Evils and Angels Part I

Travelling amongst the nine levels of Dante (warning: some of this below is not for the squeamish)

In clinical medicine the average encounters are folks who engage in the small sins we all possess. People shade the truth of what has happened to them, or outright lie about what they have done. Some follow instructions to aid in their welfare, others swear they will and promptly continue their self-destructive habits. Others eagerly ask for and accept interventions with drugs, then fail to use them, or misuse them, or forgo them altogether due to side effects that they “forget” to tell the doctor about. Ferreting out and countering these and other simple everyday frailties of the human condition are a large part of the art of medicine. But human behavior is a bell-shaped curve, and the extremes on either end aren’t just seen on the nightly news report.

The very bottom end of that curve usually involves our callous inhumanity, or even our offhand savagery, to our fellows. These require a learned suspension of empathy, and occasionally, compassion. Over 50 years two such incidents stand out in memory. One of bestial aggression, the other the cruelest of passive aggression.

During training many fledgling physicians “moonlight”. In the old brutalist days of internship and residency (wherein you were truly ‘interned’ in the hospital, later given the slight freedom of ‘residing’ there), training in county medical centers was sixteen hour days of seven day work weeks with two or three night calls per week. Some would work a “free” night off in another hospital’s emergency room. These were usually smaller community or proprietary hospitals needing someone from 11 p.m. to 7 a.m.. They paid a moderate hourly salary with the expectation of two or three hours intermittent sleep for the moonlighter.

One such hospital was Broadway General, bordering one of our more troubled neighborhoods. My night began emphatically with an elderly, wasted lung cancer patient who was dropped off between her radiation therapy center and her nursing home due to a sudden fit of coughing blood. While staff began starting intravenous fluids, setting up oxygen, drawing blood, and all those other TV medical tasks, I leaned over to listen to her heart and lungs. She had a massive obstructed cough and blew a gray blood-speckled sponge into my face. A piece of her lung, dead from cancer and/or radiation. As I recoiled in irritation, she bled out and died. Our attempts at reviving her heart or breathing were immediately futile. I washed up, changed from splattered whites to spare surgical scrubs, saw her off to the hospital “morgue” (small room with large air conditioner), and filled out the short report. In the dark parlance of trainee medicine, she was a DIER—died in the ER. Acceptance of futility and impotence, and an absence of empathy in the moment, are some of the more important lessons in medicine.

That lesson was viciously repeated a few hours hence. Nurse roused me from the sleeping closet noting a “hot shooting” was coming in. Transport from a nearby all night convenience store was police car, as the officers immediately saw that waiting for paramedics would deny the victim any chance at life. Officers and ER techs loaded a wildly thrashing young man onto a gurney outside and rushed him in as the nursing staff prepped IVs, resuscitation gear, intubation trays, and called in the portable X-Ray machine and tech in a well-rehearsed ballet. The young man, not much beyond boyhood, had been the lone clerk at the convenience store on the night three people decided to rob it. He arrived in the ER face-down on the gurney, the police officers noting he had been shot several time in the buttocks. The robbers apparently thought it funny. Many vital organs, difficult to repair, are within the pelvis. But that wasn’t the issue. We flipped him over and immediately saw the thoughtless cruelty of the shooters.

They had him lie face down on the floor of the store—a tile concrete floor. 9 mm parabellum rounds (as later determined) at close range penetrate intact. Here they had gone through the boy’s pelvis, rebounded off the floor, and returned into his abdominal cavity. The damage was extraordinary, the bleeding internally and externally a flood of escaping life. We started large bore IVs, squeezed liters of fluids in, considered an “emergency angiogram” by squirting dye by hand syringe into his veins and arteries to get a portable X-ray picture of his internal bleeding sites, and considered whether to seek transport to a trauma hospital and/or call in one of our surgeons on staff. All this in a matter of less than three minutes.

In movies and TV, victims of gunshot often drop to the ground with little fanfare, some expiring immediately and quietly. Not so in real life. Unless placement is precise, the human body can tolerate multiple rounds, especially jacketed parabellums. This man was suffering unimaginable pain, and as his life leaked away, all his fight and flight hormones were maxed out. Trying to stabilize and treat him was a real physical battle by myself, nurses, and technicians as he struggled violently against death. Death, as expected, won. The grunts and grimaces of his passing remained with all of us. Another DIER, another set of scrubs, and a remnant night of helping police fill out their murder reports.

I was left wondering, did these beasts clothed as men laugh while they needlessly tortured this relative youngster? Did they really think their methods a lark, an entertainment, not a cruel delay of needless death? Being reburied in my training hospital later that morning, I never knew of any justice that might have been obtained.

Any knowledge of justice failed in another case experienced at my training hospital. While on medicine service, we were on call two nights a week, meaning caring for all our inpatients during the day and receiving new admissions from the emergency room all day and especially all night. One large room received males, another females. I rotated new cases with the other intern on the team, both of us fresh out of medical school. “Routine” new admissions gave our jaundiced eyes one of three impressions—an awake, curious and fearful person (the easiest as they could actually give you history), an agitated uncooperative person with a dangerously unknown degree of illness due to the presence or absence of drugs or alcohol or rapidly advancing acute or chronic illness, and a lump under a sheet. My next rotation was rolled into the women’s room, a motionless and unusually short lump under a sheet.

Always best to have an initial look and listen to a new patient before reading the ER notes. Listening was not to be. Pulling down the sheet revealed a very wasted (cachectic, think concentration camp victim) female of undeterminable age curled up in a tight fetal position. Eyes open, not responsive to my queries. No obvious acute physical distress. But the fetal position was not voluntary. All her extremities, hands, arms, legs, fingers, were all tightly contracted. That is, they could not be extended by the patient or by me. She had to have been in this position, voluntary or otherwise, for a long time for her muscles and tendons to “fix” in place. Confirming that I quickly noted a large deep decubitus on her lower back/upper buttocks. Decubiti are “bedsores” that form with continued pressure on just one area of the body, and form as skin and then tissue die and slough away due to poor circulation and pressure. They always tell of malnutrition and severe neglect. I spent a half hour drawing blood for tests and cultures, placing a catheter in her bladder and sending urine for culture, checking her stool for blood, and looking over the urine sample under the microscope for any signs of infection. The same with a swab of the raw flesh in her decubitus. I started intravenous fluids and ordered a chest x-ray. That was going to be a real challenge for the radiology technician.

Since she seemed stable for the moment and certainly was “self-restrained”, I finally reviewed the Emergency Room record. Just an 8 x 11 sheet, really, with various boxes checked/unchecked, a sentence or two of the history, and brief notes of an exam just detailed enough to determine that she needed to go upstairs. As in, almost nothing—her appearance determined her immediate need for admission and her destination amongst all the specialty services.

The history was of nonchalant neglect. She had been dropped off by family, as they “were no longer able to care for her.” (This was not an unusual reason for arrival in the ER). Given her condition, any “care” had ceased long ago. Bedridden, unmoved, starved. What could have been the proximate cause of her obviously severe disability? How could a family blind themselves so long, avoid the opportunities for home care or nursing homes, etc. that existed for the bottom end of the income scales? Why, how, or who, came to the conclusion that now was the time to finally dispose of her in a way that might relieve their guilt? Was it simply a matter of wanting to avoid the legal consequences of a death at home, and the almost certain subsequent investigations that would cause? The answers were more maddening than I could ever imagine.

Over the first twenty-four hours or so of her admission we treated her with antibiotics and fluids and considered our options for “disposition” In a county medical center this is all-important. Patients tended to stay for 3-4 days or 3-4 weeks, and the latter period usually represented a failure to move the patient on to the next appropriate level of care, clogging up your panel of patients and displacing new patients into hallway beds. General Surgery had already refused to take her but were coming by daily to remove dead tissue from her bedsore. Gastroenterology was trying to figure out how to safely place a feeding tube through her abdominal wall into her stomach given the immovable obstruction of her flexed arms and legs. Orthopedics pronounced her contractures as untreatable at this advanced stage. Nursing homes wouldn’t accept a patient with an active bedsore, and her nutritional status would need to improve over a long time before any tissue and skin grafts to her decubitus could be entertained by the Burn service. Handing over such a patient to the next medicine intern rotating onto the service without a disposition was an almost irreparable badge of shame. She, however, declared her own disposition.

About thirty-six hours into her admission, the fully evil nature of her family’s passive aggressiveness emerged. She went into delirium tremens, alcohol withdrawal syndrome. Only seen in those who drink alcohol heavily and continuously for a substantial period of time. The tools available at that time to suppress the syndrome and prevent death were fairly primitive and minimally effective. Magnesium infused continuously helped quiet the storm of the nervous system, as (perhaps) did an alcohol cousin called paraldehyde. Safer drugs such as valium were not yet known or approved for treatment.

While we struggled through keeping her alive for the next three or four days, our team’s Social Worker came up with answers that we almost couldn’t comprehend. He had learned that the young woman, our shell of a human being, was twenty-five years old, and had been a severe alcoholic for some years. All that, we knew from our experiences with her. He then relayed that the young woman at home became less and less active, unable to go to get alcohol on her own, finally unable to even get up to get it from the cupboard and drink it on her own. When arousing from alcoholic stupor, she would begin screaming endlessly to be brought a drink. And so the family would do, repeatedly, until she re-entered her stupor. Eventually they just kept a bottle of vodka at her bedside, and between cleaning up her excrement and urine, fed her the alcohol in bed. They became collectively exhausted of the effort and expense, and so carried her to the back seat of the family car and brought her to our ER. At least they didn’t truly “dump” her on the pavement outside the ER, as often happened.

Neither we nor she ever saw or heard from the family again. She certainly eventually died. I know not where or how, as after another week or so I collected my red badge of shame by handing her over to the next intern rotating in. And I did not want to know anymore of her or her family. Who willingly seeks familiarity with evil?

That was the 9th level of the bell-shape curve.

PART II EVILS AND ANGELS

RESTORATIONS OF FAITH COME IN SMALL STORIES

And yet that bell curve has another end, trailing off towards divinity.

Years later, well-settled in my private practice, I greeted a young mother and her pre-teen daughter along with “Grannie” in a wheelchair. Both mom and daughter were attentive and affectionate to Grannie, noting she had lived with them for some years after her husband had passed away. Concerns were minor, a possible chest cold, but always of concern in an elderly person with very limited mobility. Grannie’s ability to give history was absent. I quickly saw that this woman, her daughter, and the husband were providing a high level of total care to this lady. Their absolute rejection of consideration of “placement” in a nursing home, etc., quickly became evident. I saw no evidence of significant infection, but clearly a significant neurological problem was present. She couldn’t sit still, squirming and throwing her arms and hands about, legs shuffling, head bobbing here and there. Hearing seemed intact, but she gave no appropriate responses, grunting now and then with a wandering tongue and eyes. This appeared to be a movement disorder called chorea, accompanied by some form of dementia. A rather horrible diagnosis came to mind.

Huntington’s chorea is an hereditary disease, transmitted as an autosomal dominant. That means that a child of a person with the genetic error is very likely to inherit the disease regardless of sex. Onset of symptoms as the nervous system decays can vary from youth to older age, and the progression is always to dementia, total invalidism, and death. Here seemed a clear case in front of me, with two additional generations probably affected. How was I to broach this awful destiny to these warm, loving, attentive descendants?

As is so often the case, the patient and/or the family knew the real situation; here, atypically, there was no denial. I told the adult daughter that Grannie appeared to have a severe neurological disorder that, if confirmed, might be very important to the family. Daughter promptly answered, “Yes, we know, she has Huntington’s chorea”, with an understanding smile by both her and her pre-teen daughter. I asked if she knew the importance of this to her family. I wondered how she could remain so placid with this situation, especially with her daughter present. Was she in denial of the consequences of the diagnosis? How was I to explain the horrible consequences?

After the briefest of puzzled expressions, daughter volunteered, “Oh yes, we know about the heredity. But she’s not really my mother.” She then went on to explain that Grannie had been their new neighbor when she and her husband and baby daughter had moved in to their present home. Grannie and her husband became close friends, and, in effect, adopted grandparents of the young daughter. When Grannie’s husband, her initial caregiver, had died, they just naturally took her in to live with them, and had continued so for years.

And so they did for some time yet, until Grannie passed away, not in hospital or nursing home, but in her adopted family’s home, surrounded by that we all seek but so often fail to find.

Evil may visit us all from time to time, but now and then, angels do live next door.