The Patients That Scare Me

Each physician has his weakness, and mine is the heme/onc patient. While everyone who comes into the ICU is critically ill, I know how to approach most of them. I'm generally okay with strokes, seizures, heart attacks, heart failure, arrhythmias, respiratory failure, hypercarbia, GI bleeds, kidney failure, electrolyte imbalances, septic shock, cirrhosis, even the patient who has been in the hospital for months. These are people I cared for in medicine and who I care for now in the operating room. I understand the diseases and the physiology well. But the one population of patients that scares me is the neutropenic crashing patient.

Cancer patients, especially during and after chemotherapy become susceptible to so many different kinds of infections, including all the weird ones. The cancer itself can wreck the body with phenomena like tumor lysis syndrome. Patients are often malnourished, with weak immune systems, suffering the side effects of their chemo. And when they come into the ICU, they are so ill. Since I did not do a hematology or oncology month as an intern, I sometimes find this to be a big black box. So it is my focus to learn as much as I can about these disease states, ask for help early, and recognize my vulnerabilities.

Sadly, we had a very young patient after a stem cell transplant for a hematologic cancer who had every infection in the book. Her gut could not tolerate any food because of CMV colitis. Her blood was growing multiple bacterial cultures. She had a history of fungal infection. Her kidneys had failed from the antibiotics. Her breathing was labored from a pneumonitis compounded by fluid overload from kidney failure. She was on continuous renal replacement therapy (similar to hemodialysis), experimental antiviral therapy, and a ventilator. In the end, she could not cope with her disease, and we had to transition her to comfort care. It's so hard for young patients. We want fervently for them to do well and try everything we can, but sometimes it is not enough.