I sit on my front porch, the smoke of a cigarette lazily curling around my fingers. I’m not a smoker, but from time to time I bum one off a neighbor when I’m feeling particularly stressed. An old habit from an old girlfriend.

My patient, Simon, is dying. Bacteria have riddled his body, already ravaged by chronic illness, and he has been dying slowly for months. Last week, with the input of his loving family, we withdrew all medical care on him, and I’ve been watching him die for days. This morning I heard the first telltale sign of the death rattle. I’ve never heard it before, but it is a chilling sound. The Reaper is standing in the room with me, and I can see his hand on Simon’s shoulder. I have been with death before, but not like this.

Simon’s room is beautiful, papered with carefully hand-lettered signs. “Simon, we love you.” “Go with God.” “Happy Birthday From All Who Love You”.

His brother, Joseph, approached me today. Joseph and his mother are concerned that by not giving Simon fluids by mouth or IV, we are making him less comfortable while he dies. From a purely medical standpoint, I know this isn’t true – at this point, hydration will only cause his lungs to exude more fluid, drowning him in his own secretions. He’ll be far more comfortable without, but I couldn’t find a way convey this.

And then, Joseph laid his hand on Simon’s head. “I’m so sorry, brother. I love you so much.” Simon, who barely focuses on anything any more, turned his head to look into his brother’s eyes.

So I decided to take the middle ground. I started extremely low-dose IV fluids – so low that I hope it won’t make a difference – and increased the pain medications in case it makes him more uncomfortable. But I know full well that more pain medications will hasten his death by decreasing his drive to breathe. He’ll die faster now, and that decision must stay with me.

I sit on my front porch, the burden weighing heavy on my shoulders. Joseph and his mother may sleep easier tonight, believing Simon to be more comfortable, but I won’t.

I just sit, and watch the trail of smoke drift up towards heaven.

The Emergency Department was absolute bedlam. In the space of a few hours multiple trauma codes, medical resuscitations, and psychotic patients were brought through our doors. One patient literally bled pints of blood onto the floor before we got her to the ICU, almost exsanguinating in just a few minutes.

One of the drunks tried sprinting through the doors until security restrained him. He was surprisingly articulate in his verbal abuse for a guy with an alcohol level of 450.

People were being pushed around on gurneys and stashed into the hallway simply to make room once they had been stabilized. The level of chaos was audible in the noise of the department. Everyone was working with a purpose.

Walking by, I overheard a woman say to her boyfriend “Wow, this is like that show ER!”

I wheeled around and smiled a bit.

“Ma’am, this is ER.”

“Code Sepsis, here now“.

Her blood pressure was tanking as a result of a systemic infection, a condition known as sepsis.  Sepsis can kill, and quickly; the most important thing to give is intravenous fluids fast, and plenty of them.  Traditional IV lines are too small – the equivalent of using a garden hose to put out a fire.

A central venous catheter is used instead, where a large bore tube is placed.  Unfortunately few veins in the body – only deep ones – are large enough to support this type of tubing, making central line insertion a potentially very dangerous procedure.  The risks of popping a lung, hitting an artery, or triggering a deadly heart rhythm must be carefully weighed against the benefits.

I remember my first central line – it did not go well.  In fact, it did not go at all.  I knew enough to know that I didn’t know anything, and got cold feet before I had the chance to seriously hurt the patient.  Let me be the first to tell you, sticking a huge needle in someone’s neck is really intimidating. And these needles are huge.  Think Nicolas Cage in The Rock (great F’in movie) and you’ve got a rough idea of the size we’re talking.  Looking back on it, it was a smart choice.   Plenty of time to learn.  No reason to go cowboy too early.

Back to the present.  When I teach medical students to do procedures, I walk them through every single step of the way, and then have them teach it back to me.  Not just in broad strokes, but the nitty gritty.  Why?  Because if you forget to put on your sterile gown – or you put it on in the wrong order – well, then, you’ve screwed the pooch just as much as if you missed the vein, haven’t you?

So, I started.  Anatomy examined.  Skin disinfected.  Gown on.  Sterile field.  Ultrasound guided.  Vein accessed.  Wire threaded.  Vein dilated.  Line placed.  Sewed in.  Finished.

Total time elapsed – 15 minutes.  Not great, but 45 minutes faster than the last one I did.  Next time I’ll be better.

A question:  Can dirty clothes stay on the ground so long that they become clean again?

Well, after an absurdly long hiatus, it is my pleasure to announce that Agraphia is back!  She may not look like much right now, but I’ll be piecing together all the old posts, comments, and site structure over the next few days.

Apparently I got hit by a hacker, and was in the process of selling crude oil to some Afghani prince when Google stepped in and red-flagged my entire domain.  Still not sure what all that was about, but either way, I’m pretty sure I’m being audited by the IRS this year.

Long story short, a complete computer reformat and a complete website reformat later, I’m now running Windows 7 and the newest and hottest version of Wordpress, and I’m ready to do some typing.  I’ve really missed being able to post on this blog… didn’t realize how much it meant to me until it was gone. Posts to come!  I’ve got 2 or 3 that I wrote while I was waiting for the detritus to settle.

-Zac

P.S. Anybody who has needs 50,000 gallons of crude oil on the d/l… you know who to ask.

P.P.S. RSS feeds are officially:

http://feeds.feedburner.com/agraphia for the main rss/atom feed (for all you google feedreaders out there), and

http://feeds.feedburner.com/agraphia_comments for the shiny, brand new COMMENTS feed (I know you asked for it!).   Pretty Web 2.0 buttons to follow.

So here’s the first post I’ve got using the new server… for now, xanga has all the old ones. I’ll see if I can’t figure out a way to put all the old posts on here.