Page 15 - Volume 70 Number 1
P. 15

I had just that morning pulled Mr. Moses’ IV because he was eating and drinking p.o. – I enlisted Dick Cashion’s \[a house officer\] help and we started to work up the fevers: blood cultures, WBC’s, diff’s, urines – I got through at 1:30 AM having learned nothing, but by that time temps had been taken again and both were beginning to come down.
By this time we had learned that a critically ill 12 year-old girl was on her way to the City from Chicopee with acute liver failure and encephalitis – a patient referred to Dr. \[Charles\] Trey \[specialist in hepatic encephalopathy\] who was putting her on Peabody 2. It sounded like a great opportunity so, despite my sleeplessness and fatigue, I stayed at the hospital
and it was worth it.
The events of that night are a tribute to the Harvard Medical Service, which mobilized at 3 AM—Dr. Trey, Dr. Tomlinson from neurology, Dr. Aster from Hema- tology, Dr. Reiner from the GI group; house officers Dick Cashion, Wolf \[Schmidt-Nowara\], Chip \[Conger\], \[John\] McGowan; Paula Kane who stayed to be special nurse; and even Jim Kenny. I just hung around, stayed with the parents for a while, helped Dr. Tomlinson with the neurological exam, and generally picked brains.
The presentation of this case was highly unusual: SGOT, SGPT of ~1000, ProTime 60 sec, BSP of 30%, but no icterus and normal blood ammonia. She was almost decerebrate in posturing but with wandering conjugate eye motion and flexor responses with the arms to pain. She was unresponsive and uttering short, garbled cries.
The neurologists felt she had encephalitis and that was that. Dr. Trey felt she had acute liver failure and would require exchange transfusion. One additional bit of information came from Dr. Aster who ran a series of clotting studies on her blood and found elevated levels of heparin. He calculated that 30 mg of protamine sulfate would correct her coagulation defect – and it did!
The girl, GG, did not improve but by Friday morning was more decerebrate and flaccid. Dr. Trey and I started the exchange transfusion bandwagon rolling by donating blood Friday morning – and after two days with no sleep \[and donating a unit of blood\] I got a little hypotensive and almost blacked out. On rounds later in the morning I sat most of the time. I was running on pure catecholamines and not having changes my clothes1 in 3 days and sweating freely,
I was something to behold.
GG was transferred to the ICU and the exchange \[transfusion\] begun at about 3 PM. ... After dinner I went back to the ward to write progress notes and again (my 2 patients) had fevers – which I again started, somewhat less energetically, to work up. But before I got very far, one patient (Mr. Jackson) arrested, and another, Charlie Bush, a legendary character who once received a $38,000 work-up for his alcoholic sequelae, and was in (the hospital) for the Nth time for GI bleeding, let loose and the iced saline lavage started. While McGowan and I
1 White pants and short white coats supplied by BCH. I took a pair as a souvenir at the end of the rotation.
lavaged in bed 3, Rohde and Herm put Jackson on the Byrd respirator – despite the fact that he was already fixed and dilated – and \[fellow student\] Mort stood looking. About 10 PM we put down a Nachlas tube and that seemed to control the bleeding for at least the time being. Cashion, Herm, and I went over to the ICU to see GG, who was unchanged, and John Markis, the AR from Medicine who is surgical consult showed us 2 articles about “Reye’s Syndrome” – a syndrome of encephalitis and fatty visceral degeneration which seemed to fit GG’s case. I finally left for home at 11 PM, suffering from total body exhaustion.
I got seven hours sleep and arrived back at the hospital (Saturday) refreshed and groggy at 8:30 AM. Bush was stable and Jackson had died. After rounds and Endocrine consultation rounds – Cushing’s Disease by Dr. Woebber – the day got started about 2 PM when Mr. Ochs go back from an IVP agitated, cyanotic, and febrile. Dave Gilmour and I started in on him when Pfaffenbach and the one nurse, Maureen Shea, started on Mr. Doherty, who had suddenly aspirated and almost arrested.
Meanwhile, Mr. Moses went into a tachycardia and an EKG recorded inverted “P” waves in II, III, and AVF indicating an ectopic atrial focus. The PR interval was 0.04 seconds. Carotid massage for 2.8 seconds converted him to NSR – it was really cool.
Mr. Ochs’ neck swelled up suddenly and he died an hour later of laryngeal edema and spasm, the result of a fulminant subcutaneous Staph infection \[Ludwig’s Angina\] – probably from a transtracheal stick done the day before. It was frightening and grisly. \[I remember thinking an hour earlier that he needed an emergency tracheostomy. Had we done that, it might have saved him – a lesson I have never forgotten.\]
Charlie Bush started to DT – or go into hepatic pre-coma – about then and it was quite a sight (seeing him struggling) to walk away from his bed with his three IV lines restraining him (as if he were spinnaker held back by its lines.) Then an admission came in – a Demerol addict. While I was down in the cafeteria (where there was free left-over food late at night) Mr. Doherty died quite suddenly around 11 PM. I started a fever work-up on Mr. Mancini who had spiked to 1030. Then at 12:30 Charlie Bush was found pulseless – about an hour after his BP had shot up and he developed a gallop rhythm. Probably cardiac failure due to overload of blood transfusions – although his Hct was 15 earlier in the day. We’ll know at post (mortem) time – he may have aspirated.
Mr. Moses was afebrile for a change and for the first time in two weeks he voluntarily used the urinal instead of soaking his bed, a real step forward.
I got home a 2 AM – a typical 19-hour day, except that three people died – five in two days. But for the first time I felt the excitement of the challenge of running the ward – just Gilmour, Pfaff, and I against disease and death. It has been a long time coming and I fear there will be many more weeks and days of frustration
Volume 70 • Number 1 Washtenaw County Medical Society BULLETIN 15

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