Tales of Survival: Hot Air

August 20, 2009

bellevue.jpgBellevue Hospital, the nation’s oldest public hospital and the heart of our residency program, provides unique and unforgettable training for new physicians.  It is probably safe to say that every resident who trains at Bellevue graduates with a lifetime of stories about the experience. “Tales of Survival” was created to convey some of those stories.

Benjamin Bergman MD

 

Sometimes surviving a hospital stay is not so easy and the reasons are not so obvious. This is the story of how I realized that doctors frequently don’t have the time or the creativity (some would say lunacy) to consider weird diagnoses. 

I was accepting a transfer from the ICU to the medical floors, an ill woman with immunodeficiency, who had been unfortunate enough to fall down and suffer a deep laceration on her right cheek. It was really a very sad story; her social worker described her as a chronically stressed individual under significant financial hardship. It turns out the reason she fell was that she was rushing around making appointments to sort out her money problems. The wound subsequently got infected and the infection spread to her brain – meningitis. She was treated in the ICU and eventually improved, however, she continued to spike very high fevers. The cause of the fevers was unknown. It was at this point that I became her physician.

The details of her voluminous chart were overwhelming. She had been treated for the right bacteria which caused her meningitis. Most recently she had been spiking fevers for weeks with an associated severe diarrhea. The obvious players had already been ruled out. She was immunocompromised, so she could really have any infectious disease out there. For all I knew she could have some fishborne flesh eating bug or MRSA of clostridium or pseudomonas or herpes or fungal infection–the list was pretty much endless.

As I started perusing her chart, I noticed she had had an intra-aortic counterpulsation balloon pump, at least as read by the ultrasound technician during a routine abominal ultrasound. She had about fifty seven x-rays of her chest and abdomen done over the prior weeks for the workup of infection. I looked at a few of them, mangled images with fluid everywhere with roadmaps of electrical wires strewn across her chest and intravenous wires mapping her large veins.

When I looked at her, she was struggling to breathe through a tracheostomy, she was hot as a firebrand with an ocean of sweat on her face. She had lesions on her back; were they bedsores or herpes or heat rash or fungal infection? The dermatologists were unable to shed any light. She was spiking temperatures as high as 105 to 106 Fahrenheit. These fevers necessitated a full-time cooling blanket, around the clock Tylenol. We were no closer to an answer.

I myself was becoming frustrated by these problems. Everything had been considered: colonoscopy was performed which was unrevealing, an infectious disease consult had ordered as many blood cultures as coffees I had drank from the Bellevue Cafe, her urine was clean, the lungs seemed interminably infested with resistant bugs, thought she did not seem to have pneumonia, all of her intravenous lines had been pulled…yet the fevers continued unabated.

I realized I had to make a choice: 1. figure it out on my own why was she having these fevers,  2. defer to the infectious disease consult to figure it out, or 3. let her sink into the quagmire of a complicated Bellevue medical patient with the dubious diagnosis of “fever of unknown origin,” or FUO.  An FUO is a beastly diagnosis with a differential diagnosis longer than an encyclopedia–essentially every intern’s nightmare, full of mind-numbing hours of transport to and from bone scans, surreptitious blood cultures, sputum cultures, a plethora of sendout tests, stool scrapings, and all else that keeps your knuckles to the grindstone. I reluctantly decided to dig in and figure it out.

I now had to step into the patient’s messy and painful sickness, and take responsibility for either success or failure. I might decide to go down one pathway that could lead me astray for days or weeks or months. Sometimes we forget, but there was a person who was suffering from this illness. I spoke with her daughter who described her mother as really not doing very well prior to the fall with stress, anxiety, and depression. I felt that this was so awful that it happened this way that I wanted to make it right again.

To make an already long story a bit shorter, after looking at all her countless labs and CT scans and x-rays, I became obsessed with this one straight line on her chest X-ray. This strange, absolutely straight white line seemed to come from below the field of view of the x-ray. I figured it was some tube or wire she had been laying on, maybe it was part of the bed itself. It turned out–after lengthy discussions with multiple radiologists and attending physicians, and vehement denials, that she had a retained wire in her aorta. I was baffled at how this could have happened: she had never had an aortic balloon pump as the radiologist thought, she had had central lines including femoral arterial lines, but this metal wire was much longer than the wires that come inside central line kits; she did not have any interventional radiology procedures which could have left a wire there. I decided that this wire was what was giving her the fevers. I had figured it out!

I then spent the better part of an entire Saturday convincing the on-call interventional radiologist that I was not insane, but that she did in fact have a retained wire. I used just about every swear word I could muster to convince him to come in and remove the line. In the end, he used some really cool tools and was able to successfully remove the wire from her aorta. I hated him afterwards because he put up such a fight, but at least he got the job done.

So that was that. The wire was out, but two days later she was still spiking these fevers, albeit now only 102-103. So I kept at it. Maybe the wire, despite how ridiculous and wrong it was, was not the only thing wrong. I started over, looked at all her cultures, examined her skin, looked at those lesions on her back…and wait a minute… either I was spiking a fever myself, or I was wearing my grandmother’s fur coat by accident, but as I leaned over the patient to listen to her coarse breath sounds, I broke out in a sweat. Hot from below, hot from above, it seemed my patient’s bed was emanating a desert-like heat wave. I put my hands on the patient, hot like an iguana bathing on sandstone. I place my gloved hands beneath her body…the bed was literally baking her! I tore off the sheets. I stopped and listened, a sinister hum in the room clued me in. She had been, for weeks now, on the same mattress, which I confirmed with the nurse, transported her from the ICU with a special inflatable mattress with an air pump attached. I pulled the air hose off and unbelievably, the air coming out of that thing was volcanic. I checked the gauge on the machine, it was set to OFF, meaning no heat.  Yet it was pumping out HOT AIR. I ripped the hose off, called the nurse, asked her to get engineering in there and turn off this sinister bed heater which was literally cooking my patient.

Two days later – no diarrhea, no fevers, wire removed from aorta, the patient was still in trouble from all her issues, but she was out of bed, no longer sweating, the rash on her back now resolving and most importantly she was afebrile.

In the end, it was not any natural disease that was trying to take my patient’s life. The hospital system itself was to blame. No physician in the prior month of her hospitalization had had the time or the creativity, some would say lunacy, to consider weird diagnoses.

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