Broken

It was bound to happen sooner or later: I finally broke someone.

Last Thursday, we admitted an 84-year old lady with bad disease of her kidneys and their vasculature. Her kidneys were too sick to make urine, making her a good candidate for hemodialysis. (In hemodialysis, a patient’s blood is circulated through a big machine that sucks waste and excess fluid out of the blood–sort of an out-of-body kidney).

The goal on admission was to manage her acute issues, find her a slot for long-term dialysis as an outpatient, and send her home. Her most acute issue? Her very high blood pressure: she clocked in at 248/160, which we call “hypertensive emergency.”

We were having a lot of trouble keeping her pressures stable on beta-blockers and arterial dilators, two common medical modalities for treating hypertension. So yesterday morning, I suggested we try a drug called minoxidil, a venous dilator. I’d seen it used in another patient with severe, refractory hypertension, and it seemed like a good choice for this patient.

Indeed, minoxidil kept her pressures within our goal range on the first day of therapy. But this morning, her pressures were lower than they ought to have been. When I saw her, she was sitting up in bed, drinking a cup of hot tea, and looking completely adorable–and more importantly, completely conscious. Still, I stopped the minoxidil, asked the nurse to watch her, and left the floor.

Five minutes later, I was on my way to get coffee when I got a page from the nephrologist overseeing the patient’s care.

“Um, hi. Hey, did you see Ms. E this morning?”

Yes, I said.

“Did she seem a little unresponsive to you? Like, just…unresponsive?”

No, I said, I’ll be right there. I hung up and ran.

When I got there, she was lying back in bed, unconscious, with her eyes rolled up and toward the left. Her blood pressures had plummeted to 85/40–worrisome even in healthy patients. We pushed in intravenous fluids, called the neurologists, ordered a head CT scan–all the things we were supposed to do. She hadn’t bled into her brain, which was good. But she also wasn’t getting better with treatment; tonight, after getting 7 liters of fluid over the course of the day, her pressures are in the 120’s/80’s at best.

By this point, it’s pretty likely that this patient has had a brain injury–a stroke–due to inadequate perfusion of her brain. No one knows how to fix her. But everyone seems to agree that it was the minoxidil that broke her.

I think this is the part where I am supposed to feel really terrible, even though minoxidil was a totally reasonable choice in this patient. I mean, when most doctors choose a course of treatment that fails miserably, they usually feel that they have failed miserably.

But I still feel OK. Maybe it’s because minoxidil really was a defensible choice in this patient–a good idea that just played out wrong, and in the most unlikely of ways. Maybe it’s because I am a cold-hearted beastie with a conscience the size of a soybean. Or maybe it’s because she has not yet been declared brain dead.

Either way, my non-reaction to this surprises me a little. Maybe I’m broken, too.

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