The day began with the unannounced arrival of Patient X, whose story I shared last year. Now in remission from alcohol abuse for more than a year, this gentleman not a year older than me is in failing health but relatively good spirits. Our relationship is very friendly, peppered with jokes and jabs at one another, but the professional/therapeutic boundaries are secure. He burns DVDs that he thinks my wife and I will enjoy. When I come to his house to check on him he puts out white paper plates with cheese and crackers, playing the host. I’ve helped him set up some electronics in his home, advised him on several purchases, and cautioned him about spending too much money on things he doesn’t need. Recently, I read through the owner’s manual of his new police scanner to help him understand how to use it. He gives me a hard time and I give it right back to him. It’s a jovial, very fraternal connection. He trusts me. I like him. It’s mutual.
“I feel terrible,” he said.
“You look like shit,” I replied.
His cirrhosis is advanced, which we know from a liver biopsy. It’s also enlarged, which was clear on the ultrasound. His colon is clear of cancer since the recent colonoscopy was negative, but we know there are esophageal varices (picture varicose veins in his esophagus) from the increased blood pressure in the “portal circulation” connected to the liver. It’s also clear that his liver has a hard time processing dietary proteins because his blood levels of ammonia are chronically high. (Yes, ammonia like you use to clean your floor---it’s a product of the breakdown of dietary protein, and a sick liver can’t get rid of the ammonia so it builds up in the blood.)
“My stool was black and tarry all weekend, and when I vomited it looked black like coffee,” he told me. “Like coffee grounds?” I asked. “Yeah, like used coffee grounds. How’d you know?” I felt his abdomen---not hard, not tender. His skin wasn’t yellow from jaundice. Last time he was in liver failure and he was jaundiced, his eyes looked like flashlights covered with yellow cellophane. Not today, though. His blood pressure, pulse, and temperature were all OK. But he was thirsty, and said he was peeing in small amounts. “I feel dizzy, and the side of my head’s been numb all weekend.”
Differential diagnosis? Well, I assumed some source of internal bleeding (colon, some part of the portal circulation around the liver, or esophagus?); dehydration from bleeding, vomiting, and diarrhea (despite lack of rapid heart rate and other signs); anemia (from blood loss, causing dizziness, pallor, and numbness of face and head). His ammonia level is probably not astronomically high because he’s not really confused as he has been when it was really elevated.
Course of action? Nothing else to do but call 911 and ask for an ambulance to come to the clinic and take him to the ER at our affiliated hospital. His primary MD was not in, all the other MDs were busy, and one of our NPs agreed with my plan as I called 911. I didn’t need anyone to eyeball him. This was a no-brainer.
The paramedics came quickly, carted him off, and I called the ER charge nurse to give her a heads up that he as on his way. An hour later, I was to receive a call from the aER resident to let me know that he was being admitted to one of the floors. I gave her quite an earful based upon knowing this patient so intimately for three years. She thanked me and hung up the phone.
My workday was now only 30 minutes old. How many voicemails did I have already?
The day continued in a similar fashion of busy-ness, and then I left for school to torture fledgling nurses with details of cardiac and endocrine disorders. I shared the story of Patient X, who is now safe in the hands of the medical team at the hospital. My students' humor and good-natured banter quickly dispelled my morose mood from the vicissitudes of the day.
I am now safe in the bosom of the homestead. One day down, four to go. Is it really only Monday?