I promised weekly updates and so here I am. I’ve got another story or two in the pipe and maybe a random thoughts blog in the future. Don’t hold your breath on those since I’m about to work a string of nights starting in a few hours.
I’d say about once a week a nurse comes up to me, either as soon as I walk in or at some point during my shift, shoves a clipboard in my hand and says “Please go see this patient next. I’m really worried.” Usually it’s because they have extremely high blood pressure (220/120) or they’re bleeding from somewhere you shouldn’t be. Honestly, it’s rarely ever serious or immediately life threatening. As much fun as we poke at the triage notes, the nurses in triage do a good job of alerting the ER docs to the severely ill patients. Most of the time I’ll take the chart and get to it in the next 10 or 15 minutes which is all they really want.
The other day though I walked in for my night shift at 6pm and one of the nurses handed me a chart saying “She’s having trouble breathing and her pressure is through the roof. She’s a young girl with no past history. Could you go see her right now?” If the nurse is giving me the chart, I’m rarely worried. The really sick patients end up in the resuscitation/trauma room and this girl wasn’t in one of those rooms. She was in a normal room. I grabbed her paper chart from the nurse, took a look at the triage note and went to talk to the patient.
She was a professional in her early 30s. No past history to speak of. She noticed about a month ago that she was having trouble walking up a flight or two of stairs without losing her breath. Now this was no overweight, out of shape woman. She was about 5′4 and 105 pounds sopping wet. She went on to tell me that over the past week she’d had a lot of trouble sleeping because whenever she layed down she couldn’t breathe. “I only slept about an hour last night and that’s when I figured I should come in.” Now I was a little worried. First because she had a believable story (not always the case in the ER). Secondly, I laid the head of the bed down and sure enough she wasn’t breathing well. Young, healthy people who suddenly have deteriorating health worry me because it usually means something unavoidably bad has happened.
We keep talking. She doesn’t see a doctor yearly, not even a gynecologist. She had never seen her blood pressure this high and it was making her a bit anxious. We chatted a bit more. She didn’t smoke or do any drugs. She drank on rare occasion. The only thing currently bothering her was her shortness of breath. No headache, no nausea/vomiting, no visual problems, no neurological symptoms. A bit odd. Her physical exam was essentially normal except for her fast heart rate. I was expecting that maybe she had new onset asthma, but she had none of the tell tale wheezing sound when I listened to her lungs. I told her I wasn’t sure what was going on but we were going to run a bunch of tests and get some X-rays and we’d certainly get to the bottom of it. I also said “Don’t worry about anything. You really don’t have any of the concerning signs that this high blood pressure has been around for a while and is doing damage to any of your organs. Right now it’s just high and your heart is beating fast and we need to figure out why so we can fix it.”
It turned out the nurse was worried about a PE, which wasn’t a bad though. Pulmonary embolism, or PE, is a blood clot that lodges in one of the large pulmonary arteries that carries de-oxygenated blood from the right side of the heart to the lungs so that it can be re-oxygenated and returned to the body. PEs are one of those things like a heart attack that can kill you cold in your tracks. The clots often come from the deep veins of the legs. The clot breaks off and travels through the venous system to the heart. It doesn’t get stopped anywhere because veins get larger the closer you get to the heart. Once in the heart the clot gets pumped around until it gets stuck in the pulmonary arterial tree. It can kill you could because if the clot is large enough it can entirely block blood flow to the lungs. Which means no oxygenated blood to the body, which means no oxygen for the heart or the brain… you can take it from there. Fortunately for her, PE doesn’t present with a month or even a week of worsening shortness of breath. It presents with a couple of hours of shortness of breath at most. But something still didn’t feel quite right.
We sent off the typical labs and as I was documenting my history and physical in her chart we got a call from our lab: hemoglobin of less than 5. Which is good news and bad news. The good news is that it entirely explains her symptoms. A low hemoglobin means your blood can’t carry enough oxygen so the heart starts beating faster to keep up with the demand. It has to pump the blood around faster to make up for the lack of red blood cells or again your heart and brain are out of luck. It doesn’t entirely explain the high blood pressure which is part of the bad news. The other part is that a hemoglobin of 5 is bad. It means something is destroying her red blood cells. She’s either bleeding from somewhere internally or her body’s immune system has gone haywire and started munching on the red blood cells as a snack. It also means she gets to have a blood transfusion. Time to have a talk…
I let her know that her hemoglobin is very low: “It’s okay though, it explains your high heart rate, and we can give you a blood transfusion to help the hemoglobin level go back up. We still need to figure out why your blood pressure is high though. And we need to figure out where all your blood is disappearing to.”
She was worried that something truly terrible was about to happen. She was still very anxious.
“I understand you’re worried. I’d be worried too if we switched places. But right now? I’m not worried about you. You’re awake and alert and talking. We figured out half the problem, once the rest of the labs come back we’ll figure out everything else. Trust me: I’ll tell you when to worry. When you see me frantic and upset: that’s when you worry. But you’ll never see me like that. I only get that way when my patients pass out. And if you’re passed out, you won’t see me all frazzled and frantic. It’s a win/win for you.”
She laughed and thanked me for explaining everything. I told her I’d come back once we knew more.
As the labs came back it was clear she wasn’t bleeding from her GI track or her kidneys/urinary tract. That made it pretty unlikely she was bleeding internally from anything else as she had no history of trauma and had no pain on abdominal exam. I went to look at the chest x-ray. More bad news. Her heart was huge and you could see more of the pulmonary (lung) blood vessels that you normally should. Her heart was in failure. It had been beating so fast for so long that it couldn’t keep up. The heart re-modeled itself and recruited new muscle tissue. We call that high output heart failure. But it’s okay, only one failing organ. We can handle that and once we correct the hemoglobin everything will start going back to normal.
The chemistry panel came back not too much later: kidney failure. She told me, almost in passing, about this kidney biopsy she had when she was around 6 or 7. They diagnosed Berger’s disease which didn’t make sense to me or my attending. Berger’s disease is today defined as a kidney disease of older men who have a long history of smoking. So we wrote it off and figured since she hadn’t had any follow-up in the last 25 years it must not have been very serious. But now her kidney’s were failing. Which surely was the cause of the high blood pressure. Most people don’t realize this, but the kidneys control the blood pressure in the body. They dictate the amount of sodium, chloride, potassium and several other elements that either get excreted into the urine or are kept around in the body. If more of something is kept in the body, more water is kept around to balance everything out. More water means more fluid which means more pressure within the blood vessels.
But she now had two failing organs. And a very low hemoglobin. Back to the bedside I went. I explained that I was going to call the ICU residents because she had two failing organs: her heart and her kidneys. I explained the results of her tests that led us to those diagnoses.
“The upside is that you’re still breathing fine and your heart rate is starting to come down. You’ll be the healthiest person in the ICU and you’ll get the best care the hospital has to offer.”
She looked at me like I was somewhat crazed and said “You’re always so calm! You’re not even the least bit worried about me with a bad heart and bad kidneys?”
“Not really. The heart will be fixed once we get your hemoglobin back up to normal. The kidneys are a problem but we have to figure out what caused the kidney to fail. It might be something that’s reversible with medication, it might be something that requires dialysis. You may even need a transplant. But it’s nothing that’s going to kill you today or tomorrow, which makes you healthier than just about every patient in our ICU. You’re conscious, you have a good blood pressure (high is always better than low) and a good heart rate and your oxygen saturation is normal on room air. Based on your vitals you look better than some of our 7 year old asthmatics in the pediatric ER right now.”
I told her the ICU senior resident would be in to talk to her and I’d let her know what our decision was after that. The ICU resident saw her quickly and decided she wasn’t appropriate for intensive care: even with two failing organs and requiring 3 or 4 units of blood and dialysis in the next couple of days she wasn’t sick enough for the ICU. I went back to tell her the good news.
“The ICU decided you weren’t sick enough to hang out with the really sick patients. We’ll have you go to the general medicine floor with one of our excellent medicine teams and the kidney doctors will be consulted to figure out what’s going on with your kidneys.”
She thanked me profusely for taking the time to explain everything that was going on and for not treating her like an idiot. Which is our first lesson for the day: never treat people like they’re idiots. Unless you’ve been directly proven otherwise, start in the middle and shift your explanations up or down based on what the patient seems to understand. Use diagrams: most people are visual learners. You’re doing yourself and them a huge service. First, a well educated patient is more likely to take their health and disease seriously, which is good for them. Secondly, it’s good for you, because well educated patients take better care of themselves and are more compliant with treatment and medication which is good for you. My job is easier when people do what I ask them to do. And I think these lessons apply well beyond medicine. Anyone who has a job dealing with customers can take this approach to improve their customer’s understanding of the product or service that you offer.
The second lesson I learned is that even when you don’t exactly know what’s going on, a calm caring bedside manner trumps all. I honestly was never worried about her. I’m not well seasoned, but I’ve seen enough to know very sick when I see it and she wasn’t it. I let my body language convey that. I was always relaxed around her and her family and I was never in a rush to do anything. I meant what I said: if I was worried she wouldn’t know it anyway, because she’d be unconscious by that point. I guess I was surprised because I don’t always feel so calm and confident internally, especially mentally. I know this is only my first month on the job. I know that there’s more that I don’t know than I do know. Sometimes I get easliy frustrated when I realize that my senior colleagues and attendings expect me to have a skill set in my first month that they likely didn’t. But I try my best to never show my patients that. They’re already in pain or another discomfort… why give them any additional reasons to be concerned.
I went up to the floors to visit her the other day. She was sitting comfortably in her bed. The nephrology service (kidney specialists) had diagnosed her with “likely IgA nephropathy”. Apparently 20 years ago IgA nephropathy was known as Berger’s disease along with the kidney disease that old men who smoke get. Some where along the way, someone realized it was really two different diseases and they split IgA nephropathy off from Berger’s disease. I wish I could explain IgA nephropathy well to the blogosphere, but I can’t. But here goes anyway: essentially your immune stystem deposits proteins into your kidney that make the kidney unhappy, so it stops working. Unfortunately for her, there’s no medication she can take to reverse the effects. She’s starting dialysis today and they’re looking for a live kidney donor. When I saw her a couple of days ago she already knew all of this. She thanked me several times for my care in the ER and told me she was so happy to have me visit her on the floor.
“You’re the best doctor in this whole hospital. You explained things to me better than some of these specialists. You took more time than they did and you always did a wonderful job of keeping me calm and in perspective. Are you sure you can’t take care of me up here?”
I thanked her and told her that the specialists are probably much busier than a lowly little intern in the ER and they were the true experts that would really end up helping her in the long run, especially now that she needed dialysis and a kidney transplant. I reassured her that come Monday the hospital would be filled with medical students, residents, fellows, and attendings who hadn’t been around on the weekend and would be dying to talk to her. She made me give her a hug before I left and I promised to check in on her if she was around the hospital later in the week.
As I was walking back down the hall to the elevators her boyfriend came out of the room and caught up with me. “I just wanted to let you know, that we’re all really grateful for what you did. We were actually talking about you right before you came into the room. She really does think you’re the best doctor she’s ever had. And I just wanted to say thank you for saving her life. I know you kept saying she was never in any real danger, but I think that’s because you made sure she wasn’t. I’d tell you you’re going to be an excellent doctor someday, but you already are.”
Sometimes it’s not the obvious lives you save that are the most grateful or stick with you. And I guess that’s as good a reason as any for why I’ll never stop loving this job.
