I thrust off my maroon Nike FreeRuns and watched them find their final resting place after a single bounce and thud. They lay on my grey carpet, in the middle of my chaotic apartment which in turn was located in Omaha, Nebraska full of tall grass and yes, bright yellow stalks of corn should you be so inclined to find them outside our small city limits.
I collapsed onto one of my floral couches [which in my defense were already there when I had arrived]. They were adorned with sunflowers of various muted colors and as I settled in for a nap I stared deeply into their hastily stitched souls. Like an old film reel my mind began to play the events of the last few days. Entranced, I watched on.
“So tell me again doctor, what is happening?” a meek voice whispered from inside our large ICU room.
It belonged to the wife of the man who lay comatose in front of us. As the days had quickly passed by so had his consciousness — fading slowly with each sun set but never to rise again when we would return in the cold early mornings. I stared at the aging lady and noticed she was tired, probably with the weight of a pending reality that remained in the peripheries, arched and ready to strike at any second. The lack of sleep probably wasn’t helping either.
I answered after taking time to think of what would be the clearest response. “There’s an infection in his brain. It’s been active for some time now and to be honest it is quite dangerous.. He is very sick, but we will continue to do our best”. One of the three middle-aged women wearing matching dark wool sweaters, silently listening up until now, quickly looked at me.
“I thought an infection wasn’t likely? Weren’t we thinking that?”.
“We were” I replied. With a empathetic smile I nodded and left the room into the bright light of our hallway.
Until we were.
I remembered the day he came in.
“…and his sodium is 119, been like that for a few days now, we’ve consulted nephrology and are sending him up. Also kind of lethargic but no need for intubation or anything” a voice crackled through the aging hospital phone.
“Sounds good to me, hyponatremia, we’ll start correcting it slowly. Anything else going on?”
“Nope that’s it” replied the ER doctor right before placing the plastic phone back into its holster.
Fantastic, should be straightforward.
The next morning however was anything but. I came in to a sight that confused me. In place of the quiet man I had met the day prior was a tangled mess of wires and tubes. I found the nurse to ask her what had happened.
“He had a seizure and needed to be intubated afterwards”.
I clicked through our EMR trying to figure out what could have prompted this. The sodium was correcting at goal….he was taking an anti-epileptic at home….that hadn’t been restarted appropriately. My eyes fixated on the med reconciliation — 1500mg twice a day?! The earlier records had much less reported, about half of that. Was this my fault?
I don’t know… maybe it was it was the sodium it had been pretty low.
I shook my head and decided to continue on.
My trance broke and I ripped my eyes off the sunflower situated at the center of my three seated couch. I stood up and walked over to my bookshelf and flipped open a thick textbook to the page labelled encephalitis, common signs and symptoms”.
There it was.
“…signs include SIADH, seizures, personality changes, confusion…”
So perfect. So obvious.
It wasn’t the sodium or the medicine, just an infection. One that had nimbly avoided the probing of imaging, lab work or even a physiological response that could betray its quiet existence. Since then the signs of symptoms of encephalitis have been burnt into my skull. So too has the realization that hindsight is 20/20. Now when I approach a patient and I’m debating what to do I always ask myself one question.
How will this decision look tomorrow?
Fictional characters and events. Inspired by my time in residency.