Damn you, sneaky patients

A particularly sick patient was recently transferred from the Intensive Care Unit for care by my team on one of the medical floors. He was the prototypical extremely nice guy who had been blindsided by one terrible medical problem after another through no fault of his own. "Bad things happen to good people," is an adage often repeated by cynical residents because, well, that's just the way things seem to go for many of the nicest patients.

Late one evening as I was getting ready to leave, his nurse paged me to tell me his blood pressure was 76/48. I had briefly examined & interviewed the patient in the early morning and knew he had required large fluid boluses for hypotension that afternoon, but I wasn't entirely familiar with his case as my senior resident had cared for him while I attended a training session. When my resident left for the day he told me I should have a low threshold for transferring the patient back to the ICU.

His nurse told me that his blood pressure had only transiently risen after the fluid boluses. When I visited his bedside I was not reassured -- his blood pressure was still low, his breathing was labored, and his abnormal heart rhythm & rapid heart rate continued despite two days of anti-arrhythmic medication delivered by IV drip. To complicate matters, his only IV access was a small peripheral line in his hand. A surgical team had tried and failed to obtain central venous access in his internal jugular vein to allow rapid delivery of large amounts of fluid or medication earlier that day. They had opted to not place a "dirty line" in a groin vein because he had not seemed unstable enough to merit the infection risk.

My patient told me his systolic blood pressure (the top number that reflects blood pressure when the left ventricle of the heart squeezes blood into the body's arterial system) normally runs in the 140s. So, loosely speaking, his body was running on about half of his normal blood pressure. He complained of continued weakness but surprisingly denied any lightheadedness, shortness of breath, heart palpitations, chest pain, or nausea.

Did I need to send him back to the ICU? I considered why he might be hypotensive even after extensive IV fluid rehydration (and no kidney function to filter his blood and make urine). Was too much fluid removed in dialysis earlier that day? Was his heart rate too rapid to allow adequate filling of his heart? This would result in a lower cardiac output and thus a lower blood pressure. Or could it be that his lung infection had worsened despite broadened antibiotic therapy and was now overwhelming his system? Hypotension and rapid heart rate together can be hallmarks of systemic infection, and he had had a fever earlier that afternoon. Worsened infection may also have precipitated his arrhythmia.

Finally, I was concerned about his rapid and labored breathing. Was it caused by his low blood pressure, potentially worsened pneumonia, or possibly a blood clot that had broken off from one of the deep veins in his legs and traveled to blood vessels in his lungs? His current condition and medical history included no fewer than three risk factors for blood clot formation. At the very least, his respiratory muscles could become fatigued in the setting of such rapid and labored breathing, which would require artificial ventilation for respiratory failure. I explained my concerns to the patient and drew a sample of blood from his radial artery to check oxygenation and gas exchange by his lungs, which themselves sounded fairly clear.

His blood gas was fine. Truthfully, there wasn't much action left to take after considering the differential diagnosis and all that had been done before. He had already been given broad antibiotic coverage for infection and was on a powerful anti-arrhythmic drug. I awaited results of new blood cultures drawn earlier that day. With all this in mind, I ordered an ultrasound of the deep veins in his lower extremities to check for a blood clot and gave him another bolus of IV fluid. His arrhythmia remained but his blood pressure rose enough that I couldn't justify transfer to the ICU, a unit reserved for people who require closer observation than a nurse caring for up to six patients at a time can reasonably provide. I implored the patient to let his nurse know immediately if he felt any of the symptoms I had inquired about or worse in any way at all. He made an ok sign with his thumb and forefinger. I hoped the mild increase in his blood pressure would hold, and I discussed the plan with his nurse and signed out his case in detail to the covering team.

I saw him first thing on Saturday morning (the last day of my rotation on the floor!) when I returned to the hospital. He looked relatively great. His breathing was comfortable, his blood pressure closer to his baseline, and while his arrhythmia remained, his heart rate wasn't quite so rapid. I expressed relief that his condition had improved and we discussed the likely causes for his hypotension the night before. Then he surprised me by saying, "You know, a lot of doctors come in here and they're just doing their job. But it's obvious you really care about my well-being, and that means a lot to me."

As some of you know, my general thoughts about my job are conflicted at best. Health care delivery is fraught with so many frustrating issues that being a physician is often unpalatable. I also never wanted to be a doctor who mainly doles out prescription medication to chronically ill patients because I don't think a steady diet of pills alone is likely to result in health even if it can absolutely stave off some of the worst sequelae of chronic disease. I maintain a great attitude at work without any conscious effort, which probably means I like my job as much as any intern could. I also get to work with some truly wonderful people to balance the few patients who do things like disconnect the blood transfusion a kind person donated when I refuse to give them IV Dilaudid (a narcotic pain medication).

But when I reflect on my path during my invariably late evening drive home from the hospital, my thoughts drift to other job possibilities, other lives I could have chosen, and other lives I might still choose. I think about moving to the country, having a garden, preparing food from whole food ingredients, teaching little hands to cook, and having time to do all of this. I chose to attend medical school because I adore studying the human body's intricacies -- through both reading and experience -- and then finding practical implications of what I learn to help others maintain or regain their health and quality of life. I also love meeting new people and hearing their stories.

Somehow the practice of medicine doesn't deliver enough of either of these two things. My focus is necessarily more on appropriate documentation than on spending significant time with patients or even on learning. While I have certainly learned a great deal through my immersion in the practice of medicine, I rarely find time to read enough to make connections with what I learn in daily life. So in the end, my current job doesn't give me much of what I love most and I wonder if the career I've chosen, albeit in a different specialty, will ultimately leave me similarly dissatisfied.

Then when patients like this one tell me that my efforts make a difference in their lives and that my work is meaningful to them, it almost makes me want to stay. Damn you, sneaky patients.