Let's continue the series of sad stories from the CICU, shall we?
It was 5 a.m. on Sunday, my second to last day in my CICU rotation. I walked in hoping it would be a calm day because I was going to be the only intern and our patient list was quite large. Obviously, by the laws of nature, this was not going to be the case. The senior resident who was there overnight had bloodshot eyes, she had hardly slept that night because one of the patients had been decompensating for the past few hours. They were at his bedside all night long adding more and more pressors and then increasing the doses of these medications to their max. She quickly tells me about him and goes to lay down for a few minutes.
I immediately start looking through this patient's chart in the EMR, every intern's best and only friend. The first thing that pops up is that this patient's hemoglobin is 5.4 mg/dL with a big, red exclamation point next to it. Looking through his prior lab results, I see that all of his previous hemoglobin levels were around 9.0. I immediately think he must be bleeding so I walk around the unit to find the overnight attending to tell him about this lab result. When I find him, it seems like he's already seen this. He looks just like that big, red exclamation point. The nidus of our patient's decompensation was starting to present itself. Literally, an internal bleed was the last thing on everyone's mind. Usually, in the cardiac ICU, it's easy and generally safe to assume the cause of a decompensation is the thing that brought them to the cardiac ICU, the heart itself. Not some random bleed.
Over the next few hours that morning, the remainder of the day team, attendings, nurses all arrive and our team is consumed by this patient. We get a CT scan that shows a massive bleed inside his abdominal cavity. How the heck did this man start bleeding all of a sudden? And why did we not see this sooner? Hindsight is 20/20 or in this case 20/24. Looking back, it seems that this bleed had been going on for a while now but kept oscillating between clotting and bleeding so we couldn't identify it from his blood pressure or the daily labs. Unknowingly, we had been giving the patient a continuous blood thinner to prevent clot formation (the right thing to do if you are not bleeding inside of your body) and suddenly the bleed opened up again. But because his blood was very thin, this time, the bleeding didn't stop.
We called upon the vascular surgeons, the cowboys of the hospital, to take our man and fix his bleed in the OR. They came, they looked at him, and then ... they declined our patient. His heart was too weak. He was too sick! Too sick for the vascular surgeons?! That's like saying there's too much snow on the ground for a snowplow truck.
It seemed like our man was running out of options. But how could this be happening? Usually, people as sick as him are too sick for their brains to work properly and are delirious. He had a breathing tube in his mouth to support his lungs, and while he couldn't voice his thoughts, he was still able to motion to us and communicate. Everything else that happened today signaled that his time was coming but I hung onto this hope that because his mentation was okay, he would get better.
Whenever we asked him what he wanted or what he thought, he would just motion to us to call his wife. Frustrating, because I had been trying to get in touch with his wife of 60 years all morning long. Apparently they had been undercover CIA agents together in Germany back in the day. Recently though, our sick patient was her primary caregiver. Turns out he was the healthy one in the relationship and she depended on him.
Finally, she arrives. Even if she was that sick, you couldn't tell. Her back may have started to hunch but her voice and aura emanated strength. You could tell that even if her health was not good, her mind was sharp despite being in her 70s.
Suddenly, his oxygen saturation drops despite being on full lung support with the breathing tube. His wife cries out, "We've been together since we were 15 years old! You can't leave me now!"
He motions to us at this point that he's done. He wants the breathing tube out. All he wants now is to spend his last moments in peace with his wife.
This is when I realize I have to step away because I cannot keep it together and my tears are flooding out. Their story was so romantic and sad, like a movie. A love story like this can't be real life. I was not supposed to break down and he was not supposed to die of a stupid bleed! He came in with a weak heart and we were so close to fixing it. The procedure for his heart had been scheduled for the next day!
But it was too late. Many hours later, he passed away in peace with his beloved wife at his bedside.
"Rambling Resident" is an internal medicine resident at a large suburban hospital in the southern U.S.