Wisdom of Galen (1/1)
RJ Ferrance, DC, MD (rferrance@VCU.ORG)
Thu, 25 Apr 2002 21:47:00 -0400
All who drink of this remedy recover in a short time, except those whom it
does not help, who all die. Therefore, it is obvious that it fails only in
incurable cases.
-Galen, (130-200)
The Red Sox had taken the Yankees into extra innings. This ended up being a
very good thing for Michelle Webster.
Because after only nine innings in the bleachers at Fenway, she and Roger
had been having a great time. It was sometime into the eleventh inning, in
fact, when he'd slipped up and forgotten to use the past tense in connection
with his allegedly former girlfriend. He'd tried to blow right past it, but
Michelle hadn't been fooled. She had been paying a whole lot more attention
to meanings in words - both overt and clandestine meanings - ever since she'
d decided on law school.
So she was now using the past tense in connection with Roger. And that was
something that *she* certainly wouldn't slip up on.
It was probably for the best, anyway. The way the Yankees were hitting - or
actually, not hitting - the Sox actually had a chance to stay in the game.
Which could mean another three, maybe four innings. And she had to be up
early for that Shakespearean Lit class. Why the hell had she let Matthew
Brennan talk her into that course, anyway?
Oh, that's right. Because he was paying her tuition.
And letting her stay in his condo in Boston. And not coming around all that
often, and being discrete when he did visit, so that Michelle didn't have to
answer any questions about her good-looking rich uncle from out west.
She pulled a Sam Adams from the fridge on her way through the kitchen toward
the extra bedroom, which she'd taken over - without apology - as a study.
The Anthology of William Shakespeare was on the desk. But then, so was her
laptop. Maybe there was email from Amanda.
There was. A virtual postcard from Monte Carlo. It looked so warm there.
And so like there was no one there who would nag her into reading her
Shakespeare. But then, the more she whined about it, the more Matt would
tell her stories about the guy. She still wasn't convinced they were true,
but at least they were entertaining.
Scanning the list dropping into her virtual inbox, she saw the familiar
address of mbrennan@peds.scgh.org. The subject line caught her eye, mostly
because it was so unlike Matt to brag.
To: mwebster@sallie.wellesley.edu
Re: I did a magnificent thing in the ICU today.
She double clicked the email and then reached for the Sam Adams as she sat
back to read.
.and I'll be paying for it for the rest of my unnaturally long life.
His name is Richard.
I don't know why God chose to bring him into this life with a malformation
in his Vein of Galen (which is in his head, btw. You probably haven't come
across that in your governmental studies there at Wellesley). I doubt that
even Galen, himself, would dare to say he knew why, and I have it upon good
authority that Galen frequently felt he knew more about the human body than
the Creator does. But I digress.
Richard is now a "former 38week term baby, day of life number twelve,
post-op day number nine from an interventional radiology procedure to coil
embolize the high-flow feeder vessels to the aneurysm." He is now three
days off nitric oxide to help ameliorate his persistent pulmonary
hypertension and over night. he did poorly.
Richard shouldn't have been alive to go into my call night with me. The
literature says that there is a 35% mortality rate for Vein of Galen
aneurysms in the first week of life, and another 35% in the month following.
If the aneurysm is so large to as to create carotid "steal" syndrome and
therefore high-output heart failure, then the survival drops to 7%. And
have I mentioned that while on the table in interventional radiology,
Richard went into v-fib arrest? Twice?
Two days after the coiling, the neurologist read his EEG as "burst
suppression." Those two words describing an EEG strike fear with an icy
spike into the heart of any pediatrician. Burst suppression is the EEG
equivalent of a big old sign saying "Walk to the Light: This Way." The
neurologist, someone I consider a friend - to myself and to children -
summed Richard up in two words: "He's toast."
Last night Richard became bored with staring at the Light from afar. He
began the walk.
He's been on a ventilator, he's had inotropic pressors off and on. Last
night, he had the ventilator and he had all the pressors money can buy, and
he had platelets and fresh frozen plasma for the bleeding through his ET
tube. He also had parents - young, cute, idealistic parents who refuse to
believe their beautiful baby is toast - at his bedside throughout the night.
I was there, too, of course. And so was the Reaper. I couldn't see him,
but I sure as hell could smell him.
Richard made one hell of a dash for that light. This won't be the last
time, I'm sure, that he'll break his mother's heart.
I'm a physician. A pediatrician. A pediatric intensivist, specializing in
treating the sickest of the sick children. I am often the last thing that
stands between them and the great precipice of grief that they fear so much.
Mothers and fathers look to me with schizophrenic expressions of terror and
hope in their eyes. They don't see me. They see the long, immaculate,
starched white coat. They see the badge that identifies me as a Seacouver
General Hospital Pediatric Intensivist. They see my nearly perfect hair and
the perfect shine to my shoes. They see a tie that is always secured in a
perfect half-Windsor. They see a winning smile. They see a shining Knight,
clad in starched white cotton armor, not only prepared and willing but
*desperate* to do battle with the Grim Reaper on their child's behalf.
I took up vigil at Richard's bedside about 1am this morning. He didn't
*look* much different. But the monitor above his warming table was showing
different numbers. His parents didn't see it, of course. Oh, they knew
those numbers were not the same ones they'd been seeing, but they didn't
know what they meant. I did. They were the Reaper's doorbell.
I added another pressor. And then another. And then the fourth.
I played with the vent settings. I played some more. I got the respiratory
therapist to change from a conventional vent to a high-frequency jet
ventilator with a conventional background rate.
I gave lasix. I gave platelets. I gave more lasix and then more platelets
and then fresh frozen plasma.
Four different pressors and four different ventilator parameters to play
with. I played with them all. A pinch of that, a touch of this. Run this
up, run that down.
I put things together in my mind from precepts and algorithms I learned so
long ago I no longer even recall the lectures. I drew on the benefit of
things I've learned from a thousand different patients - some from times
when these things worked, some from times when they didn't. What I did, at
times, made no sense when taken alone. I did things that individually might
have seemed insane, yet collectively..
I lured Richard back, Michelle. He was so close to the light even I could
taste it.
And I brought him back.
He's toast, but I brought him back. He had a chance to die gracefully, and
I stopped him. He could have taken those steps into the next life, met God,
debated the problems of the Vein with Galen himself.
But I wouldn't let him.
So he lays there, on that warming table, bloated and edematous, with an
endotracheal tube sprouting from his mouth, a decompressing oral-gastric
tube taped beside it, an umbilical artery catheter and umbilical venous
catheter both plunging obscenely into what should now be his belly button,
and a foley draining the urine from his bladder. He doesn't move. He
doesn't even have a gag reflex. He doesn't see his mother's soggy eyes, or
his father's frowning brow. He doesn't hear the lullaby his mother sings to
him almost nonstop. He doesn't feel her hands on his forehead. His liver
is failing him. His kidneys are failing him. His heart is failing him.
Just like I failed him.
He's toast, Michelle. He tried to die with grace, but I wouldn't let him.
His mother thanked me today before I left, with tears dripping from her
cheeks. She could barely get the words out through her sobs of gratitude.
Gratitude for what? What did I do? I sentenced her to a life as the mother
of a turnip and SHE COULDN"T THANK ME ENOUGH!!
I'm willing to bet Richard has some other words for me.
He's missed his window of opportunity now. He'll probably live forever.
Thanks to me.
Dammit.
Miss you, kid. Hope you're studying your Shakespeare, hope you're catching
some Red Sox games, hope you're dating - but not too much. I've got a long
weekend the first of next month and I was thinking about coming out. The
Sox are away, but I'm sure we can still find something to do. Let me know
if it's a good time for you.
Study hard.
Matt
Michelle couldn't move for a few minutes. Until she was certain her hand
wouldn't shake when she put the bottle of Sam Adams back on the desk. She
started to click reply, but then reached for the phone. It was after
midnight in Boston, but she had three hours on Matt. The fact that he'd
obviously been up the entire night before notwithstanding, she knew he'd
still be awake.
"Hi, Michelle." Anne always recognized her voice. "Let me get Matt for
you." No small talk. So Anne knew, too. But then, she always did. It was
hard sometimes to believe the two of them were really keeping it platonic,
the way Anne Lindsay could read Matt's mind. And it wasn't as if the damned
thing came with a code key.
"Michelle. You're supposed to be sleeping," he groused. "It's a school
night."
"Bite me," she tossed back. "You told me never to miss a Yankees game if I
could help it."
"They held out for twelve, I see," Matt told her.
Damn, the game was over already? "Gave 'me a run for the money," she told
him. She'd never even liked baseball until he'd started dragging her to
games when he'd come to visit. Maybe he was hoping the Shakespeare thing
would work the same way. "I got your email," she said.
"Yeah, I figured that." Of course he would have. It wasn't as if her
calling was all that frequent an event.
"You sound better," she said. Gauging his mood, especially over the phone,
was almost as difficult as reading iambic pentameter.
"Anne held me down and made me eat some Ben and Jerry's Peanut Butter and
Jelly ice cream," he told her. "That helped."
"Always does," she said. "You could have read Mary a story," she suggested.
"Well, yeah, she made me do that, too."
"Don't let her get away, Matt."
He almost laughed. Good sign. "That would imply she was mine to begin
with, Michelle. How's Much Ado coming along?"
"Great," she told him. "But stop changing the subject."
"I have to change the subject," he told her, his voice losing its shored up
timbre. "The damned thing just quit bleeding, I'd rather not pick at it
just yet."
That she could understand. "You okay?" she asked him.
"Yeah," he told her. And that answer sounded genuine. "Anne's got a couple
more quarts of that ice cream."
Michelle laughed for him, because she knew how much he liked to hear it.
"You're a good doctor, Matt. It shouldn't surprise you that sometimes you'
re too good."
There was a long silence. "You need a couple hundred more years of
practice," he told her, "before you're going to be any good at phone
therapy. Go to bed, Michelle. I'm fine."
"I know you are," she told him. "And Matt? Thank you."
Another pause. And not even static to fill the silence. "What for?" He
sounded genuinely confused.
"For sharing with me," she told him. "You usually don't. You're usually to
o busy being the rich uncle. It's kind of nice, you know, to worry about
you once in a while."
"Well, you're welcome," he told her, the voice still soft.
"Les Miz is still playing at the Schubert," she told him. "How about if I
get tickets for the first weekend of next month? We might have to dress up a
bit more than if we were going to Fenway."
"Consider it a date," he told her.
"Good night, Matt. Get some sleep, okay?"
"Will do. And thanks. It was good to hear from you, Michelle."
She spent a few more minutes finishing off the Sam Adams, then shut down the
laptop and headed in toward bed.
She grabbed the Anthology off the desk on her way.
Just in case she had any trouble falling asleep.