Submitted by Kevin Juan Zhang, MD
Published June 21, 2020
After printing off my rounding sheets and settling down to chart review my patients, I arrive at a particularly satisfying number: 58. A number that had trended down nicely from 440. As I’m finishing my review, I skim across the significant events tab.
10 pm: Patient’s eyes deviating to the left.
4 am: Patient less responsive.
6 am: Patient unresponsive, GCS 3.
My stomach lurches. He was supposed to make it out of here.
* * *
My month at the University Hospital ICU had been a grim one. Being the major quaternary academic hospital in the state of Indiana, our hospital receives a slew of incredibly sick patients. Typically they would creep in centripetally from each corner of the state, eventually arriving in Indianapolis—right in the center of the state, the crossroads of America. My team had some particularly testing moments. There were the ongoing seizures of the oldest surviving patient with pyruvate carboxylase deficiency who had just turned 18. The acetaminophen overdose that arrived at our doorstep with an ammonia of 996, only to be terminally weaned the following day. And the previously healthy 32-year-old lady who was transferred to the ICU after she was found to have hemophagocytic lymphohistiocytosis, only to have a cardiac arrest immediately after her central line placement. She was intermittently coded for 3 hours before accepting defeat. Opportunities for hope were few.
* * *
Here we have a middle-aged gentleman with pontine glioblastoma and a history of drug-induced liver injury secondary to temozolomide who presented with altered mental status. I assess the patient alongside his concerned wife and two children, who are at the cusp of becoming teenagers. I place the admission orders and wait for labs and imaging to return. One value immediately stands out: an ammonia of 440. All that’s racing through my mind is preventing cerebral herniation. We start giving him lactulose at a relentless frequency from both routes and implement strategies to reduce intracranial pressure. The next day we find out that he has herpes simplex virus hepatitis and initiate acyclovir. As days pass by, his ammonia slowly comes down and although still lethargic, his mental status appears to clear. Given his improvement, everyone starts to believe that we had successfully pulled him from the brink of death.
Nearly a week into his admission, at approximately 6 am, he lapses into a state of unresponsiveness. A computed tomography of the head shows an intracranial bleed in his glioblastoma. As the haunting image displays in front of me, I can’t help but think–why did this happen? He was improving. Coagulation studies and platelets were normal. Neurosurgery deems it as a spontaneous glioblastoma bleed, its innate vascularity lending its propensity to bleed. He is not a surgical candidate.
There are very few questions. It’s as if every family member knew that this day would come sooner or later since his diagnosis. His family accumulates throughout the day. I hold back tears as I watch his children sob over him. I’ve lost patients before but this one strikes me differently. Perhaps it’s because it seemed like we had a successful endpoint so close in sight.
Of all the complicated patients that started off with dismal prognoses, he seemed recoverable. It seemed simple enough at first—I just had to target a number. As his ammonia level went down, I could see his mental status improving. I was finally able to talk to him and build trust. Then as we neared our goal, he suffered a catastrophic bleed. The ammonia number didn’t matter anymore, and maybe it never did. I realized that I was trying to simplify things in order to sustain hope.
As I’m about to leave, his wife delivers a simple message: “Thank you”. Similar sentiments slowly echo in domino-like fashion through the room. I muster a smile, nod my head and leave.
In that moment I realized that I had forgotten a sad but valuable lesson. It was a truth I had progressively been learning throughout residency, something that had been particularly reinforced during this month. Despite all the modern medical advances, I’ve found the further I dive into my training, the more I become acquainted with the limitations of medicine. It's a sinking feeling to realize that there is nothing else that can be done. We invest years into medical education to help people, but sometimes all we can say is: there’s nothing else we can do. Those moments are as much a part of medicine as are the successes. And with her show of gratitude and acceptance, his wife simplified that humbling lesson—you can’t save everyone.
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