How We Do Harm (18 page)

As the internal-medicine doctor in charge, I am responsible for organizing the various consulting specialist teams and their access to the patient for treatment.
In this case I am orchestrating a macabre dance, pretending to be saving a life that cannot be saved.
The dance is grandiose.
I tell the intern to call for a cardiac consult.
Ask for an echo to see whether Huzjak has fluid around the heart.
Call pulmonary and get a bronchoscopy—a scope will be threaded through Huzjak’s nose or mouth and down into the lungs to look at the bronchial tubes.
Pulmonary will look for obstructions and run cultures to determine what bug might be causing pneumonia.

Call thoracic surgery, too.
We may need a “pericardial window” from the pericardial space to the peritoneal cavity.
The goal would be to let the pericardial effusion drain from the space surrounding the heart—where it’s interfering with heart function—into the abdomen.

We will definitely need to insert a chest tube and perform a procedure called sclerosis.
We will place an irritating material—talc—in the pleural space to cause inflammation of the membranes.
Inflammation will cause the membranes to stick together, thereby eliminating the pleural space in which fluids could accumulate.

I hope to God we don’t have to perform a lung biopsy to see whether Huzjak has lymphangitic spread of his cancer, if the cancer has gotten into the tissue where air is transferred.
If the answer is affirmative, this will only add another untreatable condition to the roster of untreatable, fatal conditions on this patient’s chart.

First thing, get a CT of his head with and without contrast, if possible, but we have to get one without to clear his head for a lumbar puncture.
(“Clear his head” was our language for making sure it was safe to do the lumbar puncture without danger of causing the patient’s brainstem to herniate, which means to be sucked down the spine.) For an LP, we’ll tap into his spine to collect a sample of cerebrospinal fluid for microbiological and cytological analysis.

An intern asks whether instead of the CT we want to do an eye exam to clear him for the LP.
I say no, we will wait for the CT, even if that delays his workup a day or two.
In the old days, residents were trained to look into the back of the eye with a funduscope, to look for evidence of intracranial pressure before the LP.
We were taught to do that in case we had to do an emergent LP and could not get the patient to the CT quickly.
But an eye exam isn’t as accurate.

If you do an LP on a patient who has a tumor blocking the third ventricle of the brain, you can cause herniation of the brain.
The brain swells and is forced down the top of the spinal canal.
When this happens, the patient goes rigid, takes some deep breaths, and dies.
In medicine, there are only a few sudden deaths, and this is one of them.

I could do it, I was good at it, but I was not going to attempt it with this patient.
It wasn’t worth the personal risk of being wrong.
Huzjak is going to die, and if he dies during or after the LP, it will be attributed to the LP.
I don’t want to be blamed for a death that is coming with or without the LP.

I push the intern to get these tests in quickly so she can get to her other patients, put them to bed, and get home to get some rest.
Huzjak is one of about thirty patients for whom I am responsible.
(As a resident, I am supervising two interns, each of whom has to take care of six to seventeen patients.) Huzjak is sucking up time, which means less attention to go around.
As a result, hospital stays are prolonged.
Patients can get sick from bugs they pick up in hospitals.
They have to be treated, and some do poorly.
These, too, are costs, and they have to be counted.

A patient’s wife is pissed.
We didn’t answer all her questions about her husband’s condition.
She looks like a person who is used to getting her way, and in this case her sense of entitlement is justified.

Also, some poor guy didn’t get the full attention his pain deserves, again because we were busy with Huzjak, the patient who cannot benefit from our care.

I pray for my patients, and that morning I pray that Huzjak is not really aware of what we are about to do to him.

Chapter 11

God Is Calling

AFTER THE LAB TESTS
come back, we move on to thoracentesis.
We do this for two reasons: to diagnose why the fluid has accumulated in Huzjak’s chest to begin with, whether the effusion is caused by malignancy or an infection, and to treat the problem by draining the accumulated fluid, thereby giving the lungs the space they need to expand.
Two students hold Huzjak in place as we seat him at the side of the bed.
He flops forward with his arms over a dinner-tray stand (dinner-tray stands are for this procedure—you can adjust the height of the stand to each patient).
Usually, a patient doesn’t need to be held in place.
Alas, Huzjak is unable to take directions and lacks control of his faculties.

Beth, the intern, percusses Huzjak’s back with her fingers to find the area where the fluid is.
She places the middle finger of one hand over the patient’s back, then taps on it with three fingers of the other hand.
When you get a hollow sound, you are over an area unencumbered by fluid.
When you get a dull sound, you are over an effusion.
(I use the same method to find two-by-fours beneath drywall when I do home repair projects.) Beth marks the dull-sounding area with a permanent marker.
I follow behind her and confirm the spot.
I ask her to feel the ribs and let me know where the needle should go in.

After that, Beth paints a six-inch, yellow rectangle with a topical antiseptic to create a sterile field, killing the bacteria on the skin before we start sticking needles into the pleural cavity.
She stretches on a pair of surgical gloves.
I open the thoracentesis kit.
She takes the sterile paper drape, removes some paper covering sticky tape-like strips, and places the sheet over Huzjak’s back.

A med student hands Beth a large sheet of paper with a three-inch-square hole.
The area Beth had crisscrossed with a marker peeks through the hole in the sheet.
Good sheet placement.
Now comes the tricky part, something that scares interns: you have to stick the needle directly above the rib, as close to the top of the rib as you can.
Go a bit higher and you will hit a nerve, an artery, and a vein.

Beth puts her instruments in order, checking them.
She breaks a glass ampoule and sucks up lidocaine, a topical anaesthetic, into a syringe.
She places a small, 23-gauge needle on the syringe and looks to me for approval.

I prefer hitting the bone with the needle first.
Then I raise the needle a tad, still keeping the tip in the skin, to clear the bone.
First, you squeeze out a squirt of lidocaine, creating a small bleb in the skin, something akin to a mosquito sting.
Then you pull back the needle, to make sure you aren’t aspirating blood.
If you don’t see blood, you keep pushing forward.
You keep moving, paving the way with lidocaine, and you do this until you start aspirating straw-colored fluid.

I give her the go-ahead.
She sticks the thin needle into Huzjak’s skin at the site of the mark.
He screams, but doesn’t move.
She is visibly upset.
I reassure her, and she finishes injecting the numbing medicine under the skin.

Beth knows the procedure well and executes it perfectly.
She presses into the back slowly and lets me know when she feels the needle passing just over the top of the rib.
Huzjak screams again, this time even louder.

When we see the fluid, Beth pulls out the 23-gauge needle and inserts a larger, 16-gauge needle into the numbed area.
She pulls back the piston and the syringe fills with fluid.
Even in this situation, it’s satisfying to see procedures work out exactly as they should.

She fills the syringe, turns off a valve at the top of the needle, unscrews the syringe, and hands it to the med students, whose job is to take the fluid to the labs that will analyze the chemistry, cytology, and cell count.
She places a larger syringe on the needle and slowly pulls up the fluid, 100 cc of it.
Now we are just draining the fluids.
We repeat this operation fifteen times, draining a liter and a half.
This takes about forty minutes.
If you do it too fast, the patient will lose blood pressure.

These invasive procedures are just the beginning.
We will be back, almost certainly.
We might be performing sclerosis, to eliminate the pleural cavity, or we might be putting in the chest tube.

Beth and I prepare tubes of the fluid for the labs.
They will analyze it for chemistries, gram stain it for bacteria, and culture it for bacteria and tuberculosis.
The big bag—over a liter—goes to cytology.
They will spin it down and look for sediment, which I am sure has cancer in it.

I remind Beth to order a portable chest X-ray to make sure that we didn’t poke a hole in the lung.
An air leak can cause a pneumothorax.
In a severe case, a collapsed lung can be deadly.

*

DAVE
Johnson, the pulmonary fellow, comes by.
He has a reputation for being a “have scope, will travel” kind of guy—he will scope anything for the weakest of reasons.
He
wants
to bronch poor Huzjak.
He is so eager to do the procedure, he doesn’t even bother to examine the patient.

I am pissed at his enthusiasm, but part of “doing everything” is to see if the bronchus is obstructed and needs to be opened up with radiation or by burning a hole with the hospital’s new laser.

More than anything, I need a brushing of the bronchial tree for culture.
Maybe we can find a bacterial infection we can treat.
I doubt that will wake Huzjak up and improve his quality of life, but there is a chance.
Alternatively, the bronch findings could be so bad that they will make his family do the right thing.

Wild Dave schedules the scoping for first thing the next morning.
I have to downright argue with him to wait till the workup is complete.
I want to wait in part because I want to see what the CT shows and in part because I keep hoping that the younger Huzjaks will come to their senses and realize that their father doesn’t need to be bronched.

The procedure Dave is wild about has two potential downsides.
The scope will obstruct Huzjak’s already compromised oxygenation, which could cause arrhythmia or even a heart attack.
If either occurs, we will have to put him on a ventilator.
And if the scope punctures one of the many funguslike tumors that are surely surrounding Huzjak’s bronchial tubes, he will likely drown in his own blood.

Wild Dave relents, agreeing to hold off for a day or so, until I get a CT of the chest.

*

NEXT,
I have to deal with the thoracic surgery resident, Steve Edge.
He is much more reasonable.
At first he is pissed at me for calling and bothering them with a request to work on someone who clearly needs a priest to give him last rites instead of a thoracic surgeon to crack his chest open.
I am delighted that he is pissed.
It is a pleasure to find a surgeon with good clinical judgment, a surgeon not eager to cut.
Once he reads the chart and understands the situation, he offers to talk to the family and hang black crepe.

I tell him that many of us have already tried.

A CT of Huzjak’s head had been ordered by the ER.
Now, only a day later, the radiologist has read it.
There is no evidence of metastases on the noncontrasted scan.
The third ventricle is open okay to do an LP.
We are unable to get a CT with contrast.
We cannot exclude a brain met without contrast, but I am not thrilled with giving the poor guy contrast anyway.
His serum creatinine of 1.7 tells me that he is dry and needs watering.
Under these conditions, contrast can lead to renal failure.
We’ll get the contrast test later.

I work with a third-year medical student and give Huzjak an LP.
Yet Huzjak continues to respond to one thing only: pain.
He opens his eyes, grunts, and screams, when presented with noxious stimuli.
The third-year is uncomfortable with having to cause pain for no reason.
He says he feels like this human is being treated like a lab animal.

To this day, I think about poor Huzjak screaming and moaning as we position him and stick the needles in his back.
I wonder whether this and similar experiences as a doc gave me post-traumatic stress disorder for which I have never been treated.
I mean this literally.
We cause pain to our patients, and often they die no matter what we do.
One proven way to avoid feelings of loss is to dull all feelings, to detach.
If you become emotionally involved, you become ineffective.
And if you don’t become friendly with your patients, it’s a whole lot easier when they die.

Many of my colleagues have learned to ward off PTSD by becoming assholes.
This coping mechanism wasn’t right for me, but I have developed others.
To distract myself from the clinic, I venture into politics and highly technical areas, such as cancer screening.
Numbers signifying “survival” and “cause-specific mortality” are so much easier to accept than the death and suffering they codify.

*

I
review Huzjak’s lab tests, looking for an easy root cause for his being obtunded.
I review his metabolites, I look at his thyroid function, I look at all the blood gases.
I look at the CT scan of his head.

We would later perform a CT of the head with contrast and a CT of the chest.
His spinal-fluid cytology comes back negative for tumor.
At first I am relieved that he doesn’t have evidence of carcinomatous meningitis, tumor cells scattered all over his brain, and then I realize that the standard for ruling out carcinomatous meningitis is three negative LPs.
Should we do two more of these?

Around 5:00 p.m., Beth, Claren, and I see Huzjak.
Claren hears our verbal report and thumbs through the chart.
As he examines Huzjak, the daughter walks in.
Claren greets her and suggests that we all talk.

Beth quickly finds a room down the hall for some privacy.
Claren is masterful and polite as he explains that Huzjak is dying of his lung cancer, and the process can be long.
He describes what we are doing and suggests that it might be more appropriate to focus our efforts on keeping him comfortable.
He notes that the only response we have gotten from him is expressions of pain when we move him or subject him to procedures.