Internal Medicine: A Doctor's Stories (15 page)

In the years since then, I’ve thought about her often, wondering how she’s getting along. It would be easy enough to find out how her story finally ended, but I’ve resisted. I’d like to leave her the way she is, lying in that bed with her family so pleased, beaming at me because I was wrong.

M
ARIE
P
WAS ADMITTED TO THE CARDIOLOGY
service from the Failure Clinic one day in February, a three-hundred-pound woman with a history of non-ischemic cardiomyopathy. Her heart was failing. I was a resident, one of nine staffing the CCU that month, just past the halfway point of my residency. It was my second rotation through the CCU that year.

The CCU—cardiac care unit—was a critical care service, in which teams of residents rotated call not every fourth night, as the practice was on other services, but every third. This turned an otherwise grueling month—all months in the hospital are grueling—into a marathon. On the day Marie came in from the Failure Clinic, I was two weeks into the rotation and was already exhausted. Or maybe something more. After two years of constant call, I was empty.

It was our bad luck to be admitting on the day of Failure Clinic.

“Heart failure” is a fairly common diagnosis. It sounds ominous, and it is, but the reality is less dramatic than the words suggest. It does not mean, for instance, that the heart is about to stop. The disease is actually more of a chronic condition, what used to be called the dropsy, in which the heart, weakened by a poor blood supply or alcohol or untreated hypertension—the list is long—can no longer drive blood around the body as well as it should. Fluid backs up, one place or another. If the weakness is primarily on the heart’s left side, fluid accumulates in the lungs: you cough, get short of breath, can’t lie down flat without a sensation of smothering. If it’s on the right side, your legs and belly swell, the liver stretches; the veins on your neck stand out, pulsing. And because the whole circulation is connected, failure on one side eventually becomes failure on both. At that point the patient enters the terminal phase. Then “failure” comes to mean what we usually mean by it, like “breakdown” or “collapse.” But this can take years.

The culprit in this persistent flooding is not the heart so much as the foolish kidney, which continues to do its job of regulating the body’s fluid levels, but does so in an increasingly misleading milieu. As the heart’s output drops off, the kidney senses decreased flow and in response holds on to water as tightly as it can: your weight climbs, your ankles swell, you start to feel congested: you’re suffering an exacerbation of congestive heart failure. When your doctor gets a look at those puffy ankles and hears the crackles in the lungs, she calls up the cardiology service and sends over what the admitting resident will describe to the intern as “another damn tune-up.” Marie was in for a tune-up, a four- to five-day process in which we wring out all that extra fluid, undoubtedly the dullest medical intervention a hospital can provide. Marie had gone through this so many times before that it was all I could do to lift her chart—heavy in proportion to her obesity, packed with details of prior tune-ups, diagnostic studies, lab values, and a pervading sense of futility . . . which was increasingly how my own fatigue had come to feel.

By the time I met her, Marie P had long since passed the point where the occasional tune-up would suffice; she had been discharged from her last admission on a permanent infusion of dobutamine, without which her heart would simply grind to a halt. She got it through a Permaport installed over her collarbone, and a pump that followed her everywhere.

What we were supposed to do with her was simply crank up the settings on the pump and see how much fluid we could draw off. And although this was not without risk (side effects of dobutamine include lethal arrhythmias), this is not the stuff of which careers in cardiology are made. My partner on the service that month, Alex, was applying for fellowships in cardiology. I took Marie under my care.

Such as it was. She arrived on the floor sometime in the late afternoon, competing for my attention with a man having a genuine heart attack and a woman whose aorta seemed to be disintegrating. When the nurse informed me of her arrival, I scratched out a set of generic orders and returned to the gray, sweating fellow who was heading for the cath lab. I didn’t lay eyes on Marie until after ten that night. Her room was dark, her vital signs were stable. I should have awakened her and repeated the intern’s history and physical exam. But as I listened to her snoring, propped up in her bed so that her lungs wouldn’t fill from her internal seeps and springs, I thought about the two dozen prior admissions documented in her chart, and how little changed from one to the next. I didn’t wake her up.

F
OR THE NEXT SEVERAL
DAYS
, Marie hovered vaguely on the margins of my attention. She was a tune-up, someone whose progress I would measure in liters of urine. She was a body to examine each morning, a set of labs and vitals to record, a very simple story to present each day on rounds. She herself remained tucked into the end room on the intermediate care unit, a fat little woman with a tremulous manner and a wedge of tight pallid curls that made her head, from sharp chin to spreading jowls to the bed-flattened top of her curls, a cone. I hated her.

“Hated” may be too strong a word. At that time, I hadn’t the energy for hatred. Certainly I didn’t like her. I think it was primarily the way she whimpered when I examined her. The sound she made grated on me, partly because I didn’t believe I was hurting her, also because that was all she would do—pucker her face around a sharp gasp, never looking at me or blaming me. After a week of this, my physical exam dwindled to a cursory prod at her ankles and the briefest auscultation of her chest.

There was also the issue of her Xanax. Xanax, alprazolam, is a tranquilizer, a member of the family of benzodiazepines, the most familiar member of which is Valium. It is probably the most addictive drug in its class, primarily because of the speed with which it enters and exits the system. Users get a buzz off it, and four hours later they withdraw. Unsurprisingly, Marie was a Xanax addict. People with syndromes that cause shortness of breath tend to be anxious—we’re wired that way—and often wind up on benzos. Emotionally, at least, the drug becomes as important to them as oxygen. And although none of us balks at supplying oxygen to a patient feeling short of breath—even if we suspect the sensation to be imaginary—there is something about the Xanax addict that can inspire contempt. It did in me at that time in my life.

So she was obese, she whimpered, and she had a drug habit. She also had a heart that beat with perhaps a fifth of the strength it should have. Had she been a younger woman, she would have been listed for transplant. But at her age, with her obesity and other problems, she was in a holding mode, circling the drain in rings that seemed still, at this point, so wide that the central vortex was only a dimple on the horizon. This pass through the hospital was just another one of those slow circles, routine, intolerably so. Had I known this was to be her last admission, I might have regarded her differently.

It was on day five that the dullness of things broke. That day, rounds took longer than they should have, and I was due in clinic by one. By the time we reached Marie’s door, I was so tired of standing I had forgotten most of what I had known about her. I searched my notes through a fog of fatigue. All that emerged was data: her weight so many kilograms, her urine output so many mLs. I looked up to find the attending frowning.

Not at me, thank god.

“What do you think is going on here?” she asked me.

I thought furiously. “Nothing,” I said, glancing back at my notes. Over the past few days, despite heroic doses of furosemide, we hadn’t wrung more than a liter of fluid from her overloaded circulation. “That’s a problem, isn’t it?”

“Yes,” she said. “What’s standard of care here?”

“Metolazone,” I said, naming a diuretic often used to increase the effect of furosemide. “And crank the dobutamine.”

I had answered correctly, because she nodded, still thinking. “What’s tele show?”

She was asking about the continuous telemetry of the patient’s EKG. “Nothing significant.”

“Okay,” she said, jerking her thumb upward. “Get cranking. She’s losing ground here.”

And so we moved on to the next patient, and by one p.m. I had signed out to the on-call intern that Marie was to be a liter negative by morning, and if not to hit her with an extra 120 IV at four a.m., but to watch her K.

The next morning we were on call again. I spent the half hour before rounds checking up on the three patients I was carrying going into call. I left Marie to last, my reluctance to enter her room being by this time nearly insuperable. In response to my usual question, she gave her usual answer. “Terrible. I feel so weak, Doctor. Just so weak and shaky.” She said this in her usual tremulous voice, waving the back of her hand over her face to express her weakness. I couldn’t help but notice, uncharitably, her breakfast tray, every bowl and plate stripped clean to the last sheen of grease. Her vital signs were stable, and her urine output had indeed picked up: not the entire liter we had hoped for, but most of it. It was with a feeling of hope—I might discharge her soon—that I left her room for a last check of labs before rounds.

But what I saw in the labs wasn’t good. Overnight, Marie’s serum creatinine—the general indicator of the kidney’s ability to clear wastes—had almost doubled. Worse, her potassium—the “K” I had asked the intern to watch—was over six. The number was highlighted on the screen in red. We watch potassium generally in hospitalized patients: it’s a critical element, its level easily perturbed, and too wide a deviation can throw the heart’s rhythm awry. A patient on dobutamine with a potassium greater than six was not something I wanted to present on rounds. I had three minutes to find a nurse and order the four different things that would take care of this. As I was scribbling the orders on the chart, somewhere in the back of my head I was processing the other half of this story, the one I could do nothing about. Her heart was overloaded with fluid her kidneys could no longer expel. And now, under the burden of her failing heart, her kidneys were beginning to fail as well.

I was a minute late for the start of rounds.

As another long day of call ground into motion, I carried with me through the morning’s rituals a bleak sensation of change about to happen. Or perhaps, with the shift of a few numbers on a computer display, it already had, crossing over from the well-worn track Marie’s history had followed so faithfully for so long, to the other routine that plots the hospital’s daily round, the inexorable slippage into death. Marie’s electrolyte abnormality was significant not because it put her at risk of sudden death (although it did). The real significance was that the routine tune-up was over. Our only means of lightening the load on Marie’s heart had failed. This much, at least, had become brutally clear by rounds the next morning, even after another sleepless night.

When we reached her doorway I presented the data, and ground to a halt. I had no idea what came next.

The attending turned to the fellow.

“Now what?”

The fellow tugged at his lower lip. “I think we need to Swann her.”

The attending nodded. The fellow turned to me and said, “Move her to the Unit. We’ll Swann her after rounds.”