By Arne Vainio, MD
I had just finally been able to go to sleep when my pager went off. I knew the phone number all too well and was soon heading in for a delivery at 4:00 AM. Things didn’t go exactly like they were supposed to and after several hours I consulted the OB doctor and we ended up going for a C-section. By the time I left the hospital, I was over 2 hours late for clinic. I had called ahead and most of my morning patients were rescheduled.
Except for Richard. He told the nurse he would wait and when I finally went in to see him, he had been waiting for almost 3 hours. I walked into the room and started to apologize when he stood up and walked out the door. “You wanted me to come in and you make me wait all morning? I’m never coming back here again!”
I sent him a letter apologizing for making him wait, but he never answered back. I actually really liked him and I know he liked me. He always made it a point to tell me traditional ways of doing things and let me know what he was doing during any particular season.
His diabetes was poorly controlled and he was convinced if he ate natural foods it wouldn’t affect his blood sugar. He collected and cooked his own maple syrup and he drank it right from the jar in his refrigerator. He never actually checked his blood sugars and his hemoglobin A1c was always over 12. Normal is less than 6.5 and anything over 10 is out of control. The highest we can measure in the clinic is 14.0 and he had broken that barrier several times. He had had a triple bypass about 10 years prior and six months of his medicines usually lasted him over a year. Part of his left foot had been amputated due to diabetic ulcers that wouldn’t heal. At the visit before this one he told me he had blood in his stool and I set him up for a colonoscopy. Even though he agreed to go, he didn’t show up on the day it was scheduled.
I met his truck on the road to the clinic off and on and a couple of times he waved back at me, but mostly because he didn’t realize it was me. I talked with people who riced with him and fished with him and they told me stories about when he was young. He drank for years when he was younger, but had been sober for over 20 years and tried to live a traditional life.
I didn’t see him for almost eight years and one day his girlfriend called me. “Richard isn’t acting right. He’s been really sleepy and he couldn’t remember how to put his key in the door.” He wouldn’t let her bring him into the clinic and after about a week, he was so sick she called the ambulance and they brought him to the emergency room. His oxygen saturation level was low and blood work and a chest x-ray showed he had a huge pneumonia filling his entire right lung. He could barely breathe and he had a breathing tube put in and was put on a ventilator and admitted to the Intensive Care Unit.
He was being managed by one of the Critical Care doctors and I didn’t get to the ICU until later that night after clinic and several other hospital visits. By then he was on 2 different IV antibiotics and was getting IV fluid and IV medicines to keep his blood pressure up. He was in full blown septic shock from his infection and he was critically ill. His monitor showed his blood pressure was extremely low. His girlfriend had gone home and only his nurse was in the room keeping an eye on his vital signs and adjusting his medications.
The room was dark except for the lights from his IV pumps and the monitor screen. He had an endotracheal tube sticking out of his mouth and his chest would rise each time the ventilator whooshed, otherwise he was still. His nurse gave me a brief update on his condition and what had been done so far and I counted nine bags hanging from a rack of IV stands next to his bed. A urine catheter bag hung just below the white blankets on the side of the bed and it barely had anything in it. With his septic shock and his low blood pressure, his kidneys weren’t working and he was barely making any urine. He didn’t respond to my voice and I put my stethoscope on his chest. His heart rate was fast and his heart was pounding hard. I listened to his lungs. His left side was very coarse and crackly and his right side was almost silent because of the fluid and infection.
I picked up and held his hand. It was cold and bloated and dry and I squeezed his index finger gently and the nail blanched white. If the cardiac output is normal, it should regain color in less than 2 seconds. His took much longer than that. I listened to and examined his belly, then his legs. They were cool and edematous and I couldn’t feel any pulses in his feet.
I picked his hand up again and leaned in close to his ear. “Richard, it’s Doctor Vainio. You’re in the Intensive Care Unit and you have a bad infection in your right lung. Your blood pressure is extremely low and your kidneys aren’t working because of that. You’re on a lot of medicines and antibiotics. I don’t know if you can hear me, but you’re really, really sick.”
His nurse brought me a chair and I sat by his bedside and held his hand. The ventilator whooshed again and his chest rose, stayed there, then the ventilator let him exhale and his chest went back down.
“I remember your stories and I appreciate what you tried to teach me. I wish I could have gone ricing with you and heard you knocking rice as the flocks of redwing blackbirds rose and fell by the thousands in the rice beds. I’ve thought about you sitting by the fire on cold February nights with the stars bright above you and the trees popping and snapping from the cold as you cooked your maple syrup. I wish I could have been sitting with you as you told me your stories. I want to learn some of our songs and I always hoped you would teach them to me.”
The ventilator whooshed and his chest rose…held…fell.
“I don’t know how to make things better and I wish things could have been different between us. I wish we would have stayed friends.”
Almost imperceptibly he squeezed my hand and held that for just a few seconds. The ventilator whooshed and his chest rose and then fell again. I stayed with him for another ten minutes or so and I walked to his window. The lights of the city were bright and I could see a helicopter coming in to the hospital and the lights on the landing pad blinking. Only a few stars shone through the lights of the city and I could hear a siren far off in the distance.
The ventilator whooshed as I left the ICU and I got home at close to midnight. My pager went off at around 3:30 AM and it was Richard’s nurse informing me he went into cardiac arrest and they were unable to resuscitate him. Pneumonia used to be called “the old man’s friend” because it’s a relatively peaceful way to die. If he had come in a week earlier, I could have treated his pneumonia with a handful of antibiotics.
I wish things could have been different between us.