Handling fear—carefully

I have had a passing interest in gastroenterology for a while. I considered it as a career, but my brother beat me to it. In medical school, I wrote a thesis “Epidemiology of Liver Disease in West Africa,” and my houseman jobs were in GI units. Of course, cimetidine put my surgical team out of work (how many vagotomy and pyloroplasties have we avoided). I’ve forgotten more about GI than I ever learned. In those days, the rectal was routine. My staffman once told me “if you don’t put your finger up it, you’ll put your foot in it.” Sort of a mixed metaphor, I suppose. Along the way, I’ve seen lots of reflux, very little PUD, some IBD and dwindling amounts of cancer. I’m amazed by the resilience of the liver, after liberal amounts of alcohol and various toxins have passed through. My brother did his fellowship in GI, wrote books on endoscopy, authored papers and ran conferences. I got by. Read: Dr. Hector Baillie: Scottish patter I was well into my residency when it happened. I was the senior on a medical floor, with housestaff taking care of business (and me taking care of them). Our patients were spread over several floors, recovering from pneumonia, going for dialysis, rehabilitating post-stroke and coping with organ failure. Heather and Marge* were smart R1s, Bruce and Gord enthusiastic interns, and—along with Michelle, the bashful student—we were out to learn through experience. Bruce and Gord** had Scottish roots and played it up frequently. They wore tartan on ward rounds (their kilts were a hit with the nursing staff). They were young, smart, dedicated, hardworking and available (remember of the 3As—availability, affability and ability—the most important is availability!) With 50 patients under our care, we knew we were overloaded. The staffman was at his cottage on the lake most of that summer. One night, I learned how important it was to be on site. Liver failure is a pretty bad diagnosis. Mark Daniels was 44, a salesman, divorced with two kids. He had been admitted with jaundice and anemia. He bruised if you looked at him sideways. He had no appetite, and you could see his muscle bulk was pretty poor. But Mark was not an alcoholic (an occupational hazard for salesmen). He had idiopathic hepatic fibrosis. Mark was a candidate for a liver transplant, if he could get through the screen for cardiorespiratory health and psychosocial wellbeing. Of course, someone had to die for Mark. Usually in an MVA. Bikers were popular donors, in the days before helmets were mandatory. Mark was on floor 4A, room 23, and I was his doctor. Actually, his gastroenterologist, Dr. Nasrallah, was his doctor, but not this night. Mark had varices, and had been admitted after a bout of melena. Portal hypertension, splenomegaly and thrombocytopenia were his lot in life, along with impaired synthesis of coagulation proteins. Mark knew he wouldn’t last long without some tragedy at an intersection on the edge of town, probably at night in poor weather. Grieving family. Considerate mother. Multi-organ donation at short notice on the weekend. He’d get the liver, and the young diabetic down the corridor a kidney transplant—if all went well. After all, he didn’t deserve this diagnosis, it came from some genetic anomaly that cursed him and not the next guy. Alpha-one anti-trypsin deficiency, but somehow his lungs were spared. I got called to see him at 4:30 pm. He’d vomited about a pint of blood (that looks like a lot, and smells awful). His vitals were soft, his colour poor, his pupils dilated and his brow—covered in sweat. He was terrified. I called Dr. Nasrallah. He was in his office, seeing patients. “I can’t make it in,” he said. Bugger. “I think you’ll have to put down a Sengstaken-Blakemore tube, and call me back.” Dr. Nasrallah was running an outpatient clinic somewhere, and dumping this horrendoma on me. In those days, you did what you were told, seldom questioned authority and learned on the fly. I hadn’t seen a Sengstaken tube before, nevermind used one. I knew it was an NG with a balloon half way down, and on the end. By inflating the upper balloon, one could tamponade bleeding veins in the oesophagus. The distal balloon—when inflated—could compress high gastric varices too. And I was going to learn this skill—tonight. I approached Mark. I told him he was bleeding from his oesophagus. I told him he was in trouble. Yes, I started saline, ordered O-neg and a cross-match for 8s units RBC and 4 of plasma. The labs came back with a hemoglobin of 68, an MCV of 109, platelets of 60,000 and an INR of 2.1. I looked at Mark. And he looked at me. I told him I would pass a nasogastric tube along the floor of his nose (always horizontal, don’t ever go up into turbinate territory, or you’re screwed). At one point, it would curve into the nasopharynx, and he would sip water and swallow to help its journey south. When I thought it was in place, I would inflate the lower and mid-point balloons with saline, and apply just enough traction to know it was OK. An X-ray would confirm the position of the stomach balloon. The proximal end would be gently weighted to keep it in position. I looked at the tube, a big sucker. I lubricated it with gel, and told my intern to connect it to suction. I’ve passed an NG tube before, but nothing this big. But Mark knew his life depended on this snake going down. And it did. I didn’t think of any other outcome but success. I was here to save Mark’s life, and tonight I would do just that. In the process, I used up heartbeats, sweated buckets, got grey hair and swore many times beneath my breath. How could I be landed in this spot? Because a GI ward has these sorts of patients? Or because my staffman wasn’t on site? Did I learn something that night? Yup. Could Mark have died from aspiration, oesophageal perforation, massive hematemesis or arrhythmia? Yup. But he didn’t. I never found out if he got a liver transplant—my rotation ended and I went on to the next one without the key feedback I needed. Was this ever going to happen again—no. I got my scout’s badge for hematemesis that night. And later in my career, I got others from similar unwanted challenges. As in intensivist in a small rural hospital, running between an MI in the ER—and a pneumothorax on a ventilator. My sort of stress test, I suppose. * Dr. Heather Domke, family practice, Winnipeg, Man. and Dr. Margaret McDiarmid, retired health minister, B.C. **Dr. Bruce Reid, retired orthopedic surgeon, Griffin, Georgia, USA and Dr. Gord McTavish, ob/gyn surgeon, Winnipeg, Man.

Handling fear—carefully

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