ANASARCA

Today was the beginning of what I foresee will be a long and torrid love affair - tempestuous and ambivalent - with the ICU. I should be writing up a month's worth of SOAP notes (which are due tomorrow, since they're a requirement now and all), but I feel compelled to share. I'd been getting tired of outpatient medicine; I'm not putting it down, but when I fantasize about medicine, that's not what comes to mind. And thus, I had high hopes for today - part of me feared that, after looking forward to it for so long, I'd realize that I didn't care for the acutely ill. That couldn't have been farther from the truth.

The first patient of the day was an acutely ill woman who'd been brought from her nursing home yesterday with some respiratory distress, had worsened in the ER and been intubated, and then had had seizure. She was unresponsive when I saw her this morning, lovingly attended by her sister - who now decides that she's supposed to be DNR. This woman's electrolytes were all out of whack, her heart was going a million miles a minute, and respirator-rhonci were almost audible sans stethoscope. I'll be following her all week - I'm fascinated by this. More time was spent with the computer records than the patient, because (1) she was unresponsive and (2) she really wouldn't have been able to answer questions in the detail necessary. She wouldn't have known that she was hypokalemic, or why - was it due to the steroid injection, or one of the 29 (that's right - twenty-nine) medications swirling in her system, each of them changing her regular and disordered physiology in their own, unique ways.

Next door to her was a man with cardiomyopathy, and by that I mean that his heart was failing. However, he was being kept alive by a tandem heart - a cardiac assist device that helps to circulate up to 5L of oxygenated blood when the heart isn't doing what it ought to - textbook cardiogenic shock, rescued from the depths of the grave by science an ingenuity.

The doc we're with is a lot of fun, and told me something I found fascinating - apparently, precalcitonin is a more sensitive marker of bacterial sepsis than either cultures or neutrophilia. That may mean nothing to you, but it's frickin' awesome to me.

Now, I'm thinking about cardiology and thus that Tandem ought to have been the hi-lite of my day. However, that honor was reserved for one gentleman in liver failure. This guy had some end-stage liver disease, hepatorenal syndrome, and hepatic encephalopathy. When we got to his room, we learned that his family had taken him off the transplant list and made him a DNR. The thing that I will never forget, though, was that he had edema everywhere.

Now, I saw pitting edema every day in the outpatient setting; folks may not have their HTN meds or whatever appropriately managed, some of it's just due to age - and so their ankles swell, and when you press your thumb over their tibia, it leaves a lasting dent in their skin. This guy had anasarca - which is when you get that pitting edema everywhere. In his case, it's because his liver pooped out and was no longer making albumin, which keeps fluid in the vascular compartment, instead of leaking out into the skin and the interstitium. I kid you not...this guy had pitting edema of his abdomen.

I love it. I mean...poor guy; he's not going to live long - but I'm fascinated and excited. This is more interesting than delivering babies.