Marsha had sailed smoothly through it all — at least, everybody had thought so — until the third day, when the connection between intestine and stomach pouch broke down. This had allowed her pancreatic and gastric juices to leak out inside her abdomen, and she began to digest herself. The digestive enzymes literally ate their way up through the incision, and her abdomen became an open draining wound about twelve inches in diameter. The nurses kept it covered with baby food, in the attempt to absorb some of the pancreatic juice and neutralize the enzymes. For weeks now the putrid and penetrating smell had turned everybody's stomach. But for me the worst thing about the case was that I knew I couldn't handle it. No way.
When I entered the small room where she was isolated, the situation was as bad as it could be. Her skin was a terrible jaundiced gray, and her hands were flapping feebly by her sides. The nurse seemed relieved that a doctor had come, but, instead of gaining confidence from that, I could only think, Oh, you silly girl, if you could see into my mind you'd see nothing at all, a big void.
Marsha Potts had apparently suffered total body failure. Leafing through the stacks of charts and laboratory results, I tried to get some hint of what was going on and buy a little time to collect my wits. A large black cockroach clung to the wall over the bed, but I didn't bother it; we'd get it later. It was hard to imagine that life in any form depended on my thoughts.
Yet a bit of information was beginning to drift across my mind. The pulse, yes. I felt for it and found it strong and full, about 72 per minute, almost normal. Good. Now, if the venous pressure had gone to zero while the heart seemed to be working okay, it must mean there wasn't enough blood on the venous side. At least I was thinking. The last thing I wanted to do was remove the bulky, sodden dressing from her abdomen. Drops of perspiration rolled down my face. It was damn hot in here. Blood pressure? The nurse said it was 110/90. How the hell could her blood pressure and pulse be so good without venous pressure? With no venous pressure the heart wouldn't fill, and if it wouldn't fill nothing would come out, hence no blood pressure or pulse. That's how it was supposed to work, but obviously in this case it wasn't. Damn those physiology professors. In the medical-school physiology lab, they had a dog with tubes sticking out of his heart, arteries, and veins. Everything worked perfectly there, as it usually did in the laboratory. When the professors reduced the blood in the dog's heart by dropping the venous pressure, the dog's blood pressure followed suit and fell rapidly. It was automatic and reproducible, as if the dog were a machine.
Marsha Potts was no machine. Still, why couldn't she work like the animals in the laboratory, instead of presenting me with an insoluble, overwhelming mess? I hardly knew where to start my examination. She didn't have any swelling of her skin from fluid retention, except on her backside — the usual place for such edema, as a result of lying in bed too long; Marsha had been flat on her back for about three months. I bent her left hand back, and it jerked forward. Fantastic. She had liver flap. When the liver fails, the patient develops a curious reflex: if you bend the hand back onto the wrist it jerks forward in a flapping movement, like a child waving bye-bye. Experiencing the joy of a positive finding, I looked again at the chart. Liver flap was not listed. I didn't know much about venous pressure, but I could write whole pages about liver flap, which I had found only once before. I tested her other hand, and the reflex worked again. It meant she was in very bad shape. In fact, while I was slipping into an academic appreciation of my diagnosis the woman was dying before my eyes.
In truth, she was already virtually dead; yet, technically, she was still alive. She had friends and a family who thought of her as a living person. But she couldn't talk, and every organ system was failing. Could she think? Probably not. In fact, for just a moment I knew she'd be better off dead, but I pushed the notion roughly away. How can you know someone's better off dead? You can't; if s sheer presumption. Marsha Potts's case was getting physically confusing, too. The woman with the herpes on her breast had looked alive but was in fact dead. The one in front of me in that small hot room was alive, but… What about the intravenous?
"How much IV fluid has she had over the last twenty-four hours?" I asked the nurse.
"If s all here, Doctor, on the input/output sheet. It's been about 4,000 cc."
'Tour thousand!" I tried not to appear surprised, although it seemed a lot to me. "What has it been?"
"Well, mostly saline, but some Isolyte M, too," she answered.
What the hell was Isolyte M? I had never heard of it. Twisting the bottle that was running, I read "Isolyte M" and, twisting it the other way, "Sodium, chloride, potassium, magnesium…" No need to read farther; this was a maintenance solution. The input/output sheet was a jumble of seemingly random figures, but I liked that. Right from the beginning of medical school I had been fascinated by the balance of fluids and electrolytes, so fascinated that I could sometimes worry about the sodium and almost forget the patient. This patient's input seemed to match her output except for what had soaked into that huge dressing covering the wound. A sump suction had been set up to pull fluid from the bottom of her abdominal wound, but it didn't seem very effective. Also, the bland food she was getting probably didn't have much nutritional effect. It was delivered to her stomach by a tube through her nose; since her own digestive juices had formed a fistula, or passage, between the stomach and the colon, the food was actually going directly from the stomach to the large bowel and out the rectum essentially unchanged.
Although she did not appear to be dehydrated, her urine showed obvious evidence of infection, in the form of blood, bile, and small bits of organic matter floating around in the catheter bag. With so much crud in there, the only way to learn if her urine was too concentrated was to test its specific gravity.
"I don't suppose we have a hydrometer on the floor, do we?" The nurse disappeared, only too pleased to be given a task, regardless of its potential merit. I still had no way to explain Marsha's venous pressure. I continued to examine her, looking for some sign of cardiac failure to explain it and finding none at all. Apparently the inevitable was closing in: I would have to look at her wound. "Is this what you mean, Doctor?" The nurse handed me a bottle of papers designed to test urine for sugar.
"No, a hydrometer, a little instrument you float in the urine. It looks like a thermometer." She disappeared again while I looked at the label on the bottle she had given me. Perhaps I'd test the urine for sugar anyhow; no reason not to.
"Is this it, Doctor?"
"That’s the baby." I took the hydrometer and unhooked the catheter bag. Holding my breath to avoid the smell, I poured into a small vial what I guessed would be enough urine to float the hydrometer. Carefully I lowered the instrument into the urine, but I couldn't get a reading. The damn thing kept sticking to the side of the flask rather than floating free as it was supposed to. I held the flask in my left hand and tapped it with the knuckle of my right index finger, trying to free the instrument. I only succeeded in splashing urine on my arm. By adding more urine to the vial, I finally got the hydrometer to bob up and down. The specific gravity was within normal limits — in fact, was absolutely normal — so Marsha wasn't dehydrated. For some reason, medical people shy away from the word "normal" without its qualifiers; if s always "within normal limits" or "essentially normal."