Thursday, February 19, 2009

When things don't go as planned...

Several months ago, I met a patient who had already been in and out of the hospital for months. He already had had many complications and was pretty sick. This guy had bladder cancer and had to have his bladder taken out. His ureters - the tubes that carry urine from your kidneys to your bladder - were instead fused to a part of his colon so that urine was diverted to his colon instead of his bladder. Immediately after the surgery, he had a heart attack, which is not common, but can happen because surgery takes such a big toll on your body, including your heart. He recovered well from this, and went home. Unfortunately, two days later he came back to the emergency room looking incredibly sick. It turns out that his wound had started to come apart, which is a potential complication of any surgery. His ureters were de-attaching from his colon, leaking urine into his abdomen, and he possibly had an infection within his abdomen. They had to open him back up and fix everything. In the end, it was all still leaking, so they had to place stents within his kidneys that led outside his body to drain the urine instead. He was discharged to rehab.

One week later, he was having his stents changed, and he suddenly became very very sick - he had a fever, the chills, and looked really sick. That's when I saw him. He had developed a very serious infection called sepsis where the infection is basically all throughout your blood. His blood pressure started becoming way too low and he had to eventually be transferred to the ICU where they could start him on special medications to keep your blood pressure up and your heart pumping. It turned out he had multiple types of bacteria growing in his urine, as well as fungus growing in his blood! That's pretty rare, but he had many potential sources of infection - not only did he have the normal sources that every else has (lungs that can develop pneumonia, urine that can develop urinary tract infections, and blood that with even just a blood draw can potentially develop bacteremia or sepsis), he had stents in his kidneys as well as an ostomy (his colon came to his skin and his stool came out through a bag) that were at high risk for infection. Moreover, he was a pretty sick guy, and he'd been in the hospital quite a lot over the last few months, so he was immunocompromised and at higher risk for infections, including hospital-acquired infections. Eventually, he was discharged about two weeks later to yet another rehab facility after being treated with multiple antibiotics.

Two weeks later he came back again. Actually, he had two emergency room visits in between as well. This time, he had developed serious bleeding from his gastrointestinal tract, requiring many blood and platelet transfusions. Over the next 6 weeks, he developed sepsis again and multiple infections, and also developed respiratory failure requiring intubation to help him breathe. Although after several weeks we were able to take the tube out and he could breathe on his own, he was still incredibly sick and his prognosis was very very poor. After many discussions and having dealt with this for nearly 6 months, his wife decided to make him DNR. After 6 more weeks in the hospital and the ICU, he eventually died.

I tell this story because sometimes, it can be amazing what a relatively simple procedure can lead to. I would not call a bladder removal a simple procedure, but I'm pretty sure this patient and his wife went into the operation with an optimistic attitude. He had bladder cancer, but it would be removed, and he would have to pee in a bag for the rest of his life. Traumatic, perhaps, but something you could live with. Instead, he had 6 months of increasing medical complications that eventually led to his death. I don't think the doctors did anything wrong at all, or could have done anything differently - sometimes it's just bad luck and unfortunately, patients and their families are often not prepared for things like this.

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