Even though I Walk Through the Valley of the Shadow of Death

Written on July 27, 2009

Psalm 23: 4-5 (NIV) “Even though I walk through the valley of the shadow of death, I will fear no evil, for you are with me; your rod and your staff, they comfort me.”

As I reflect on last week and this past weekend, the predominately theme that resonates in my mind is death. And I keep asking myself, what could I have done differently? Could I have saved this patient? If I had all the resources I needed, would that have made a difference?

Out of 60 patients on the medical wards, six patients died over the past week. Two of them were in their 20s. Surprisingly, the family of these patients seem to be at more peace with the loss than I am. I want to save these patients and sometimes it’s hard for me to face the reality that there’s nothing I can do.

Indulge me as I take you to the bedside to see what I see. I will describe three of the cases. If you have a weak stomach, skip this part and scroll down to the section titled “A Success Story.”

Female Ward

At the beginning of the week, I was called to the bedside of patient who had advanced AIDS and who we were treating for severe anemia. She was thin, but not cachectic. She was covered with her blanket but on her face and head, I saw dark tumor-like lesions on her lips, face, and behind her ears. This was nothing new as I had previously recognized this to be Kaposi’s sarcoma, skin lesions that can arise in patients with advanced AIDS but not commonly seen in US. The reason I was asked to see her prior to rounds is because her skin was sloughing off. I pulled back the blanket and all over her abdomen, back, chest, and legs her skin was literally peeling off to reveal the reddened tissue underneath. It was like she was burned all over her body. She was in no obvious distress from this but was uncomfortable. This was no doubt an ominous sign. After quickly running through a list of differential diagnoses in my head, my top differential diagnosis was a medication side effect. One the medications she desperately needed had likely caused this. We treated with IV fluids to no avail. She died several days later. In talking with other physicians, there was nothing I could have done differently.

Male Ward

During the middle of the week, I was paged by one of the other Internal Medicine attendings to assist with a combative patient. When I arrived at the male ward, I saw a big commotion around one patient’s bed. There were two people restraining an elderly appearing (though only 56) slender male as blood poured from his nose. There was a puddle of blood next to his bed and his gown was covered in it. Apparently, he presented with an altered mental status of unclear etiology and epistaxis (nose bleeding).

His nose had to be packed. But how?! He was bleeding so profusely that merely packing it with gauzes wouldn’t help because he would end up swallowing the blood and later vomiting it. Or worse, the blood would end up in his lungs. But also, if you put a Foley catheter (commonly used to drain urine of the bladder, but has an inflatable balloon on the end) in his nasopharynx (nasal passage as it leads to the throat) as I did on a patient several days prior, you run the risk of him pulling it out and causing more damage. So I decided to pack it. So I ran to the emergency room (ironically called Casualty) to get my necessary supplies — iodine gauzes, adrenaline, and forceps. I ran back to the patient’s bedside and someone was holding pressure over the patient’s nose. Reluctantly, I asked them to remove the pressure so that I could see what I was dealing with. I couldn’t see much more than blood in his nose. I quickly squirted adrenaline (hoping to constrict the bleeding vessel) onto the gauze and shoved it as much of it as it could as far back as I could. This helped temporarily but did not solve the problem. We called the surgeons but, but they agreed with our management and did not want to pursue any further interventions.

So why was this happening? There was no trauma to explain it. Blood tests showed that his various blood cell lines were low. Again, I asked myself why? So we got a blood smear to look at his blood cells under the microscope. Suddenly, the clinical picture became clearer. He had acute leukemia (cancer of the blood). There wasn’t much we could do, but keep him comfortable. He was Muslim, but we still had the Chaplin to meet with him and his family. He died two days later.

ICU

Monday was an on-call night for me and it would prove to be a busy one, primarily because of a very sick patient in the ICU. He was a 23 year old male with hyperthyroidism (overactive thyroid gland) for years who was receiving poor care at home with no management of his thyroid disease. Apparently, his uncle noticed how poorly he was doing and decided to bring him to the hospital. The patient was admitted to the ICU on Sunday by another physician as I was off that day. When I rounded on him Monday morning, I knew that it was going to be a long day and night for me. He was an extremely wasted (thin; literally skin and bones) young male, barely verbally responsive with his eyes protruding out of the orbits (known as proptosis; a sign of advanced hyperthyroidism) and saliva running from the right corner of his mouth. But he was alive. He undoubtedly had thyrotoxicosis. His blood pressure was recorded as 74/50 but I assumed that it was mildly higher given that the adult blood pressure cuff was too large for his child-sized arms and his femoral (groin) pulse was bounding. His heart rate was in the 90s but was recently in the 130s prior to getting Propranolol (medication to decrease heart rate). He had a facemask on for oxygen delivery but there was no machine to tell us accurately what his oxygenation was.

Instinctively, you want to give a patient like this boluses of IV fluids. However, his clinical picture was also confounded by evidence of heart failure on physical exam and chest X-ray. Nonetheless, the physician who admitted him tried bolusing fluids which had caused him to require oxygen because the fluid pooled in his lungs. Eventually, I placed a large bore IV into his external jugular vein so that we could administer pressors (drugs designed to boost the blood pressure). This worked overnight, but overall his prognosis was poor.

Two days later, after bathing him  that afternoon, the nurse noticed that his pupils were fixed and dilated. He died.

A Success Story

Remember the case of the young university student who presented with symptoms that I had a hard time timing into an all encompassing diagnosis? The young lady who I was thinking about either a brain mass or meningitis? Well I treated with antibiotics empirically for bacterial meningitis. Her family was not able to afford to send her to another medical center for a CT scan. Nonetheless, she got better! I have no idea if the antibiotics did anything to help her but she is walking, talking, and ready to go home. It’s at times like these that I am reminded of the motto of the hospital, “We treat. Jesus Heals.”

My spirits remain high. I know that I’m making a difference. Death may come, but so does life.

Psalms 23: 6 (NIV) “Surely goodness and love will follow me all the days of my life, and I will dwell in the house of the Lord forever.”

Peace and blessings,

Darrell

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