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Luger RoundsA Medical Mystery
By William Lynes
iUniverse, Inc.Copyright © 2012 William Lynes, MD
All right reserved.
I AM COMATOSE: "AN unconscious state from which a person cannot be aroused even with powerful stimulation; insensible, lifeless, and cataleptic." A prisoner in the intensive care unit, I appear unconscious to those around me. In reality, I am locked in. The horrible truth is that I am aware—I hear, feel, and even see everything. Ensnared in this real-life nightmare, a victim of an attempt on my life, I lie trapped and dying. Death would be preferable to my tortured condition. I am a nonperson ensnared in a medical prison, hurting, frightened, and angry.
Unbearable pain is my constant nemesis, an agonizing bedfellow, a continuous and horrifying reality. Existing is anguish; searing hurt is never far from my tortured consciousness. Pain is intense when I am turned from side to side; lying on my back is an incessant agony. Fever racks my useless body, its explosive appearance or rigors unbearable, its occasional absence excruciating as well.
With pain comes merciless fear, my gripping and unrelenting acquaintance. Vivid, demented dreams haunt my every moment. I long for the occasional image of peace. Through every moment of every day, I live a helpless and lonely life, racked with pain and unable to escape the terror that is the ICU.
It's obvious to me now. The state of coma is nothing like the unresponsive, unaware condition I was taught about in my medical-school hall of learning. I hear, I feel, and as a blind person knows everything about his or her environment, I see all that is around me. I am acutely aware. My existence includes daily doses of medically caused torture. As a physician, I treated comatose patients without knowing this reality. I have gone from healer to trapped patient: agonizing, fearful, tormented, and slowly dying in the ICU.
To colleagues and guests who visit me, I will not survive. Somehow I see them through closed lids as they stand quietly at the foot of my bed, diverting their eyes and staring without expression, my incredibly poor prognosis written on their faces as my monitor monitors away and my ventilator forces breath after painful breath. I am gorked, brain-dead, a train wreck, a Luger rounds candidate—all variations of the same hopeless theme that percolates behind their silent eyes.
Luger rounds—the term now sits bitterly, such an ironic and cruel phrase. The expression implies ending the life of a patient whose illness requires an overwhelming effort to maintain while it renders the patient too sick to survive. It is a pessimistic, gloomy, sarcastic idiom floated from one overworked staff member, intern, or resident to another. In the past, I used the term myself in an offhand and sick manner. It's an insensitive concept tossed around by physicians stressed by the never-ending hours of their postgraduate training. They spend many spans of forty-eight or seventy-two hours unsure when they last saw the light of day, hustling, writing orders, seeing patients, and hurrying through the wards. They're in the hospital seven days a week in a never-ending pattern, day after day. This ongoing, oppressive lifestyle eventually affects even the most noble of us.
I can hear myself in my past life, casually joking and using the term: "He needs Luger rounds. The guy in the unit—what a train wreck! You're covering for me tonight. Promise me! Luger rounds, please!"
Now, ironically, I am one: a clinical disaster, a dying corpse, a Luger rounds candidate. There is a difference, however. In my case, someone took the phrase to heart—at least metaphorically; the weapon was not a bullet. Keeping me alive now requires immense medical effort, and my chances of survival are so low that I myself, the victim of an attempted murder, have indeed become a Luger rounds candidate.
Over time, a patient in the ICU becomes a withering corpse, depressing for visitors and horrendous for patients like me who are trapped here. As time passes, fewer will arrive to pay their respects. As my case drags on, day after tragedy-filled day, visitors will become infrequent and rare.
To guests and staff, I am nonresponsive and brain-dead. Oh, I wish that were the case, for much worse than that, I am totally conscious and feeling inside. My eyes are closed, but I regrettably see everything. I am nonresponsive, but somehow I hear all, even at the nursing station. Here, imprudent conversations seem common.
"Page the resident on call," the nurse says to the ward clerk.
"Yeah, this is Dr. Wyburn. I was paged."
"Are you on call for Dr. Thomas in bed seven?"
"Yeah, what's up now?" the doctor wonders sarcastically.
"His temp is up again. He's febrile, 103 rectally. The Trendelenburg and the fluid bolus raised his BP for a while, but his MAP is down below sixty again. Can I get an order for another fluid bolus?"
"What was his last hemoglobin?" Dr. Wyburn asks. She woke him up again for this?
"It was seven this morning," the nurse responds.
"How much dopamine and Levophed is he on now?"
"Ah, let me look at his flow sheet," she answers while scanning her notes to see the dosage of IV medications. "The dopamine is at five micrograms per kilogram per minute. The Levophed is running at three micrograms—"
"What about his urine output?" the resident asks abruptly.
The nurse pauses. "He has put out only sixty cc's in the last eight hours."
"Okay, he's dry," he says to himself. "Give him two units of blood, packed red cells. And yeah, give a bolus of five hundred cc of normal saline for MAP less that sixty."
"Can I give him some more Tylenol?" she asks. "He's not due yet, though."
"Yeah, ten-grain suppository." Click.
"He is so rude," the nurse says to herself as she replaces the phone and walks to the supply room. She grabs one half-liter of saline and returns to the nursing station. On the phone, she orders two units of cross-matched blood from the blood bank. The nurse turns to her colleague, asking for help.
Upon returning to my room, she hangs the saline and begins infusing the five hundred cc through one of my IVs rapidly, a process know as fluid bolus. Both nurses silently glove up. Turning to the med cart, the nurse removes a Tylenol suppository and peels it open. I am helpless as they turn me. Once I'm on my side, the woman inserts the suppository with a gloved hand into my burning rectum. The drug works over time, treating my fever and relieving some shaking chills. While helpful, however, that friendly suppository is hell on my anus.
While she's at it, the nurse gets help placing the hammock to weigh me. I've gained weight from edema, the presence of fluid in my skin and other tissues, while my muscle mass dwindles as if eaten up. That tissue fluid is present from the massive amount of intravenous fluids used to support my blood pressure. The nurse carefully records an increasing weight on my bedside flow sheet.
The ventilator cycles with an annoying rhythm. The MedVac drips IV fluids through my veins and screeches, demanding the nurse's attendance. As the days have passed, I have become more and more aware, and time begins to plague me.
It is in general a poor sign that I am now in Trendelenburg position. With the foot of my bed elevated and my head dangling, my tiring heart beats along rapidly. This position increases cardiac filling in a desperate attempt to raise my refractory blood pressure, treating a severe case of hypotension. Drugs called dopamine and Levophed are running rapidly. These drugs are pressers, raising the blood pressure by contracting arteries to increase vascular resistance. Yes, they can raise blood pressure, but those sick enough to warrant the use of Levophed have a very high mortality. It is not the drug but the condition warranting its use that is troubling. I may become living proof that the intravenous drip of Levophed (pronounced leave-o-fed) is synonymous with the intern's casual moniker leave-'em-dead.
Yellow vitamins color the total peripheral nutrition (TPN), but the calories seem to drip through my central line pessimistically. Despite this concentrated nutrition, three thousand inefficient calories per day mixed with amino acids and lipids, I waste away daily.
Adult respiratory distress syndrome (ARDS) and pneumotho-races treated with multiple chest tubes convince me that comatose does not mean "without sensation." Cut-downs to find rapidly dwindling veins; DIC (disseminated intravascular coagulation); renal failure; liver dysfunction; and the need for Foley urethral catheters and nasogastric tubes shoved down through a painful nostril rudely demonstrate to this reluctant patient that covering the ICU is much preferable to imprisonment here. And with eyelids closed, I see the shadows, the people, the corners of my closing tomb of a hospital room.
I am Dr. Philip Thomas. In the sixth year of my residency, I am a chief resident in urology at one of the nation's most respected teaching institutions. When well, I was a thirty-two-year-old male of average height, weight, and appearance, with brown hair and brown eyes. I am a physician. I am supposed to admit people to the ICU rather than residing in it. Why, then, am I a corpse-like figure, wasted and thin, my hair greasy despite nurses' attempts at bedbath-type hygiene, with a spotted, half-shaven, dirty beard? What explains my ICU presence, supine in Trendelenburg with hands secured in soft restraints, an involuntary witness to my own cardiac monitor? Why do tubes enter through every bodily orifice? Why do I have persistent shaking chills and fever, tachycardia, and dangerously low blood pressure? Why do I have dwindling urine output and bleeding from every tube-inhabited site?
Sepsis with shock is the apparent reason. Sepsis refers to the wide constellation of signs and symptoms secondary to the presence of a pathogen, generally bacteria, in the bloodstream. Sepsis is a complex condition, but in simple terms, bacteria make toxins, which circulate and adversely affect every organ's function. The presence of these gives tortuous rigors and fever. Shock occurs, a condition of low blood pressure primarily caused by inappropriate dilation of arteries, which results in vascular collapse or septic shock.
This shock state poorly perfuses organs with blood and explains many of the findings in sepsis. Poor perfusion of the brain results in confusion and coma. The lungs fill with fluid, become stiff, and do not exchange gases correctly, resulting in low blood oxygen or hypoxia. This effect on the lungs has been termed adult respiratory distress syndrome, or ARDS. Here, a ventilator at high pressures must ventilate the lungs, and pneumothorax, or collapsing of the lung, often follows and must be treated with chest tubes. In sepsis, kidney function (renal function, in medical terms) is compromised. In addition, sepsis has caused disseminated intravascular coagulation or DIC. In this process, because of bacteria in the bloodstream, widespread clotting occurs. The result of this clotting is the consumption of platelets necessary for clotting, causing bleeding in other locations, such as IV sites.
While sepsis is the syndrome that is responsible for my condition, the septic source that began this illness is not so obvious. Sepsis, caused by an overwhelming infection, raises the question of source. While the medical staff do not know the cause of this overwhelming infection, herein lies my anger: the assassin knows.
Sounds, sights, and feelings fly around me, a bit like a seriously bad dream. Bits and pieces of conversations are stuck together in a disjointed array. I am trapped, locked in, and alone in my tortuous world. I am helpless and terrified beyond words as if continually falling. Tears of despondency appear at the corners of my seeing but closed eyes and are wiped away thoughtlessly by the busy nurse. My throat burns from the irritation of tubes. I long to swallow but cannot. Six chest tubes exit between traumatized ribs. I am paralyzed pharmacologically with Pavulon. The ventilator aerates another painful puff, somehow always off time. A nasogastric tube fills my nostril; a ghastly smell fills my one free nasal orifice. It is putrid and rotten like burnt tar, suggestive of hell, and I truly wonder whether they have admitted me to that eternal, frightening place. I have taken care of many in my condition; I didn't think they thought or felt, much less saw. You're trapped when you are here. It is frightening, but what can I do but think?
My mind drifts from the torturous prison of my life in the ICU to dreams, memories of the past and extraordinary created scenes. One moment I drift through a pleasant, historically correct reminiscence, and the next I am twisting through a frightening, psychotic world obviously created in my cortical brain. Then my level of consciousness clears, and I am aware of my tortured surroundings—sound, vision, voices, and most of all pain seasoned with unrelenting fear.
Physiologically, these dreams and feelings most relate to the rate of my morphine drip. The drug is used in this setting for its property of sedation. Without sedation, the patient bucks or fights the ventilator. Morphine works quite well, destroying the will to oppose the ventilator as it fills and empties my burning lungs. Like all medications, morphine works for its intended purpose but carries side effects as well. In the case of morphine, the adverse reaction is a huge one, for in the future, if there is one, withdrawal symptoms will torment me more than all the needles used to puncture my body by far.
My days are empty except for pain, fear, visions, and dreams. I am livid and viciously angry, unable to retaliate; my hidden assassin roams the halls of learning a free man. The morphine drip provides relief, but dreams of destruction often plague me. I begin to drop off. A rare peaceful scene takes over as a dream of the past appears, faraway and serene.
Chapter TwoMedical School
HIGHWAY 10 STRETCHES TO the horizon, a perfect black line of boiling asphalt. Heat blazes overhead, the sky a clear blue with spectacular white clouds, as I blast through the Texas summer. The red VW Bug's tiny engine screams while wisps of hot air blow ineffectively through the open windows and wind wings. This trip began two monotonous days before in the temperate climate of Southern California and continues now through the scorching heat. On and on the road stretches forever as I race along through small forgettable towns lined up along the interstate, making my way toward a new page in my life and medical school.
I must stop, pulling to the side to stretch my aching muscles and void behind a desert bush. I open the car door and slowly get up out of the Bug. As I stretch, I realize that I am lean, in shape from the years of competitive swimming, but the road has taken an immediate toll. I have become a professional student of sorts, and thoughts of school permeate my mind as I stretch. College is now history, and a new life at the University of Texas Medical Branch awaits me. Medical school looms as an ominous obstacle, and I am thankful to have been admitted after what was an incredibly competitive application process.
Back on the road, I speed on. From Houston, Interstate 45 takes me south toward my destination: Galveston, Texas. It is a historical treasure trove. The state legislature established the first medical school west of the Mississippi in the 1890s in what was at the time the largest city in Texas. I cross the causeway and realize, for the first time, that the city stands on an island in the Gulf of Mexico.
A modern city now sprawls around the huge university campus, the center of which is marked by the building of ruddy color affectionately called Old Red. The first medical session opened on October 5, 1891, with just twenty-three medical students and thirteen faculty. The building's true name is the Ashbel Smith building; it is a Romanesque revival structure constructed of red pressed brick, Texas granite, and sandstone.
The overwhelming heat is lessened somewhat as I stand in the shadows at the foot of Old Red's massive entry. I am twenty-two years old and dressed in a flowered Hawaiian shirt, cut-off blue jeans, and worn-out deck shoes. Galveston in the summer is overcome with oppressive humidity, and its musky smell pervades even my dream. Massive three-story arches loom above me, detailed in red stone masonry with arcades of windows finishing circular wings and an ornate portico, a testament to nineteenth-century architecture. I open a huge door and step into a dark and rundown two-story entry covered with what was once beautiful, ornate rosewood carpentry. Old Red is mostly abandoned now; only anatomy science labs occupy the first floor.
Through a door, I enter a room lit by surrounding floor-to-ceiling windows and ineffectively cooled by silent ceiling fans turning peacefully. Before me sits a world-renowned anatomical bottle collection covering black tables and filling glass cases that sit on the floor. Here hundreds of formalin-filled jars display detailed dissections of the human body. As I pass these transparent tombs, my dream is gruesome; the stagnant air smells of formaldehyde. Hands, forearms, shoulder girdles, and trunks are laid out with brilliant colors identifying arterial supplies, venous drainages, and nervous system plexuses. Chests, thoraces, pelvises, and detached arms and legs look back at me silently in their watery homes. A head encased in glass and formalin on the last table is startling. The helpless donor is a remarkably close match for the present chief executive, President Gerald Ford. Blue eyes stare back in indictment; his neck has been dissected skillfully and laid out in patriotic red, white, and blue colors, important landmarks pointed out with black arrows.
Excerpted from Luger Rounds by William Lynes Copyright © 2012 by William Lynes, MD. Excerpted by permission of iUniverse, Inc.. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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