” he said in his cheery Nigerian accent. I listened and jotted some notes. It seemed to be a straightforward old lady with pneumonia; breathing tube and all of the appropriate drugs were started in the ER. I would continue to monitor her overnight. I ran back to the table and shoved a few more fries in my mouth with a loud slurp of soda when the pager went off again.
“Great,” I muttered, “another one?” But it was the MICU paging this time. I called back and the nurse on the line informed me that Mr. Terry was having frequent and prolonged PVCs on his monitor–abnormal heart beats which can mean a sign of heart muscle irritability and impending deadly rhythm. So I hurried upstairs to the MICU and nothing happened. And nothing happened. And nothing happened. More of the electrical abnormalities on the heart rhythm monitor but his heart kept on chugging along.
After putting out some “fires” in the ICU, I proceeded to lay my heavy head down around at 3am—then something happened. The pager went off. I groggily reached for the pager and cleared my throat. “This is Dr. Nagavi,” I said, trying to hide the thickness in my throat.
“You better get here right now your patient is coding!”
A jolt shocked through my chest. I threw the sheet off me and stumbled for my white coat and slipped on my clogs and dashed out of the room and down the short hall to the ICU. It couldn’t have been more than 20 seconds. I looked up at the monitor and his heart was in an unstable rhythm called ventricular fibrillation. That meant his heart was shaking like a buzzer and wasn’t doing any actual productive beating. Finally, as expected. The nurses were already performing chest compressions. “Let’s get some pads on him,” I yelled out. One of the nurses reached for the pads in the bedside cabinet and I asked the other what had happened.
“He was just getting more tachycardic and continued his PVCs until he went into v-fib.”
“OK,” I said, “are we charged at 200 biphasic?’
“Yes.”
“Is everyone clear?” The nurse performing chest compressions stopped and stepped back and everyone nodded and mumbled yes. I pressed the “Shock” button on the defibrillator and his lifeless body jumped about a half foot in the air. “Let’s do that again,” I said, and pressed the charge button again.
“Is everyone clear?”
“Yes,” the nurse said. I pressed the Shock button and again flew pale Mr. Terry in the air.
I ordered the nurses to resume compressions and to push a round of drugs that might revive his heart. We knew full-well that they were exceedingly unlikely to do anything to revive his poor tired heart. We knew why his heart had stopped. It had died slowly over the past four days due to lack of blood nourishing it. No amount of shocking or drugs could stir it back to life. “Let’s call it,” I said, “3:12…hopefully he is with his God now.”
–DrMedicineMan
That’s a powerful story. Great writing, hope to read more soon.
Some cases really stand out for social/personal reasons. This was definitely one case the whole team obviously respected the patient’s wishes, but some of us had difficulty personally coming to terms that the patient was so easily treatable, but we could nothing due to his wishes. And he was otherwise so healthy and young!