SCENES FROM A PRACTICE The Law of Averages

MEDICINE, LIKE ALL SCIENCES, TENDS toward mathematics. It’s frequently about likelihoods, probabilities, standard deviations, and averages. What’s good for the average may not be good for the individual, but taking care of sick people is an individual enterprise. I have never had an average patient. Sometimes the mathematics and the individual just don’t mesh.

Doctor Stan Perkase is a very scientific guy. An anesthesiologist by training, Stan had overall responsibility for the critical care unit. He endeared himself to the administration with his organizational talents. His manual of critical care procedures covered ever)’ eventuality imaginable. His disaster plan had been adopted by many other hospitals. His secretary’s word processor sang all day with census graphs, directives, and cost reports. He took very seriously the charge to maximize resources and prevent waste. He acted as a one-man steward of Medicare and the Social Security Trust Fund. On the phone, not surprisingly, he came straight to the point.

“John, the house is getting kind of full, I’m calling to see if we can move your patient, Harbaugh, to the floor,” he asked.

“Are all the beds in the ICU full?”

“Not yet, but it’s Friday, and there’s a high probability we’ll gel three-and-a-half admissions today,” he countered.

“Three-and-a-half admissions?” I asked, pondering “half of an admission.

“Well, yes. See, March generally runs a bit heavier, and for the last four years, March Fridays usually fill the house. Three-and-a-half to three point seven admissions per Friday in March.”

“Mr. Harbaugh’s a pretty sick guy, Stan. I’d feel better keeping him right where he is. Give me a call if things really get tight and we can talk about it.”



Peter Harbaugh had successfully avoided doctors for most of his 58 years. I had never met him prior to his unplanned visit to our emergency room-Peter came to our town for a convention of insurance underwriters. He had felt vaguely unwell for several days prior to his current crash. The tightness in his chest, a little wheezing, and a dry, hacking cough progressed to extreme breathlessness. The panic of near-suffocation drove him to summon help, and the subsequent parade of paramedics and ambulances brought him to us, very near death.

In the emergency room, he sat bolt upright on the litter, grasping the side rails tightly, his short, rapid, harsh gasps for air consuming all of his attention. He seemed both angry and frightened and he was rapidly turning blue. Blue people provoke a pretty quick response in the emergency room. Oxygen, arterial blood gases, and chest films happen almost automatically.

It was clear that something was desperately wrong with Peter Harbaugh’s lungs. The problem was not cardiac, it was pulmonary. His blood oxygen was critically low and he was not retaining carbon dioxide, so whatever was going on was obviously acute and not something superimposed on chronic lung disease. Instead of meeting warm, juicy, welcoming sheets of alveolar cells, his oxygen molecules were being rebuffed. The initial chest X-ray displayed only a hint of generalized haziness, which was not nearly as startling as Peter’s condition suggested. Light banter in the X-ray viewing room kept us from musing too seriously about the implications of this illness. We could all predict the outcome: a long, difficult time or a quick, dramatic demise.



Desperate diseases are by desperate measures relieved, or not at all. as Shakespeare (sort of) said. Desperate measures begin with intubation. Deciding to breathe for someone is presumptuous beyond consideration, which is why we don’t consider it very much. We just do it. Breathing is, after all, a rather personal activity. A beating heart and breathing define us as alive. We breathe easily most of the time and without much contemplation. For someone to do it for you is the ultimate parentalism.

After the initial shock of being paralyzed and having a large, soft tube thrust through his larynx, Peter was relieved. The suffocating pillow had been removed and his air thirst was slaked. Millions of biological engines ceased their screaming for lack of fuel, Blue became pink and all was well. For the moment.

Peter was moved to the critical care unit.

When in doubt, shoulder the shotgun and let fly. If death seems near, anything is worth it. or so doctors contend. Take cultures from his sputum, blood, and urine and begin broad spectrum antibiotics (could be sepsis). Give him large doses of corticosteroids (could be allergic lungs). Administer some diuretics (don’t want wet lungs on top of everything else). Tinker with the respirator settings. A little PEEP (positive end expiratory pressure) couldn’t hurt, and maybe a little more rebreathing tube to add just a dollop of carbon dioxide.

The diagnosis was not difficult, although the precise cause eluded us: Peter had ARDS-acute respiratory distress syndrome. Doctors call things “syndromes” to hide our ignorance of true causes. A syndrome is nothing more than a concatenation of symptoms and signs. It is reassuring only in that syndromes have been seen before by someone else. But if a doctor says you have a syndrome, don’t feel better. Be concerned.

Acute respiratory distress syndrome involves the entire lung and is characterized by a massive leak of plasma into the tiny air sacks. The plasma lines and cements the walls of these air cells and oxygen can’t get through. In children, we call it “hyaline membrane disease” and in adults, we call it ARDS. Infections, allergies, prematurity, and toxins can all cause it, but seemingly at random. Even oxygen (too much) can cause it. Peter, for whatever reason, had it in spades. Over the next few days, his chest films showed a progressive white-out. The plasma leak looked like Ko-Rec-Type spilled onto the X-rays.

Hooked up to the respirator, Peter was alert and sharp, but without it, even for brief times, he became breathless and panicked. With the respirator, of course, he could not talk, but he could write. He had the kind of script shown on commercials or on letters in movies, the full, rich writing of a practiced hand. Morning rounds became a dialogue of questions from us and letters from Peter. He had wit. The food he couldn’t have was awful, he wrote. The entourage around the bed looked worse than he did, he wrote. The metal urinal was colder’n a well digger’s ass, he wrote. He wrote and he joked but he got no better. We reached an uneasy, but steady, state: on the respirator, pink; off the respirator, blue.

Peter’s family arrived. A stout, honest, no-nonsense wife and two sons, all grappling with the fact that their No. 1 was tethered to a machine and not getting better, while not getting worse. Reasonable questions were answered with unreasonable responses. No, we can’t do lung transplants. No. nothing new in research. Yes, we have the pulmonary specialists in attendance and no, we don’t know how this happened.

Again, all the king’s horses and all the king’s men convened. They each rendered advice and counsel in their different dialects. “A little azotemia. Pre-renal and aminoglycoside induced,” opined the kidney doctors. “Ejection fraction pretty good and normal end diastolic pressure,” from the heart doctors. “Might want to bronchoscope him and brush for Pneumocystis,” offered the infectious disease doctors. Nothing happened. One by one, the entourage melted away to more pressing or more promising consultations. Our small team of doctors and critical care nurses maintained an uneasy vigilance and became more distressed the better we knew Peter. His banter continued. How could anyone so sick be so bright and alert? The primitive event of dying ought to be accompanied by primitive acts and gestures-grunts, moans, and coma-not clever conversation. Peter knew how fragile his condition was. He knew of our growing worry but he was careful not to press us for more information. Not because he was afraid of confirmation of the gravity of his disease, but because he didn’t want us to suffer more.

One day, an ugly, fluorescent yellow sticker appeared on Peter’s chart-a not-so-subtle message from the Utilization Review Team that Peter had now passed the average length of stay for the admission diagnosis and did we need assistance in discharge planning? Peter’s family became almost frantic and we felt impotent. Then Stan Perkase returned.

“Full house and one in the emergency room,” he announced.

“Yes?” I answered, knowing full well what was to come.

“Harbaugh is the most moveable,” he said, tapping his finger on his clipboard.

“Come on, Stan. He’s one of the sickest people here and you know it.”

“That’s not the point. Plug him into an algorithm and he doesn’t make it,” said Stan with an impatient edge in his voice. When I didn’t reply to what he believed was obvious, he continued with the lecture.

“Look, a persistent p02 of less than 60, more than 72 hours of an Fi02 of greater than 80, a similar time interval of PEEP, and a BUN of 50 puts him in the 95 percent non-survival category. There’s a bed in the intermediate unit and they can care for the respirator needs.”



For most patients, going from the intensive care unit to the intermediate unit is a graduation, a step up, and a step back from the brink with a time frame that shifts to days rather than hours or minutes. Intermediate unit patients can think realistically about home, a niece’s wedding, barbecues in the backyard, and changing the oil in the car. For Peter and his family, however, the intermediate care unit was a hospice, a gathering place of old, sad elephants. Peler accepted the lame “it will be quieter and more comfortable” with a generous “sounds good to me.”

Expectancy and action gave way to vigil. The order of the watch was, “Don’t just do something, stand there.” In spite of this, or perhaps because of it, Peter started to get better. His X-rays showed a few patches of nearly normal-appearing lung. His oxygen status crept up and he could tolerate longer periods of breathing on his own without the respirator. Having draped crepe and begun to mourn for him, we were slow to accept these hints of improvement. There was no way he could make it, we thought at first, but after two more days of improvement, our rounds became more festive. The gentle repartee between us became real and not forced. We were beginning to rejoice.

Then Peter died,

His weeks of wavering back and forth and desperately inching toward health suddenly stopped. The code blue was over in 15 minutes. Sudden apnea was followed by cardiac arrest and there was no response to body blows, hand-bagging respirations, searing watt-seconds through the nipples, and long needles into the ventricle. It was all over.

Sometime during the days before Peter’s death, a long rubber bullet, a clot. had begun to form in the deep veins in his leg. When its weight overwhelmed its tenuous hold on the vein’s walls, it broke free and ricocheted up the cavernous vena cava into his right ventricle. The heart’s turbine shot it the last 6 inches into Peter’s main pulmonary artery where it finally wedged, saying, “Enough of this nonsense.”

Peter almost beat the 95 percent rule He was almost outside two standard deviations. Five percent live there, and, statistically, if I keep at it, I’ll find them.

1 really want to beat Stan Perkase.