Traveling Companions

By Elisabeth Rosenthal|Tuesday, September 01, 1992
On hospital wards there is a symbiosis that develops between new young doctors and their patients. The patients rely on these newcomers to start IVs, treat minor pains, and explain the meaning of the four-syllable words dropped by busy physicians during their rounds. In return the interns depend on their patients to learn about diseases firsthand, to perfect skills like drawing blood, and to muddle through their first conversations about suffering and death.

While senior doctors breeze through on rounds for five minutes a day (Feeling better? Any questions? Let’s check that hematocrit), interns spend hours in patients’ rooms. It’s partly a matter of gaining experience: it takes a new doctor many minutes with a stethoscope to make sure there is no heart murmur. But more important, interns and patients are comrades in the trenches; at three in the morning they are alone on the wards and, both miserable, hold each other’s hands.

Amid this give-and-take deep bonds are sometimes formed. Six years ago, during my first week of internship, my patient Mrs. Lacey helped introduce me to the world of medicine. This year, as she lay critically ill in the emergency room I now supervise, our lives touched one last time.

In July 1986 I had countless reasons to be grateful to her. Within a month I had graduated from medical school, moved to a new town, received prescription pads bearing my name, and suddenly found myself responsible for 15 patients on a hospital ward. I still remember the utter fear I felt each time the senior doctor said good night and left me there alone; I viewed his silhouette receding down the corridor with the panic of a shipwrecked sailor watching a rescue boat steam away.

And of course one night, half an hour after he left, I got a page from the admitting department telling me about a 65-year-old, Mrs. Lacey, with stomach pains and intestinal bleeding. I placed my stethoscope and an index card listing the essentials of the physical exam in my pocket and headed to the emergency room to perform my evaluation. I stopped in the rest room to straighten my white coat and to make sure my badge reading e. rosenthal, m.d. was prominently displayed.

Although I must have been obviously nervous, Mrs. Lacey treated me with respect the second I entered her room, never asking how old I was or where I went to medical school. She answered my dozens of questions about her symptoms (read surreptitiously off the card) and allowed me to prod her upper abdomen for several minutes until I was confident I had detected an oversize spleen, a possible sign of a blood disease or infection.

When I probed into her past, she told me that as far as she knew she had only one medical problem. It’s called p. vera, she said, but it hadn’t required treatment for a while. Ah, polycythemia vera! I racked my brain.

You’ve heard of it? she asked.

Sure, I’ve heard of it, I answered. Technically true, but all I could remember was that it was a rare blood condition.

For the next week Mrs. Lacey endured my somewhat clumsy efforts to start IVs, while I read everything I could about p. vera and gave her long lessons on the disease. She introduced me to her husband as my favorite doctor. I hand-delivered requisitions to get the best blood specialist in the hospital to consult on her care. She asked me if her disease was lethal, and I, still unable to face death, said, Over time it can lead to problems, but for now you’ll be just fine.

Polycythemia vera is a disease in which the bone marrow mysteriously begins churning out large numbers of red cells, the main component of blood, which carry oxygen from the lungs to the rest of the body. Too few red cells cause the weakness and fatigue of anemia, but too many are equally problematic. People with p. vera can have twice the normal number of these cells, causing their blood to be unusually viscous. This in turn prevents the blood’s smooth flow through arteries and veins; it gets stuck in the body’s tiniest vessels, which act like clogged irrigation pipes. Sometimes the area that the pipe feeds is simply deprived of oxygen and nutrients. But sometimes the pipe bursts from the pressure within it, leading to bleeding, which can be even more serious.

The effect of the blocked vessels depends on where they occur: in the brain, they lead to small strokes; in the lungs, to shortness of breath; in the intestines--as in Mrs. Lacey’s case--to bleeding ulcers.

Ironically, Mrs. Lacey’s normally revved-up red cell production had initially caused doctors in the outpatient clinic to miscalculate the severity of her bleeding. Her stool specimen had tested positive for blood. But when the doctors ordered blood tests to estimate the magnitude of the loss, her red cell count was 48--a bit higher than normal. What they hadn’t realized was that Mrs. Lacey’s blood count was often above 60, and significant hemorrhage had already occurred.

To add to the confusion, Mrs. Lacey looked too good to have a bleeding ulcer. She wasn’t pale or weak, because she had a built-in reserve of red cells. While a person starting with a normal count of 40 would have been close to fainting after a 12-point drop, aside from her stomach pains, Mrs. Lacey felt fine. (In fact, when a person with p. vera develops serious symptoms from skyrocketing red cell counts, the first-line treatment is bloodletting. Doctors insert a needle into a vein and simply drain blood into a bottle on the floor.) Was the disease, as Mrs. Lacey had asked, lethal? Yes and no. Although most people with p. vera ultimately die from the disease, they typically live one to two decades before they succumb. So my hedging in response to her question was not entirely unfounded.

There was little to do for Mrs. Lacey during her first hospital stay. We restricted her diet and gave her medicine to help her ulcer heal, and beyond that we just checked daily blood counts to make sure her blood loss did not get out of hand. Within two days her count ceased dropping and stabilized at a healthy 39, and she was ready to go home.

Over the next three years of my hospital training I saw her from time to time in my outpatient clinic and got occasional reports from the hematologist who was now primarily directing her care. To make certain of the diagnosis of p. vera, he had extracted some bone marrow from her hip with a large needle. And intermittently, when her counts started rising to around 60, he drew blood from her or put her on drugs to suppress the wildfire cell production. Every once in a while she would end up back in the hospital with another bleeding ulcer. But generally she did very well. Just before I finished my training and began work in the emergency room three years ago, she and her husband were planning a trip across the country in a van. Since then I had exchanged frequent greetings with her through her clinic doctor.

So I was shocked one day last summer when I rounded the corner to the emergency room’s intensive care area and saw her lying on a stretcher, her eyes half-closed, her face a deathly gray. They just wheeled this woman down from the outpatient clinic, a nurse volunteered. She’s barely conscious.

I know her, was all I managed to say. She was my patient when I was an intern. I started an intravenous line--Mrs. Lacey barely winced-- and watched as the nurse gathered data. Her blood pressure was 90/60, way too low for someone who normally ran around 140/90. Her heart rate was 130 beats a minute, way too high. Her breathing was labored. Something was terribly wrong.

Does she normally look like this? the nurse asked. I knew why she was raising the question. We have all wasted hours in the emergency room trying to cure patients who we later learn are hopelessly, chronically ill and who want nothing more than comfort care.

No. She’s normally a walkie-talkie, I said, our slang for a functioning human being. She’s a terrific person.

Before trying to rouse Mrs. Lacey, I pulled out the notes from the outpatient doctor. Despite her critical condition, the story I read made me smile. Mrs. Lacey had been doing well until that morning, when suddenly she felt so weak that she couldn’t walk. While some patients call ambulances for sprained ankles, she and her husband, believing that ambulances were only for really sick people, took a cab instead. Likewise, when they arrived at the hospital, her husband borrowed a wheelchair from the supply desk in the lobby and brought her to the outpatient clinic. And naturally when a slumped-over gray person arrived in an area set up to accommodate routine sore throats and bladder infections, all hell broke loose. A nurse practitioner rushed her to the emergency room.

Mrs. Lacey, Mrs. Lacey, I called, gently shaking a lifeless shoulder. It’s Dr. Rosenthal, remember me?

The lids lifted slightly, but the voice was barely audible. Oh, Elisabeth. Yeah, hi. I feel lousy.

What happened, Mrs. Lacey? Has this been going on for long?

She was fading in and out, and I needed more information to continue her care. She felt fine when she woke up, I learned, but at breakfast she felt a pain in her left side. The pain got worse and worse, and she felt she was going to pass out. So she lay down on the floor and remained there until the taxi came.

And how’s the pain now? I asked.

Terrible, she said. It was the first time I had heard Mrs. Lacey complain. I asked her to point to the area that hurt, and as she lifted up her nightdress and rubbed her upper abdomen, I immediately saw the problem. That slightly swollen spleen that I had to work to feel six years ago was now huge and bulging, visibly stretching the overlying skin. Now even an intern could have seen it across the room.

The spleen is basically the Dumpster of the human body, where old blood cells are broken down and their components recycled. The organ is always a bit large in people with p. vera, since it is processing more than the usual number of senescent cells. But this spleen was enormous. I gently pressed to feel its contours; it gave way like a boggy sponge under my hand. It’s your spleen, from the p. vera, I said.

And then the question I’d heard before: Am I going to die? By now I had gotten better at talking about death. I also knew I had to level with her because it was important to know what she wanted done.

I hope not. But I think you’ll need emergency surgery to pull through this time, I told her, choking on the words. We’re doing everything we can.

She nodded her head. Do what you have to, she said.

My physical exam suggested that Mrs. Lacey had bleeding in her spleen, which is surrounded by a capsule that expands like a balloon when blood accumulates underneath. When a nurse unfamiliar with the case announced cheerfully that her blood count was normal, 35, I groaned. Bearing in mind that her usual count was often around 60, I calculated that the balloon I had felt in her belly contained over a quart of blood. A CT scan confirmed that it was there.

In normal individuals the spleen is resilient and can be injured only by a very strong impact. But in p. vera patients the swollen spleen is unusually fragile, prone to bursting with minor taps or trauma. Since bleeds in the spleen are life-threatening, they are normally treated by an emergency operation to remove the organ, which performs a useful but not vital function. But patients with p. vera do poorly in surgery because they tend to hemorrhage. Given Mrs. Lacey’s debilitated condition, I feared she might not even make it as far as the operating room. I also wondered if I would be able to find a surgeon brave enough to take the case.

I called both her hematologist and the senior surgeon to discuss her problem. While the former advised me about how to prepare her for the operation, the latter was predictably reluctant to proceed. He estimated her chance of dying on the table to be at least 60 percent--and her chance of leaving the hospital alive to be almost zero.

And if we do nothing?

I’m sure she’ll die, he said.

After a moment’s silence, I pulled out my ultimate weapon of coercion, the one that even in the sterile scientific world of hospitals always seems to hold sway. Look, she’s a really great lady. She wants to live. I’d love to give her every shot.

Within an hour Mrs. Lacey was in the operating room, having her spleen removed. Six hours later, after my shift had ended, I watched her being wheeled, still anesthetized, to the surgical intensive care ward.

For the next 24 hours the doctors tried to stem her postoperative bleeding. It was to no avail. She never regained consciousness. Two days after I had last spoken to Mrs. Lacey, a surgeon called to tell me my buddy from the trenches had died. I guess it was my last initiation rite into the medical world.
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