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Before sunrise...

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taxico
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Before sunrise...

Postby taxico » Sun, 14 May 2017 1:30 am

Sunrise

https://jtopin.wordpress.com/2017/02/28/sunrise/

What do you do when you know someone is going to die? I’m not talking about death when it comes at the end of a long protracted illness or a terminal diagnosis. Or the final act at the end of a “good” life, when the body and mind have ultimately given way. I’m talking about when you realize the twenty-five-year-old woman in front of you, who you met five minutes ago, has no idea she will not survive to see another sunrise.

Moonlighting in my last year of residency in the ICU of a community hospital, I was summoned to the ED to evaluate a feverish, septic young woman. Walking thru the curtain into the ER bay, my first look triggered warning bells in my head. In his book, Blink, Malcolm Gladwell describes the gut/reflexive first impression we make before our “thinking” brain starts getting in the way of those initial thoughts. My first thought was, “Sick!”

The mottling of her skin, with lacy lines on her arms and thighs coalescing into a dusky blue on her hands and feet, told me she was in shock, constricting the tiny blood vessels in her skin in an effort to preserve blood and oxygen delivery to her vital organs, her kidneys, heart and brain. The visible rapid rise and fall of her chest told me she was working hard to blow off the accumulating acids in her blood and body. Her eyes told me she was afraid, and rightfully so. The rapid pulse and low blood pressure were punctuated by red on the monitor up in the corner of the room. She looked sick, but the reality was worse. I had known her now all of ten seconds. But I didn’t know she was dead. Not just yet.

A couple of quick questions followed, trying to piece together some sort of story. Context for her critically ill state. Fever for two days along with chills and rigors. No obvious source of infection. No cough or pain in the belly or when urinating. But then, the next critical piece of information. The one bit of information that took this from the realm of critical illness to literally life and death.

She had no spleen.

I forget the reason why. Prior trauma or injury during a past surgery. It made no difference how. Its absence was the crucial part. The spleen is a funny organ. It sits in the abdomen, tucked under our breathing muscle, the diaphragm, and surrounded by a protective bony cage of ribs. It is basically a big bag of blood that we can do without. But it does play a crucial role on the front line of our immune system, acting as a giant filter or sieve for our blood supply. Screening for intruders or invaders. Bacteria that have somehow breached our first line of defense and gotten access to the blood supply can now use the high speed highways of blood vessels to travel and infect, almost instantaneously and simultaneously, anywhere in the body.

As medical students and young doctors we are trained to be cautious with overuse of antibiotics. More often than not, fevers are due to viruses, not bacteria. The pace of a bacterial infection, in most people with an intact immune system, is slow enough to temper the need for reflexive antibiotics given for any new random fever. But one of the first exceptions to that rule is when a patient has no spleen. Antibiotics are to be given early and quickly. Within hours. Treat first and think later.

She’d had a fever for more than forty-eight hours.

Forty-eight hours. Two days for this infection to have run amok, unabated. Two day’s head start with her kidneys failing, circulation failing, her breathing failing. Blood stream infections can be life threatening all on their own. Compound that with one arm of the immune system tied behind its back and a two-day head start without antibiotic reinforcement and she was gravely ill.

Truth be told, there was no time to think all that much about what to say. There was work to be done. She needed a tube placed in her lungs to breathe for her. She needed a large IV in her neck to replace the fluids that were leaking out of her blood vessels. She needed a dialysis catheter in her groin to help with her electrolytes and acidic blood. She needed medicine to support her heart. She needed powerful antibiotics to start fighting the infection. She needed a special blood thinner infused, that at the time was thought to help increase her chances of survival when dealing with overwhelming infection. As I told her and her father all this in the tiny little ER bay, this young woman, through her labored breath, asked me if she could talk with her fiancé first, before we put the breathing tube in her.

Did I forget to mention that she was engaged? Her fiancé was currently in the waiting room.

If I am being completely honest, I will admit I did not know for sure if she was going to die that night. I know I was scared. Scared for her. Scared of her. Scared I wouldn’t know the right things to do. Not so much by what needed to be done medically. But I was overwhelmed with the responsibility of what to tell this twenty-five-year-old woman, my patient for all of fifteen minutes, with her dad beside her. A few minutes away from life support, and along with it, a drug-induced sleep from which she would likely never awaken.

Do I tell her she might die? While truthful, it kind of understates the risk at the moment. Do I tell her she is more likely than not to die? More accurate. But do I need to add to the immense stress and worry that she and her family are already under? Does she even want to know? She has potentially five minutes left to be awake and cognizant in the world. Not much she can do, right? But what would she say? To her dad? To her fiancé? Are there things that have been left unsaid? “Wrongs” to apologize for or to be forgiven? Words of love assumed but not spoken? Five minutes could mean everything… But who was I to make this decision for her?

I was her doctor. A doctor moonlighting in his last year of residency. A doctor whose brain was filled with a growing body of practical knowledge, but still short on experience and wisdom. But there I was, and without the luxury of time, I started talking, more by feel then design.

“Let’s get your fiancé in here. You’re pretty sick.”

The young man came into the room and held her cool, dusky hand. I talked to the three of them as the Emergency Room doctor walked in to place the breathing tube.

“You are critically ill. Probably from a life threatening blood infection. Your spleen being gone is part of the problem making your immune system weak. Your organs are shutting down. You need to go on life support.” And then…

“You may die from this.”

Those words hung in the air for a long moment. Only to crash down all around them under the weight of their meaning. I am not sure how much was understood. The tone of my voice and concern in my face reinforcing those words.

What do you do when you know someone is going to die? They do not teach you this in medical school and no simulation or role playing can prepare someone for this. I don’t know if I made the right choice that night. I did the best I could. I did what “felt” right in those few minutes I had to talk to her and her family. It felt honest. It felt like I balanced the gravity of the situation without depriving any hope. I felt she would use those minutes with her family knowing that her next few words might be her last.

I don’t recall much after that. Thankfully there were not many questions. A hug for dad. A tearful kiss and embrace between her and her fiancé. I tried to disappear into the background of the small ER bay. Quiet words were spoken. What was shared only for them to know. The two men tearfully left the room.

We placed a breathing tube. We used a respirator to breathe for her. We moved her to the ICU. We gave her medicine to make her sleep. We placed large IV’s. We gave powerful antibiotics. We gave her medicine to make her heart and blood pressure stronger. We tried dialysis, but she was too sick. We did compressions on her heart when it stopped the first time. We did compressions on her heart when it stopped the second time, her fiancé and father never more than a few feet away.

She died before the sun rose the next morning.

- Jeremy Topin
Aut viam ad caelum inveniam aut faciam

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x9200
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Re: Before sunrise...

Postby x9200 » Sun, 14 May 2017 11:46 am

It is one of these very few professions requiring very special individuals to manage own empathy and not kill her/himself in the process. Majority fails I am afraid getting completely immune and treating the patients purely subjective, but with the obvious deficit of the said individuals they are also needed.

Taxico, purely technical question, why in the cases like this, fully developed sepsis where the chances of survival are very slim, it is though that the patient has better chances without dialysis or transfusion, or, I don't know, something based on extracorporeal circulation treatment? I realize there is some stress involved, but these are the toxins that shut down the organs in the first place, or not?

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Re: Before sunrise...

Postby PNGMK » Sun, 14 May 2017 5:02 pm

The economist has had a couple articles on death recently:

http://www.economist.com/news/internati ... -it-better
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taxico
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Re: Before sunrise...

Postby taxico » Sun, 14 May 2017 7:29 pm

<long experience/jargon-filled reply deleted>

no two patients will respond/react to treatment/symptoms in the same exact way.

in general we should trust the doctor(s) decision - it will be based on the equipment, drugs and knowledge available at the time.

it's not (always) easy for a doctor to withhold treatment, but that might be the best decision after weighing the risks and benefits.

perhaps the family concurred with the doctor... and/or her cognitive function may have been impaired by that time, coupled with significant acid-based abnormalities and no improvement to the infection and inflammation...

and in come cases, patients run out of time.
Aut viam ad caelum inveniam aut faciam

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Re: Before sunrise...

Postby PNGMK » Sun, 14 May 2017 7:53 pm

My GP told me a startling story of being asked to attend to his wife's distant relatives case - she was in private hospital. Elderly Diabetic patient. He showed up to discover she had gangrene to her bones (leg bones showing) and then discovered half the family were resistant to amputation and the people who had called him in were in that group. It seems they wanted a sign off on leaving this poor lady to die with her legs from septicaemia - rather than following the specialists advice to remove her legs. Why? I don't know? Maybe to hasten her death? Regardless he refused to be involved and stated they needed to follow the specialists advice and to do so urgently and left feeling very disturbed.
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x9200
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Re: Before sunrise...

Postby x9200 » Sun, 14 May 2017 8:31 pm

taxico wrote:<long experience/jargon-filled reply deleted>

no two patients will respond/react to treatment/symptoms in the same exact way.

in general we should trust the doctor(s) decision - it will be based on the equipment, drugs and knowledge available at the time.

it's not (always) easy for a doctor to withhold treatment, but that might be the best decision after weighing the risks and benefits.

perhaps the family concurred with the doctor... and/or her cognitive function may have been impaired by that time, coupled with significant acid-based abnormalities and no improvement to the infection and inflammation...

and in come cases, patients run out of time.

It's not that I don't trust - there is not enough data and I don't have sufficient knowledge anyway to pass any judgment, so no, I didn't. I was just curious about possible reason. I understand from your response, that procedures I mentioned can or are routinely be administered?

One somehow related thing. A close friend of mine lost his spouse (30yo only) in a really bizarre case that started as what appeared as a stomach flu slowly progressing with general symptoms, health deterioration, weakness etc. Nobody could diagnose the condition properly and in 3 month he was dead from what appeared to be severe sepsis (at the terminal stage). It is beyond me, why in Singapore, in such case, where clearly young and healthy person dies, nobody seems to bother to investigate what happened.

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Re: Before sunrise...

Postby ecureilx » Sun, 14 May 2017 10:36 pm



having seen a friend, pass away due to late detection of liver cirrhosis and recently another, who had his spleen removed due to blood infection ... painful :(

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Re: Before sunrise...

Postby earthfriendly » Mon, 15 May 2017 8:57 am

For me, honesty is always the best policy. There are very few (if ever?) situations in life that warrant the withholding of truth. This is even more critical in doctor-patient relationships. I was interviewing for hospice volunteer work in USA and the director mentioned cases where relatives would withhold truth from the dying , e.g. on the short amount of time left remaining or just kept delaying and not get on the process sooner. And hospice workers had to hurried through the process. And guess what, it ended up shortchanging the ones dying.

I had a SG relative whose family withheld the severity of her medical condition and the short amount of life span left. Is this more common within Asian cultures? And is this even legal? Withholding medical information from the patient, herself. And then what, the fateful day just befall and she found herself out of luck on this earth? Any regrets she might have? Wishes and things that she always wanted to do but had been putting it off. This was all 3rd person info and I was not there to witness what took place. I am just imagining what could have been.

It is best to leave this earth with no regrets lah, says "Earthfriendly" :D . How could dishonesty be compassionate? For me, it is the opposite. I always wanted the truth. Nothing but the truth. So when my time comes, y'all, please just give me the complete and unabridged version.


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