Missing House MD Part II

In my earlier post I wrote about a middle aged lady who was just not passing any urine. And the problem didn’t seem to be in her kidneys. Her body was swelling with the water she was taking. All of it was just going into her tissues, and the swelling was rising. Soon she had at least 2-3 liters of water just in her stomach (abdominal ascitis). The nephrologists advised us to investigate her heart. So we went about getting her a cardiac consultation. The coronary care unit in our hospital did an echo cardio graphic study of her heart. It came out positive for mild mitral regurgitation and rheumatic heart disease. She had had episodes of this kind of swelling in the past two decades, but it was never so severe and it went away on its own in a day or two. At least we had a diagnosis. Or so I thought. The cardiologist said that the extent of mitral regurgitation and rheumatic heart disease was just not enough to explain the severity of her swelling or the severe lack of urine output. Yes, there was a problem with her heart, but it wasn’t the thing causing her the trouble she was having.

We were back to square one. It wasn’t her heart, it wasn’t her kidneys, what about the liver? You see, her albumin was low. Albumin is the protein in the blood that helps keep the water in the blood vessels, within the blood vessels. We had been correcting her low albumin with albumin infusions. It didn’t rise too much, but even with the amount at which it was, her edema shouldn’t have been that severe. Her liver enzymes, which are a marker of liver function, were raised, but marginally. She had mild jaundice. She had no viral infections that would affect the liver. We had to get a CT scan. Maybe that would give us some answers.

Meanwhile, her two sons, who were about 25 years old, were getting frustrated by the day. They had been told that it was intestinal obstruction, and then they had been told it was a problem with her kidneys, and then they had been told that it was a problem with her heart, and then they had been told that the problem with her heart was not responsible for her symptoms. Tempers were starting to rise.The patient was highly unco-operative from the start. We had to encourage her every time we gave her any medication. Soon, the swelling in her limbs was so much that she needed a central venous catheter to deliver the drugs right into her central blood stream. Not a single vein could be found in her limbs, at least not one that lasted more than a few hours.  A central venous catheterization has inherent dangers. There have been incidences of death, although rare. Still, the permission and co-operation of the patient are absolutely necessary. Co-operation was the one thing we were just not getting. She wouldn’t consent for it; she wouldn’t even keep her head still for the procedure. This was dangerous. If the anesthetist tried to place the line, and she moved, it could puncture into some pretty dangerous places. Without the central line, we couldn’t give her any drugs. 

The next day, I had a huge fight with them. Finding a peripheral vein in her for giving the morning drugs would’ve been impossible for me. They kept asking me to do it. I told them I would, but I could only find the time after a few hours. I had too many patients whose work was pending. They accused me of negligence. They started saying loudly that I was purposely ignoring my duty. I’m not sure if I raised my voice at them, but I think I did, because the nursing staff came to my aid when they heard me. The central line was ready for placement I told them. I had borrowed it with a special request from a different department, so that they wouldn’t have to spend their own money. They just couldn’t get her to co-operate. If she wouldn’t listen to them, if they couldn’t even convince her to keep her head still for a minute, how could they blame me, I told them. I felt bad, terrible really. It’s hard to get things done quickly in government hospitals. There’s a waiting time for everything. I had been running for days to get her scans done quickly, her echocardiography, her references, her CT scan, getting her free central lines, getting her two failed anesthetist consultations, which came and just went  because she just wouldn’t let them do anything. It’s a terrible feeling when you work so hard, and get blamed in the end. But their mother was dying. And if that had been my mother, I probably would’ve been worse than them. This thought was my only solace.

The CT scan report came that day. There was nothing in it. Only water water everywhere in her abdomen. Her kidneys were structurally normal, so was her heart. So was her liver. In fact, so was her bowel. Her intestines had no sign of a block, no perforation. It seemed perfectly fine. Why she had presented with obstructive features initially, I don’t know. One thing was clear. She didn’t need surgery or surgical management. My bosses wrote to the medicine department to affect a transfer. There was not much that we could do in our capacity. But then, they refused to go.

I tried to explain to them that they needed a medical diagnosis, not surgical management. But they wouldn’t budge. It was getting to be an impossible situation. That night at about 2 am, I got a call from her ward. It was our emergency day, so I rushed from the emergency to see what was wrong. The patient had started to have severe anxiety and breathing difficulty. We put her on oxygen and respiratory dilator inhalation. Then I rushed to get the anesthetists. She needed an ICU bed. But all the beds were full. The anesthetist on duty came with me to see her. There were two things we could do, she said. The first was to continue on high flow oxygen and monitor her every half hour, or put a tube into her throat and put her on a portable ventilator. But this was a woman who wasn’t even letting us give her medication through a central line. If we put a tube in her throat, she would just rip it out. I sat with the patient and her family. Every half an hour for the next 2 hours, I took arterial blood gas samples and didn’t leave till I knew she was going to be better. After an hour or so, her sons apologized to me for the allegations that morning. It was nice to hear, but by then it didn’t matter somehow. 

The next morning, she consented for a central line. She got her medication. Soon they agreed to be transferred to the medicine department. That evening I asked my co-pg’s in that medicine unit what they thought the problem was. They said, they didn’t know, but it might be some tumor that was causing her symptoms. It’s true, some tumors do have para-neoplastic syndromes that could resemble her symptoms, but it would’ve shown up on the CT scan. There was nothing there. I got back to work. Five days later, I called up her son to find out how she was. Her son wasn’t in the hospital, neither was she. She had died, 2 days after her transfer from a cardio-respiratory arrest. Her son had been told that her blood vessels were just not able to hold the water within them. This was because of the blood transfusions that we had given her at the start. Some immune reaction had probably happened that caused a septic shock like state. I kept down the phone. This was not an explanation. It made no sense.  That patient made me realize how important sense is in medicine. 

I’ve seen patients deal with cancer. I’ve seen them deal with the loss of a leg, even extensive scars and disfigurement after burns. But dealing with not knowing, that’s the worst. Continuously searching for answers, not knowing what's wrong, what can be done. There’s no way a person can move on from that. I guess that’s the point behind House MD. That’s the point behind a man obsessed with answers. Because answers are often more important than solutions. In this case, the family wanted answers. They needed House I guess, and I was missing him dearly.