Long before the fish left the sea for land, there was conflict between complex and single-cell organisms. The conflict persisted in spite of a great deal of evolution by both, and in spite of the creation of numerous arrangements which allowed these very different forms of life to cooperate from time to time.
Mankind altered the relationship irreversibly over a half century ago. The large scale production and mass distribution of Penicillin ushered in the change. Ever since then, the bacteria have been evolving immunities to commonly used antibiotics, and mankind has been inventing new antibiotics for the Darwinian-surviving bacteria.
Last week I got a first hand look at the conflict. Some antibiotic-immune bacteria, which I will affectionately call Darwinian survivors, ran roughshod over my home turf. In short, I had a case of Sepsis, and it was the most intense illness I have ever experienced.
My brief and intense suffering has a public-service message embedded in it: If a doctor ever enumerates a set of symptoms that merit “aggressive treatment,” please pay attention. When the symptoms arise, muster whatever energy you have left, and — pronto, rapido, snell, sans tarder — check yourself into an emergency room ASAP.
My experience can illustrate that lesson. I apologize that this account is a bit long. Writing this is not entirely for public service. I have another goal. I am trying to come to grips with what happened and make sense of it. Writing brings closure after traumatic events, so this is therapeutic too.
(Also, apologies to all medical professions if I get some of the medicine wrong in the account below. Just email me. Thanks.)
Not near death
There is an old principle from statistics about the asymmetry between the general and the specific. After the slot machine arm has been pulled — and the winnings have arrived (or not) — the full distribution of probable outcomes no longer matters.
That principle does not apply to medical outcomes because humans have learned to intervene. If you will excuse a mixed metaphor, humans can change the odds after the slot machine arm has been pulled. Medical intervention can turn a little win into a bigger one. In my case, I faced a situation that could have resulted in a total loss if there were no intervention, but smart intervention turned it into a very painful inconvenience.
Perhaps this is why, after the worst was over, doctors seemed to revel so much in telling me how much worse it could have been. In very bad cases of Sepsis the victims do, in fact, get near death, or just die. I did not do either one.
My experience was just not as bad as the patient who got a fever of 107, or the patient who got Sepsis and found out he had cancer too, or the patient whose fever lasted over a week. This is what passes for urban myths inside a hospital. Nobody can reveal too many specific details because of privacy concerns, but there always seems to be somebody who had it worse.
That description of the general possibilities will frame where I am going, and the lesson in those events, namely, early intervention reduces the probability of a poor outcome.
The whole episode started innocently enough. On Tuesday I had a biopsy of my prostate to check for cancer. It is routine procedure after failing a routine screen. Many people who fail this screen do not have cancer, while some do. Like almost anyone who fails the screen, I wanted to know which I was.
As it turns out, the biopsy shows I do not have prostate cancer. The news came in the midst of the worse moments of this the Sepsis, however, so I did not really savor the news.
The Sepsis really started with a wee little part at the start of the biopsy. Before the biopsy every patient gets a piece of paper. “There is a small risk of complication from the procedure.”
“Small” means the vast majority of patients have the biopsy and move on. A countable few do not move on. My own primary care physician has been in practice for twenty years and he told me I was the first patient he had ever known to have the complication. You get the picture.
Here are the gory details. There is a small risk of infection to the prostate from the biopsy. Doctors have become proactive about it, giving patients antibiotics in advance of, during, and after the procedure. Why wasn’t that enough for me? I had the misfortune to have a Darwinian survivor in my gut — a bacteria with immunities to some commonly used antibiotics. How? Why? Who knows. Where did it come from? Lots of possibility.
This might never have mattered. The great beauty of the large intestine is how it keeps all those bacteria away from everything else in the body. But a biopsy disturbs that equilibrium. Those same bacteria suddenly found a way out of the intestine and into the blood stream.
That is what turned my body into a battleground between some (recently evolved) bacteria and some (recently evolved) antibiotics.
Aggressive treatment for aggressive infections
Here is what it feels like to have Darwinian survivors in your bloodstream. At first you do not notice anything. Then it hits a little, like a bad case of the flu, and then, before you notice the time pass, it hits real hard, and like nothing I have ever experienced.
I had taken the biopsy on Tuesday afternoon. I was tired most of Wednesday. On Wednesday evening I got a low fever (between 99.7 and 100.4), called my urologist as instructed (in the event of a fever), and we talked. He gave me some very precise instructions about symptoms to look for. His voice changed in a subtle way. If I got a few special symptoms, he told me to check into an emergency room for “aggressive treatment”, which is not the sort of thing you hear from a physician very often.
I will admit that he caught my attention with the change in voice and the phrase “aggressive treatment.” Catching my attention turned out to be a good thing.
He prescribed another antibiotic I had not ingested, which my wife dutifully went out and got right away from the closest 24-hour pharmacy (twenty minutes away — I love this woman for a reason, but I digress…). I took it and went to bed.
My urologist later told my wife that half the time a new antibiotic is enough to keep a patient out of a hospital. Translation: Half the time a fever indicates a Darwinian survivor is around, and a new antibiotic is enough to kill it and stop the infection.
Once again, I got lucky. The new pill did not work. I learned that comparatively quickly.
I awoke after midnight and my stomach did not feel settled. At about 1am I put on a bathrobe, and went downstairs to watch the TV, hoping this was merely a stomach ache from the new antibiotic. Maybe it is a symptom that I was not thinking straight already by that point, but I tried to see if I would feel less nausea by watching some TV with, um, upbeat content. I wanted something that would put me in a good mood.
There is not a lot of high quality content on TV after 1am on a typical Thursday morning, even with all the options available on cable. Mostly at that hour the typical program is a rerun of Love Boat or paid advertising for rather dubious products for weight loss and sexual enhancement. I did notice the absence of paid commercials for how to get rich quick by flipping real estate, which had been popular when my kids were babies, which is the last time I had surveyed these offerings with any frequency, so the choices had been reduced a little.
I went back and forth between reruns of Elena Kagan‘s confirmation hearing on C-span and the Disney channel. The senators were talking more than Elena, so I settled on Disney, once again demonstrating that I was already beginning to lose it. It was playing “Phineas and Ferb,” my kid’s favorite cartoon (and I like it because the writers makes adult jokes above the kid’s head, the way classic Bugs Bunny used to). That was fine for an hour. Then Disney’s programming switched to the Little Mermaid, which might cause nausea in some adults, but did little to me at that moment, which is another symptom I was slipping.
I started vomiting around 3am. That took a while. Then I did something foolish. I did not follow the doctor’s orders. I went back to the TV, hoping I might feel better. Perhaps the new antibiotic had merely upset my stomach, I thought. I had no idea that three hours later I would be on my back in the ER with barely enough energy to talk. Soon I got the chills. I felt awful. An internal debate began. “Aggressive treatment” kept coming back to the center of my thoughts.
At around 3:40 the doctor’s orders had won the debate. Or maybe I could not bring myself to watch Hannah Montana, which had now come on the Disney channel, and really does make me nauseous. I do not remember this moment very clearly, which is another symptom I had begun to slip.
I walked up the stairs to wake my wife. I got to the bedroom, and told her we had to go to the hospital. Thank goodness I have a wife who does not fuss over these things (I love this woman…). She got out of bed to go. Then the effort of walking up the stairs caught up to me. I vomited again. I did not realize it at the time, but the illness was beginning to accelerate.
She got dressed, and helped me get dressed. I noticed that I was having considerable trouble getting the energy to put my legs through my pants. I was not scared, but I was a bit confused. I did not understand what was happening.
We went downstairs and waited for her sister, so the kids had someone to watch them. I sat there for what seemed for a long time, but really was ten minutes. Then we drove to Evanston hospital. I noticed again that I had a very laborious walk to the car. Again I wondered.
It seemed like a long drive, but I have done it many times, so I know it is only fifteen minutes maximum. During the drive I kept thinking of a scene from “Stones for Ibarra,” a beautifully written book by Harriet Doerr. She writes of a moment in which a wife drives her very ill and unconscious husband to the hospital along a lonely Mexican road late at night, and she cannot help but notice all the details along the road, such as the beautiful flowers in the car’s headlights. It is such a lovely passage.
What a random association to pop into my mind at that moment. I had not thought of that book in years. I did not notice any details along the road. I could not focus on anything except the bumps in the road. I wondered which bump would make me vomit. I did not ask my wife if she noticed the flowers. I wondered when I would lose my grip.
We got to the hospital, and that would make everything better eventually. So let me say at the outset that I had a great experience with the doctors and the nursing staff, who were smart, competent, kind, caring, and first rate. However, I experienced two administrative snafus in the ER unit. Because I am a management scholar, normally I am the only one who notices snafus. However, these errors were so egregious everybody involved in my case saw them too, and other staff were embarrassed. (Note to senior administrator at Evanston hospital: FIX THIS!)
The first error hit us immediately. We walked into the ER and found no registration nurse at the registration station. We inquired. A few minutes later somebody said something about a bathroom break. I sarcastically thought “Yea, right.” The time involved was too long for any mere tinkle. More to the point, sustained lack of coverage of a critical station in an ER unit is unacceptable — even by the most forgiving norms of medical practice. But I was too tired for righteous indignation. I put my head down on my folded arms on the desk in front of me, forehead propped up by the arms, the way I used to in my college library when I wanted to take a nap at my desk. We waited for many minutes after that. Simply unacceptable.
A registration nurse did appear eventually, and things began to happen. By then I did not have the energy to stand for a couple minutes, or even sit up in the chair to talk to someone. I could barely answer questions. Somebody asked me if I needed a wheel chair and I said yes without hesitating. I already knew I could not walk a hundred feet, and maybe not even ten. Somehow I ended up on a bed and somebody started IV fluids. Doctors came in and spoke with us, then with each others. Time passed.
You know you are in a dangerous medical situation when the emergency room physician asks you to give your name, birthday, and the day of the week (this happened at around 6:30am). He was checking to see if I was still with it, and I understood that he was doing that. The moment felt surreal.
In fact, this was a sign that things were about to get better, though I did not know it at the time.
The question had a purpose. The infection progresses in quasi-predictable set of stages, and the doctors were not guessing about what illness they were facing. It was not one of hundreds of illnesses. They were pretty sure it was Sepsis, a known complication from a prostate biopsy. And all the symptoms fit that diagnosis. They asked me the questions because the doctors were trying to figure out what stage I had reached, so they could figure out which steps to take first. If I was coherent they did one thing. If not, another.
My wife (who is an ICU physician) filled in the detail for me later. If my blood pressure had dropped to a crisis level (e.g., the upper number falls below 70) I would have been incoherent or slurred my speech. My ability to answer such questions crisply did give the ER doctor a clue — along with readings of my blood pressure (e.g., around 87) and other vital signs — about how far the infection had progressed.
The rest is routine medicine, which is amazing to those of us who are not doctors, but actually is not all that amazing to those who do this regularly. The very first act was the most useful. IV fluids prevented my blood pressure from falling further, and, therefore, prevented me from going into shock, which was the biggest real risk at 6:00am.
As it turned out, early IV fluids had another benefit. It is also what helped me survive the second administrative snafu at the ER unit, which was, once again, so egregious that it went beyond any definition for acceptable medical practice.
At about 6:45 we spoke with the head urologist about what they had decided to do — a cocktail of IV antibiotics and more fluids. It was settled, and because it seemed to satisfy my wife, that calmed me. He told us he was headed to the operating room for another prostrate case, and that he would check in after he was done. At around 7am I was transferred from the ER to a regular room on the second floor.
That all would have been ok, except somebody failed to communicate the doctor’s order to the nurses station at my new location. I arrived, and no nurse had any permission to do anything. Later the administrative scholar in me would wonder “Isn’t there some sort of checklist about such orders when a patient leaves the ER? Dell sends a piece of paper with every product as it moves, so where is my paper? This is easy for an MBA.”
But we did not know that at the time. Some delay is not surprising because I arrived at 7am, the moment when nursing shifts were changing. Nonetheless, after an hour my wife got fed up, and started gently and persistently inquiring (As I already said, I love this woman for a reason….). Calls were made, messages were left, and everybody knew the doctor was in the OR, but staff had changed shifts so it was hard to trace anything back. Nobody could find any orders or his chief resident. My wife knew the orders in detail from our conversations in the ER unit — even the specific antibiotics the doctors had decided to employ. But, of course, she could not write the order.
Here is why orders matter. Nurses cannot do anything until they have them. During this time the nurses were putting ice packs all around me for the fever (this actually works, BTW). They did not yet have permission to administer Tylenol (as I learned, there are ways to do this that are not oral). Additional IV packs sat there on hooks, but our nurse did not connect them because she did not have orders to do so. I only had the one IV bag from the ER. The situation was absurd. More to the point, the bacteria and my body were still fighting (white blood count at 17000). The delay was both unnecessary and medically dangerous.
My wife told me later that during this wait she occasionally would take my blood pressure to see how I was doing. She could tell I was not getting any worse, and that was one of the main reasons she did not get too alarmed.
It took two and half hours for somebody to come and give proper orders to our nurse. Someone finally arrived and fixed the situation. She explained it all to my wife, and at first did it in a way that gave no ground, sounding evasive. The apology was perfunctory. All we wanted was a simple factual statement that ideal practices had not been met, and a sincere declaration that the next time would be better. Finally, I mustered up enough energy to use the sentence “I was neglected.” She said that she was sorry I “felt” neglected, which is the wrong answer. I did not have the energy for righteous indignation, to point out that I had not said anything about my feelings. I was simply stating a fact.
Her response finally set off indignation in my wife, who usually prefers to be cooperative with other medical professionals, and tries to act like the model patient she likes to serve. My wife, bless her, now used the words “two and half hours” and “unacceptable” in the same sentence. My wife is one of the best pediatric ICU physicians on the planet. When she says something like that, well, it really bites. I would have smiled if I could have smiled at the time, but that took too much energy. The other person stammered and left the room. At least I got my orders.
All along the IV fluids had done their job, and I had maintained a minimal level of coherence. The IV fluids had not worked miracles, nor could they, but it had set me up for the next step, IV antibiotics. Sooner would have been better, but only an expert could tell me now how much better.
As it was, they hooked me me up at 10am.
Routine Medicine and Darwinian Survivors
This is how the war between mankind and bacteria goes. The doctors are the generals and soldiers. The human body is the battleground.
One doctor told us later that they held a couple special antibiotics in reserve, which, so far as anyone knows, no bacteria can survive (but have some potential side effects, so they are a last resort). Several doctors also told me that I made this episode more challenging because I am allergic to penicillin, which is like removing a big set of weapons from the arsenal.
As it turned out, they did not need the special antibiotics. Somebody made the right guess early on, probably in that first meeting by the doctors in the ER Thursday morning. That cut short the suffering, for which I am grateful.
Here is how it felt. Think of the worse kind of flu at 101 or 102, then double or triple the consequences. I ran high fevers (102.5 to 104), had debilitating weakness and light-headedness, could not focus, could not gather enough energy to speak more than two short sentences, got chills lasting ten or more minutes, had an ever-present headache and dry mouth, and felt waves of nausea. It took all my strength and focus just to pee into a great big plastic container. My world became very small and immediate, never leaving the bed. My mind’s eye could not see the beautiful day outside, though the sunlight poured into our room.
On Thursday it never let up. Friday was a little better because there were times (that lasted an hour or more) where my fever was less than 101, followed by, well, the usual cocktail. I learned that the proper term for the return of the fever was a “spike,” as in the following sentence “A spike quickly came on at 10am with chills and a 104 fever, and the spike lasted several hours.” (That is a sentence I never want to say again.)
Did I mention that I could not eat or drink anything? I tried some water on Friday morning, but threw it up. I did not try again until Saturday.
Here is another benchmark for how bad a spike could be. Friday’s spike was so bad I had to turn off the World Cup. (No! Gasp!) And not just any game (Which one?!). In the middle of the Brazil/Netherlands quarterfinal (No! Not that game!). The spike happened at the worse possible moment, in the second half when the teams were tied one to one! (You are kidding! No! Gasp!) I was unable stay awake. I felt so miserable I had to turn it off and go to sleep. (Unbelievable! Oh! What timing!) Many hours later when I awoke I kept wondering… “How did it turn out?”
(Look, if you do not understand that last paragraph, then you are another dumb American who does not love soccer. I just cannot explain it. Let’s move on.)
Let me digress again for one amusing moment. There were not many of them, so I will savor the ones I got.
Many doctors came to talk to us. Several things produced that. First, my wife is a doctor, so — from the viewpoint of my doctors — she is the optimal spouse for a patient. She understands everything, asks great questions, etc. Second, there was an ounce of professional courtesy at work. Third, and probably most important, Sepsis does not come through the hospital every day. The case was rare, and, to the scientist in every doctor, my case was an interesting petri dish to observe. They wanted to check it out, and watch the progress.
When I was barely conscience but just hitting some stability on Thursday afternoon, a couple infectious disease doctors came for a visit (along with a couple residents). The doctors lingered, chit-chatting doctor-talk with my wife, while I lay there barely with it. I have heard this talk before, and I always joke that it involves too much Latin for me to understand. I tuned out. But then my wife told the doc I was a Northwestern Professor, and gave a little background, etc. He asked her what topic my dissertation was in… Before I could muster the energy to answer, she says “Internet economics.” He responds with… “A dissertation in Internet economics twenty years ago? That was foresighted.” My wife does not know what to say. There is enough of a pause that I get the energy to say “Computer economics” which uses about as much energy as I had at that moment. My wife told me later that she had thought I was asleep. She and others were surprised when I spoke. At that point, the doctor decided it was time to go.
Anyway, back to the main thread. After two truly miserable days … I woke up Saturday and the fever was gone. The doctors kept warning me not to celebrate too soon because spikes had a way of coming back, but the fever never returned. It was the only example in which a rare outcome went in my favor.
I was discharged Sunday morning after the last regimen of IV antibiotics. Waiting for that to finish I ate a hospital omelet with cheese, mushrooms, spinach and tomatoes. It was my first and only big meal since checking in to the hospital. I did not eat Thursday or Friday and ate lightly on Saturday.
When I got home I weighed myself and learned I had GAINED five pounds. How is that possible? The culprits were the many bags of IV fluids, which had made me bloated full of water. Ever since I got home I have been peeing every two hours.
It could have been worse
One doctor told me my body would feel like it had just run two marathons. That is an apt metaphor. As I write this, I bet I could manage to walk two hundred feet, but not at a brisk pace, and not much more. I do not care. It is great to be up and about.
Mankind’s fight with bacteria hit my home turf. Some great doctors and nurses intervened. Their actions changed the odds. I gained some bad experiences, which are now bad memories, but I am grateful for the outcome. It could have been worse.
So remember the lesson: please pay attention when your doctor says “aggressive treatment.” And do not stop to watch the Little Mermaid.
Late post script. A curious reader asks about the plot of the episode of the Little Mermaid — the episode I watched while deciding whether to go to the hospital. Funny question. Well, the plot went like this. Under the influence of some headstrong mermaid friends, the Little Mermaid joins them in a party without telling her father, directly disobeying her father’s command to always inform him of her whereabouts. Predictably, a storm approaches and the panicking father cannot find his daughter, which produces a crisis under the sea. In the end it all works out (this is Disney, after all), and the Little Mermaid learns a lesson. The lesson is about following the sage advice of parents, and doing so even in the face of potentially more satisfying and more immediate temptations. That overlaps a bit with the main lesson from my experience if one equates the authority of Little Mermaid’s father and that of a physician (a stretch, to be sure). That is, the lesson is to trust a doctor’s advice, even when other alternatives might appear easier or more convenient.