 |
Even forewarned with the knowledge that since the age of eight she has required twice-daily insulin injections to control her diabetes, anyone meeting Grace would have good reason to see in her the personification of that idealized image of a past generation’s sketchers and artists, the American Girl. Certainly it is a great deal easier to think of her as a wholesome, smiling beauty contestant than it is to imagine her mottled and swollen, in a delirium of fever and near death, being rapidly wheeled toward an operating room one spring afternoon four years ago. She had been assessed a Class 5 risk for anesthesia, in the opinion of every physician who saw her. To this day, she’s not sure whether to credit her survival to the flabbergasting marvels of modern scientific medicine or the spiritual intervention of her long-dead father, and even a few of her doctors sometimes wonder. Either way, it took a miracle to save her life.
The American Society of Anesthesiologists describes a person in Class 5 as “a moribund patient who is not expected to survive without operation.” No one, doctor or otherwise, seeing Grace Lopat just before those preoperative moments had reason to dispute that description, and most observers would have projected her survival period to be hours rather than days. I was her surgeon, and I’ve now had four years to think about it. I’m absolutely convinced that I have never taken a sicker patient to the operating room, even if I include in my recollections those few who didn’t leave it alive.
"When she said she couldn't feel her arms or legs. I knew I had to get her down to the hospital right away. Then she told me she couldn't even feel her feet touching the ground."
He reason for Grace’s survival is no easier to pin down than is the origin of her sudden catastrophic illness. Although our clinical team was later able to trace the details of the process that made her so sick, we’re still puzzled by the “why” of it. We know the culprit but have no idea how it managed to get as far as it did as fast as it did. Even the instructions we gave Grace after her recovery were based on guesswork: she was told never to eat pork again. The injunction had no scientific basis. In fact, it was nothing more than a kind of clinical rabbit’s foot that none of us were willing to throw away, probably because it was the only piece of advice we could think of. Grace never shared our concerns; I recently discovered that she eats pork whenever she can.
Actually, the amount of pig meat consumed by our patient in the days before the onset of her illness was not enough to indict it. She’d had a Chinese dinner about 40 hours before her first symptoms, and it included pork fried rice and spareribs. Other than that, she has no recollection of having eaten anything at all different from her usual fare.
Grace’s medical saga began in May, on the Monday of final-exam week at the state university where she was completing her sophomore year as an education major. She had just taken the performance exam for a dance course in which she’d been enrolled that semester. It was about three o’clock in the afternoon, and she was walking across the campus, feeling pleased with how well she’d done and thinking about the coming series of finals.
“All of a sudden, I was on the ground—I couldn’t imagine how I got there. I got up quickly because of course there were a thousand people around the campus, and I was thinking, ‘Dear God, I hope no one saw me fall.’ I looked around and there were no stones, no sticks, no cracks in the sidewalk—there was absolutely nothing that I could possibly have tripped on. It was like my legs gave out, and I thought it must have been because I’d just danced for an hour. My roommates said later that I was such an idiot I must have tripped over my own two feet.”
On the following morning Grace awoke feeling sick.“I was vomiting, I was running to the bathroom with diarrhea, and I was sweating. I thought, ‘Oh great, I caught some kind of a grippe, some kind of a flu. I went back to bed, but I kept going in and out of it. Finally, my roommates began to get worried because there had been several times in the past when I got dehydrated and had to go to the hospital because my diabetes went out of control. But when I tested my sugar, it wasn’t any higher than usual.
“Finally, the girls started to get scared. They called my mother at work, and she took me home. I drank lots of diet ginger ale the rest of the day and used suppositories to stop the vomiting. That whole night I was dizzy and throwing up, and drinking water and vomiting again. By early the next morning, my abdomen was aching and I couldn’t feel my arms and legs. I tried flapping my arms around and I still couldn’t feel them. No matter how weak I’d been in the past, nothing like that ever happened before. I was in hysterics—it was like a nightmare.”
Anne Lopat, Grace’s mother, has been teaching elementary school for more than 20 years. After her husband, Bill, died suddenly of a coronary when her only child was ten, Anne became not only the small family’s sole breadwinner but Grace’s entire support system. After Grace’s juvenile diabetes was diagnosed in 1978, Anne took it on herself to learn all she could about the disease, and to become something of an expert in the various ways it manifested itself in Grace. Her job wasn’t always easy. Like most diabetic kids, Grace had a way of breaking the rules, and it sometimes took all of Anne’s accumulated diabetic wisdom to extricate her child from the consequences. Occasionally her efforts failed, and it would then be necessary to rush the dehydrated girl down to the Yale–New Haven Hospital emergency room. Over the years, actual admission had been necessary seven times, always to treat acidosis, the rapid buildup of metabolic products in the blood of diabetics, which can lead to air hunger, coma, and finally, if not reversed, death. The last admission had been only six weeks earlier.
 |
There was no prolonged wait in the emergency room when the Lopats signed in at 6:19. As Grace recently told me, “Generally, you can come in holding your head in your hands and they tell you to wait. But when you’re a diabetic, they take you right away.”
Blood samples were drawn and intravenous fluids were started without delay. About an hour and a half after her arrival, Grace was told that her test results seemed reasonably satisfactory. But she couldn’t be reassured, and she began to feel herself become increasingly panicky. Soon she was shouting.
“Nothing felt right. At that point, the doctors and nurses were changing shifts, and no one was paying any attention to this screaming person. I was yelling, ‘Won’t someone listen to me? There’s something wrong!’ My abdomen really, really hurt, like it was a tight, tight muscle spasm and everything was all squeezed together. That frightened me, but I tried to blame it on the 24 hours of vomiting. But what really scared me was that I had no body perception. I didn’t feel like I was there. It was that same spacey feeling I’ve had when I’ve had a tooth filled and been given gas. It’s like I have no body at all.
“My mother kept talking to me all the time, trying to calm me down because I was yelling and thrashing around. And then she asked me if I knew I was going to the bathroom—I didn’t. Then I heard her yell, ‘My God, it’s blood!’ and she began calling out, ‘Nurse, Nurse!’ The nurse came right away, and after that my only perception was dribs and drabs of the faces of the doctors and nurses around me.”
In fact, Grace’s blood tests had not been normal at all. The most striking abnormalities were a markedly elevated white blood cell count of 28,500 per cubic milliliter (the normal level is about 5,000 to 10,000) and what is called a shift to the left, which refers to a large increase in the number of mature and immature granulocytes, cells that increase in number when an acute infection must be fought off. At 654 milligrams per deciliter, the blood sugar was elevated to some seven times its normal value, and a moderate degree of acidosis was present. The entire picture was characteristic of the abnormalities that rapidly appear when a diabetic develops serious infection. Once the proper cultures had been taken, the emergency room physicians started Grace on several intravenous antibiotics.
