Life at Grady: Groundhog Day

The following post, by Kimberly Manning, FACP, is adapted from her blog Reflections of a Grady Doctor and reprinted with permission. Names have been changed to protect privacy.

It had been a long week on the wards.

One of those weeks where you round and round on the same people over and over and nothing seems to change. Your medications don't seem to be working, your interventions don't seem to be helping, and your consultants don't have much to add. Yeah. One of those weeks.

The kind of week that just might drive a person to drink. That is, if spirits are their thing.

The worst part of that week was that it always seemed to start and end in the same place--the 5B stepdown unit. This floor was dedicated to those patients who were too sick to be on the regular medical floor yet not quite sick enough for the one-to-one nursing required by the intensive care unit. I had two patients on 5B that week and they were both right on the tippy-tip edge of being just sick enough to be in an ICU. But not quite.

This is what made that week suck.

I love the nurses on 5B, so it wasn't them. I even had love for my two patients that were on that floor. But what I didn't love so much was their ruthless medical problems, both of which were alcohol-related.

And these two patients weren't just sick. They were sick-sick. But despite all that, these problems were the kind that, more than anything, were treated with supportive care and watchful waiting. Which after about four days without any improvement whatsoever was getting kind of old.

Oh woe is me, right?

I know. I shouldn't have been complaining about the situation considering I'm the one who signed up to be a Grady doctor, right? But the thing is--the honest to goodness truth--is that this had nothing to do with why they had been hospitalized. No, it wasn't the self-inflicted liquor-thing at all. It's just that. . . .I like seeing people get better. I like seeing them ambulating through the hallways and getting well enough to start complaining about the food. I like when they get to the point of fussing about the poor choices of television channels and leaning over the nurses' station like it's some sort of neighborhood bar.

But these two? They wouldn't budge. No matter what I did.

(Click "more" below to continue reading.)

So every morning, I walked onto the 5B corridor and stopped at Mr. Paxton's room first. He had been admitted for alcoholic hepatitis complicated by alcohol withdrawal. He was mostly somnolent; eyes hidden behind puffy eyelids. In the fleeting moments that his eyes did crack open, the goldenrod hue that had replaced the whites of his eyes revealed the most startling jaundice that I'd ever seen.

Mr. Paxton had decided to stop drinking -- cold turkey. Bad idea considering he'd been drinking for his entire adulthood. Man. That body of his rebelled like nobody's business with seizures, agitation, vomiting and terrifying hallucinations. His blood pressure shot clear up to where they land the Grady helicopters and then his liver went berserk. Totally berserk.

All of this bought him one day in the Grady ICU but once he was stabilized, he came down to 5B . . . and subsequently my team. Great.

His wife looked tired. I remember how thin and haggard she appeared each day at the bedside and almost every time I secretly wondered if she was just worried or if she, too, had a thing for spirits. I never quite teased out which it was.

Anywho. The day Mr. Paxton came to us was punctuated by the arrival of another man who would eventually become his 5B neighbor--Mr. DiMarco. Like Mr. P, Mr. D had a long, strong history of throwing back stiff ones. He also had a doting wife who consistently sat perched by the bed or who could be found quietly ringing her hands in the family waiting area.

Mr. DiMarco was a lot older than Mr. Paxton. He probably had him by a good twenty years or so, and in those years he'd become set in his ways. Despite a weakened heart from alcoholic cardiomyopathy, he was still unapologetic about his daily drinking.

"Old habits die hard," he said to our team the day we'd met him in the Emergency Department. On second thought he sort of puffed those words because he was so short of breath from his decompensated heart failure.

I remember grabbing Mr. D's wrist while we were talking and feeling his speedy pulse. It was going well over 100 and was what most would describe as "irregularly irregular" -- a term reserved for the erratic rate noted in a type of heart dysrhythmia called atrial fibrillation. Though common in several other conditions, both chronic and binge alcohol drinkers tend to be at risk for this. The problem with atrial fibrillation is that the blood begins to sludge inside the ventricles from all that catty-wompus beating--which ultimately puts the person at risk for a stroke.

Mr. DiMarco's love for the spirits hadn't made taking medicines--like the ones designed to control his heart rate or the ones for thinning out his blood to avoid blood-sludge--much of a priority. And so. That galloping heart rate in an already pooped out heart made things worse. So we jumped on him full guns blazing--and seemed to be gaining headway after a few hours. That is until someone called us to ask:

"Was he weak on his left side before?"

Crap.

So yeah. Mr. DiMarco with his weak heart muscle and fast heartbeat now had a stroke to boot. Oh, and did I mention? He was a daily drinker so we could count on his body to start withdrawing just like Mr. Paxton's in five, four, three, two. . . .

*beep, beep, beeeeeeep*

Sigh.

So here is the part where medicine gets real. Extremely real. Where all that novelty starts wearing off and reality starts doing more than just kicking in. It starts kicking your behind.

Oh, and these were just two of the eighteen people we were caring for. Um, yeah.

So every day, I'd come and round in the morning on 5B with my team starting with Mr. Paxton. I'd hear what the intern and resident thought and listen to the update on the labs. Then I'd walk in the room with the team in tow and carefully examine him.

First, I'd say hello. No response. Next, a knuckle in the sternum to see if he'd respond. Nada. Unless you count a flash of fluorescent yellow eye-white as a response.

I'd feel his belly and listen to his heart and look for signs of seizure activity. Nothing.

We'd wrap up the plan and head over to Mr. DiMarco's room two doors down.

*ssshhhh, sssshhhh, sssshhhh, ssssshhhh, sssssshhhhh, ssshhhhh*

The sound of every person pushing their hand under the hand sanitizer dispenser followed by a synchronous sound of hands rubbing together that I can't quite describe. Just like before, the first thing would be a greeting. If his wife was there, it would be to her first. And then to him.

"Hey there, Mr. DiMarco!"

*heavy breathing in response*

With the team forming a semi-circle at the foot of the bed, I'd examine him, too. . .periodically glancing up to ask my resident if the Neurology team had any new recommendations for us beyond their initial interventions.

Nope.

So seriously? That week was starting to feel exactly like that movie Groundhog Day. You know -- the movie where Bill Murray wakes up over and over the same thing keeps happening no matter what. So this was what it was like. No matter what we did each day, nothing changed. At all.

And all because of spirits. Whiskey and bourbon and gin and beer. And sometimes grain.

I would end my day on 5B as well. Hoping that somebody would surprise me by asking me to get them a Co-cola or to even rub some salve on their foot. Something. Anything. But every single day the same thing. Nothing.

On the seventh day, I couldn't take it. The late afternoon sun was beaming through the windows and casting a glare on the electronic medical record. Labs--unchanged. Clinical findings--stagnant. With both patients. After seven days.

Great.

I got up from the nurses' station and slid my coat on. One of my favorite nurses, Ms. J, looked over at me and caught my shoulders curling downward. Next I let out a big, exaggerated sigh and she tenderly said to me, "It's gon' get better, Dr. Manning."

And I looked over at her and then just closed my eyes and sighed again. Because I wasn't sure. Was it going to get better? I mean, yes, technically my week would but would these patients? Would they? The jury was still out on that. On second thought, the jury was about to come to an agreement and I wasn't exactly excited about their decision.

"You know, Ms. Johnson? I don't know what else to do. I'm serious. These two patients just aren't getting any better."

"Well. . .they're not getting worse, Dr. Manning. That's one way to look at it."

"That's not good enough for me. I need them to get better."

Ms. Johnson furrowed her brow and looked over at me as she opened up the tube filled with medications she'd been awaiting from the pharmacy. She shrugged her ample shoulders and raised her eyebrows. "You know what, doc? Sometimes it ain't in your hands."

But this wasn't what I wanted to hear. I wanted my patients to get better. I wanted my hard work and all my fretting and reading and worrying to pay off. So this? This wasn't what I wanted to hear.

"So how do we do this, Ms. J?" I plunked back down on the seat with my coat on and lay my head into the crook of my arm.

"We just think and try and give our best. But at some point you realize it's something bigger involved in all of it, you know?"

I whipped my head up and stared at Ms. Johnson intently. "Well, this might be one of those times because I'm all spent." I gave a sideways smile and released the world's most anemic chuckle. I hate to admit it, but I was spent. I felt worn out and out of gas.

"Maybe, Dr. Manning. Maybe." Ms. Johnson stood still; studying me with her wise eyes framed with graying brows matching the crown of silvery curls on her head.

This was feeling heavy. Heavier than I wanted so I tried to lighten things up. I playfully lifted my hands in the air, "Alright, Jesus! I need a consult! An intervention! A somethin'! Come on and help a sista out!"

And Ms. Johnson and I both laughed out loud which lightened things up indeed.

"You want me to put that in the computer?" Ms. Johnson teased as she headed off to administer her medications. I gave her a playful wink, threw my bag on my shoulder and waved goodbye.

"See you later, Ms. J."

Yeah. See you on Grounhog Day.

The following morning, my resident was in clinic. I'd arrived earlier than normal and decided to sneak by 5B before making work rounds with the interns. The floor was quieter than normal. I attributed this to being the seven o' clock hour unlike our normally later rounding time. I couldn't decide if it was peaceful or eerie. Regardless of which it was, I followed my standard Grounhog Day ritual. First, I stopped at Mr. Paxton's room.

Hmmm.

Bed one had a lady in it that I didn't recognize. I strolled over to bed two -- his bed-- and froze. Empty.

No, no, no! It can't be!

Recognizing that alcohol withdrawal and alcoholic hepatitis can both be life threatening, I had to know that having them both at the same time could not portend the best of prognoses. But damn. I wasn't expecting Mr. Paxton to be gone. I realized how right Ms. Johnson was when she'd tried to encourage me by saying, "At least your patients aren't getting worse."

Well this was about as "worse" as it could get.

I dreaded getting the details. And even more, my heart began to sink as I imagined looking Mrs. Paxton in her tired eyes. I dragged my feet over to the nurses' station and found a clerk sitting behind a computer.

"What happened to Mr. Paxton?"

The clerk seemed to find my anxiety a bit off-putting and didn't hide it one bit. "He's in room 52 now. He got moved," she said nonchalantly. My face washed over with relief and I let out an audible "pheew!"

I turned toward 52 and paused. Well, this was convenient. He was now in the same room as Mr. DiMarco. Mr. Paxton in bed one and Mr. DiMarco in bed two. Imagine that.

I stuck my hand under the foam dispenser and approached Mr. Paxton's bed while rubbing my hands together. My mouth was already fixed and ready to ask my daily rhetorical question and it came out before I could even take in what he looked like.

"How you doing today, Mr. Paxton?"

And do you know Mr. P was leaning over the tray table circling his choices on the food menu? He glanced right up at me with those canary eyes and replied, "I'm good 'cept for y'all ain't got nothin' for me to eat. What's the RE-NAL DIET? I don't wont this. Or the no salt."

Seriously? I almost leaped on that bed and patted his face. I wanted to squeal with delight but instead kept it cool. "Mr. Paxton, you're talking! I'm so happy to hear you talking!"

And the whole time I examined him, he bitched about that diet and I swear it was music to my ears.

"I'm 'on have my wife brang me some real food up here today. She on her way."

"She is? That's great!"

Mr. P acted like he hadn't been knocked out for seven days and looked at me like I was crazy. "Seem like every channel y'all got is Jerry Spranger or a damn judge show!" he went on.

And that? That really made me want to waltz around his room with him.

Finally, I stepped out of the room to reapply the hand sanitizer before going to Mr. DiMarco's bed. "Well at least somebody has turned a corner," I mumbled to myself while extending my arm. Just as my hand went below the dispenser, I froze in my tracks. . . .recalling the last few words exchanged between Ms. Johnson and me the night before. I could hear her voice like she was right there:

"We just think and try and give our best. But at some point you realize it's something bigger involved in all of it, you know?"

I nervously pushed the dispenser over and over allowing way to much foam to go into my hand. For some reason, my pulse was quickening and I didn't know why.

What if. . . .? No.

When I stepped around the curtain, the first person I saw was Mrs. DiMarco. Her hand was wobbling and she was carefully scooting a cup of water with a straw in it up to husband's lips. The hairs on my neck began to stand at ninety degrees.

"Good morning, Mr. and Mrs. DiMarco," I spoke quietly.

Mrs. DiMarco looked over at me and smiled sweetly. "Oh hello, doctor," she said with a Kathyrn Hepburn-esque tremor in her voice. Her lips quivered gently as she shifted that smile back to Mr. DiMarco. From the corner of my eye I saw his left hand and arm moving toward the cup.

No. Way.

"He's moving the left side now?" I asked incredulously.

"Yes. It started late last night," Mrs. D responded while still focused on her husband.

"Wow." I couldn't hide my amazement at his improvement.

"Well," she spoke in her bumpy voice, "the Neu-rologists did say that we could start seeing some improvement and that it was just hard to say with all the rum fits and all."

The spirits. That's right.

By my second visit to 5B late that afternoon, those two guys were in there talking crap about the food and the television together. It was unbelievable.

Why they were put in the same room, I have yet to find a solid explanation for it. At least, not one that makes clinical sense. And I promise you--as sure as my name is Kimberly Manning -- this series of events is a true story. Hand over heart.

Okay, honestly? Y'all know I'm a person of faith. I've always been transparent about that among other things when writing here. But this? This shook me to my core. It really did.

"We just think and try and give our best. But at some point you realize it's something bigger involved in all of it, you know?"

You know? I think Ms. Johnson was right. There has to be something bigger involved in all of it. The human body and healing it is way too complex for it to be just explained by what's in our books. Regardless of what you believe or don't believe or are undecided about how you feel on what that "something bigger" just might be. . . . there are just some things that do not make clinical sense. Changes in patient outcomes that seem to happen almost independently of the things we are doing. Sometimes for the worse. And other times for the miraculous better.

No. I'm not saying that what we do medically isn't extremely important. But I am saying that I recognize that I am just a piece in a puzzle. A puzzle that is far more complex than even I understand. And that? That week on 5B? That was about more than just me, man.

At least that's what I believe.

Labels: Groundhog day, Life at Grady

posted by Jessica Berthold at 7:00 AM