Thursday, May 17, 2012

Plugging the holes

There isn't a lot of 'curing' that goes on in internal medicine. 

We don't do surgery, which means that we don't get the satisfaction of curing your early-stage cancer by cutting in out.  We don't deliver babies.  We don't prescribe chemotherapy, so we can't cure cancer.  We don't fix broken bones or reattach limbs.  We can't stop bleeding ulcers or put a stent in your clogged arteries.  We can't retrieve the uber-small clot in your brain and cure your stroke.  And however much I wish I could travel to a 3rd world country and fix a child's cleft palate, it's just never going to happen. 

Nothing we do (at work) is very sexy.  And if you don't do anything sexy, you don't make as much money.  Insurance just doesn't reimburse for brains.

What we are very good at, however, is managing chronic disease.  You know the type of people who can keep an old car running waaaaay longer than it should?   We are the medical equivalent of a crafty mechanic.  Although we can't cure many patients of their ailments, we can keep them alive for much longer than they would ever be expected to live. 

Keeping chronically ill patients alive can isn't as easy as you might think.  Take one of my patients that I'm currently caring for in the hospital.

Mr. K is 67 year old living in a body that is physiologically much closer to 87 than it is 67.  He is a musician by trade.  At age 62 he went on disability - and unlike many of my patients, he actually has a good reason to be on disability.  His problem list looks something like this:

Uncontrolled diabetes
Chronic renal failure on dialysis
Peripheral neuropathy
Coronary artery disease
Previous myocardial infarction
Congestive heart failure

Treating a patient like this is similar to plugging holes in a dike.  Once you have one plugged, it's only a matter of time until another hole starts to leak.  It's usually manageable - at least until you run out of fingers.  And I've just about run out of fingers with Mr. K.

He was brought to the hospital 2 weeks ago by his family because he had severe pain in his tailbone and was acting strange.   Xrays were negative.  He was acting strange because he family had been loading him up with opioids to try and control his pain.  I admitted him to observation with the thought that I'd just hold his pain meds and he'd wake up enough to discharge him home the next day.  He's still in the hospital 2 weeks later.

After his mental status cleared, I was able to get more history.  He tells me he's been falling for the past 3 months.  Hmm.   Why is he falling?  He has double vision.  On exam I see that his eyes don't move back and forth like they should - he has a bilateral cranial nerve palsy (this is very abnormal).  I don't have a good explanation for it, so I consult neurology.  We get a battery of tests and imaging that all come back normal.  Hmm.

Meanwhile, Mr. K is seen by physical therapy for evaluation and refuses to work with them.  Why?  Because his tailbone hurts too much.  Hmm.  But his xrays were negative - shouldn't the pain be getting better by now?  He has to lay flat in bed because any movement causes him pain.  So I order an MRI.  Next day I get a call from the radiologist (never a good sign).  Turns out Mr. K has a completely fractured sacrum - the worst he has ever seen.  It was displaced so much that he couldn't really flex or extend his feet because the broken fragment was pressing on his spinal nerves. 

After consultation with neurosurgery and orthopedics, I was told that there was nothing surgically that could be done to fix this.  It would have to heal on its own.  

The next day, he went into atrial fibrillation, a heart arrhythmia that can cause blood clots in the heart that can then lead to a stroke.  I started him on a blood thinner.

2 days later I get a call from a frantic nurse to come to his bedside stat.  I lift up his sheet and see a huuuuuuuuuge pile of blood clots coming from his rectum.  I dig through the mountain of clots and find bright red blood pouring from his rectum.    Hmm.

I transfer him to the ICU and GI comes to scope him.  They find an arterial bleed in the colon - and there's nothing they can do to stop it.  I call surgery.  They come and say that he is too unstable for surgery and proceed to stuff his rectum with a large wad of packing.  He required six units of blood (thank you anonymous donor), a lot of fluids, and vasopressors to keep his blood pressure up.  Fortunately the bleeding stops and the next day he is out of ICU.

Then I get a call back from the radiologist (even worse sign).  After reviewing his back MRI, he notices that there may be osteomyelitis of his spine (infection in the vertebrae).  I consult infectious disease.  He doesn't know if this is infection and requests a bone biopsy.  I talked to interventional radiology, who politely declined the biopsy as they couldn't reach the area in question with a needle.  

Meanwhile, his rectal packing falls out when he has a bowel movement and he starts to bleed again.  More packing is inserted, and bleeding stops.

By this point he has now been in the hospital for 10 days.  Prior to coming here, he was essentially bedridden for 3 weeks, making it more than one month that he hasn't been out of bed.  He's incredibly weak.  He's malnourished because he has no appetite.  And he can't get out of bed because of the pain in his sacrum.

The next night he spiked a fever to 102 degrees.  I order a urine sample.  The nurse brings me a specimen cup filled with something that resembles thick almond milk.  No thanks, I prefer cow's milk.  And I'm really not hungry or thirsty anymore.  I start him on antibiotics for a UTI.  

Believe it or not he has weathered the storm and is doing well.  Now we're trying to get things arranged for him to go back home.  He kindly refused rehab placement - he just want's to go home.  He understands that if he goes home, he may never get up enough strength to get out of bed on his own.  But he's tired, he tells me, and doesn't have the energy to keep fighting.  He just want's to go home.  I don't blame him.

Fortunately there were enough fingers to plug all the holes this time.  Actually I really shouldn't say that yet, because he's still in the hospital.  There are still plenty of things that can still go wrong.  But assuming that he gets back home, then I've done my job.  His quality of life will be worse, he'll still have pain, but he's alive.  That's what I do.  I keep that old, broken car alive for one more ride.  

Sometimes I wonder if I'm fooling myself by thinking I've done a good job by keeping someone alive.  Personally I'd never want to go through much of what I put my patients through.  But there's something about living with chronic illness that I guess you can't quite understand until you've had to live with it.  Even when faced with death, many chronically ill patients will choose to keep fighting right up until the end.  When death is the alternative option, I suppose living in a nursing home doesn't seem that bad to a lot of people.  

So as long as there are chronically ill people who want to keep fighting, I'll be around.  My job isn't sexy and I'll never be regarded as highly as the subspecialist.  I probably won't cure you of anything, but I'll try my best to keep you alive.  And odds are, I'll be successful.  Your engine may still sputter and smoke, your lights may be dim and your tires may be worn, but I may be able to keep you together long enough to enjoy a few more rides.

Have a great day, and stay tuned.


  1. I've tagged you in a post-feel free to ignore:

  2. I'm a undergrad wanting to go into medicine. I've shadowed a little bit (mainly relatives in surgery), but I got shivers reading this--not because of the...vivid imagery, but the realization that medicine extends beyond the instant gratification that I've come to experience.

    For lack of a better phrase, thank you so fucking much. I aspire to do what you do.

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