Looking back through my archives, it looks as though I’ve referenced “my lady,” but never told her story completely in one place. (If I have, sorry, here it is again, and the inconvenient archives here are one reason I’ll be changing sites in May.)
It was a Saturday in the middle of summer, and I was on call, and still hadn’t quite figured out how to keep track of which residents were doing what, or how to sweet-talk the OR charge nurses into letting me see their add-on list. I found a cholecystectomy, watched that, and then the resident (whom I’d just met) suggested that he would be quite happy for me to go to the next case, a diabetic foot debridement, by myself. (I know now that that’s always a bad sign.) It was a nasty case, and I watched on the edge of nausea, while the attending gleefully chopped away with rongeurs (miniature bone-eaters is the best description; they come up bloody, and have to be assiduously kept clean by the scrub nurse – or medical student).
I found the next patient by observing the resident and anesthesia team reading her chart. An elderly lady – not of the bird variety; she would have been tall and strong, before her recent decline. As it was, she lay in the hospital bed, talking nonstop to her tall grandson, a local EMT. We all had some difficulty understanding her, partly because of her heavy accent – she had immigrated from Europe after WW2 – and partly because of the oxygen mask which was necessary to keep her O2 sats anyway near acceptable. The anesthesiologist was unhappy with her pulmonary status, and could barely wait to get back to the OR and intubate her before things got any worse. But first he had to get an arterial line in. This was complicated, because she was on the edge of delirium, and she could not lie still. Watching her, I realized the meaning of the classic description of ischemic bowel: pain out of proportion to the exam; patient moving restlessly, can’t get comfortable. The only thing that kept her from rolling completely over in bed was that her right leg was completely cold and stiff – and had been becoming so for three days before she and her family decided that between that and the abdominal pain, maybe she should see a doctor. It didn’t take the angiograms to tell the surgeons that she had clotted off a significant segment of her bowel, as well as her entire right leg.
As befitted her story, the surgery was epic: to no one’s surprise, half of her small bowel was black. That part was easy to fix. It was her leg which occasioned a lengthy discussion between the two attendings (one had come in from home, not on call, for the occasion). They tried a fem-fem bypass, working in tandem on both sides at once, like master tailors creating a pulsing bridge between the live leg and the dead one. That brought her femoral pulse back, but nothing else. The leg and foot were still cold and pulseless. If they would survive, they would require complete fasciotomies to prevent compartment syndrome, so the resident carefully opened all four compartments with long, deep slashes. This served a double purpose: the muscles could be directly visualized and examined. They were dark, unresponsive to stimulation, and didn’t bleed at all. That was definitive: they had been without oxygen for too long; even the most successful bypass was not going to restore them. The primary surgeon scrubbed out and went to talk to her family, while the rest of us closed her abdomen and the scrub tech got out the amputation set, in anticipation. It was a long time, but finally the surgeon returned: he had persuaded her family to consent to an above-the-knee amputation. She would continue to be in critical condition, but with any luck we had gotten good margins around the dead bowel and the rest would heal, and the bypass was pulsing strongly, and hopefully there would be enough collateral circulation to keep her thigh viable. Technically, the whole leg should have gone. But no one wanted to do that to her: go to sleep for bowel surgery, and wake up with one leg entirely missing. The lower half missing would be bad enough.
She was in the ICU for a week, on a ventilator. Even so, whenever the nurses lowered her sedation, she would be alert, mouthing words around the tube, wanting it out, demanding an explanation about her leg – which she would promptly forget, and ask again in a few hours. Her family was there, taking turns sitting in the room with the matriarch. She had had six children, and grandchildren to match. Although she wasn’t pleased with her situation – she knew she was in restraints, intubated, coming in and out of consciousness, and with a leg missing – she was not unpleasant to be around. She was grateful for all the care she received, and could usually be calmed down with a little conversation and hand-holding.
Eventually she was extubated and moved to the floor. Things were looking up. Her abdomen was healing, bowel function returned, she was breathing on her own. But she never got well enough to leave. Two weeks after surgery, her amputation site was beginning to look unhealthy. Her O2 sats dropped whenever she was on less than 6L of oxygen. When she required continuous CPAP, she was moved to a special respiratory care unit. (Somewhere around here I moved to a different service, and had to keep up with her by dropping in to read the chart and talk to the nurses.) She had surgery again on her leg. She developed pneumonia, and couldn’t be weaned off the ventilator. Eventually, her family decided that her desire for life would not outweigh her desire for independence and dignity. The ventilator was turned off, and she died.
She sticks in my mind. Maybe because she was the first patient I followed all the way, from surgery through recovery to eventual death. But mostly I think because of her powerful personality: although her body was dying, mentally she was strong, insistent, as alert as possible considering her chronic hypoxemia and the sedatives she was being given. Dylan Thomas wrote about her: “Do not go gentle into that good night; rage, rage against the dying of the light.”
I know that every patient I see with mesenteric ischemia will remind me of her, and I will fight fiercely for them, trying to keep them from following her path.
The other night I was at some social event in the area. A girl ran up to me, with beautiful curly red hair, her eyes shining. “Alice! Don’t you remember me?” I must have stared at her pretty blankly, because she went on, “Annie – remember?” People look so different when they’re dressed and made up, not sick and pale in a hospital gown in the middle of the night. It was the girl who had the appendectomy a couple weeks ago, who was so anxious, whom I ended up praying with and holding her hand all the way to the OR. She hugged me right in the middle of the crowd, and chattered happily for a few minutes. I like grateful patients :), but I have no idea what to say to them.
I feel like the best things I’ve done in the last year have been of that type: holding patients’ hands, soothing them through a thoracentesis or an epidural or whatever, when the nurses and doctors are too busy to do so. Those are the things that patients have actually appreciated about me; and soon I’m also going to be busy, maybe too busy and too “macho” to hold hands or spend time talking. I don’t want that to happen – but on the other hand I would like to be the one actually doing the procedure that makes the person better, not just standing and watching.