Joel L. Chinitz, MD, MPH
Philadelphia, Pennsylvania, United States (Spring 2011)
Adriaen Coorte, Dutch (1660–1707)
Oil on canvas
19.72 × 16.3 in
When the doors flew open, the noisy hoard—many in dirty, white jackets and floppy, bloodstained, green pants—circled the nurses’ station and overran the medical Intensive Care Unit. Wednesday renal rounds had begun. As two aides jumped back and fell into a linen cart, the unrelenting column spilled down the hallway, squeezed through a doorway, and disappeared into 512. Once inside the windowless, green-tiled room, Dave Ferguson, senior nephrology fellow, led Professor Burton Phillips, a stooped, grey-haired figure, to the foot of the bed. Residents and students scurried into crevices between the bed, the walls, and the chrome and plastic pumps, motors, and monitors.
Ferguson opened the patient’s chart and coughed, a signal to the undulating bodies surrounding the bed to secure their clipboards and shut up. The beep of monitors and the hissing of a ventilator suggested that somewhere in the middle there was a patient. The card read “Agnes Mulligan.”
The senior fellow opened the chart and raised his chin to its anatomical limit, “The patient is a 103-year-old white female who developed acute renal failure following cardiac bypass surgery.” The stooped figure to his right, Burton Phillips, the Leland Snodsmith Professor of Medicine and Director of the Division of Nephrology, peered between the dialysis equipment and the cardiac monitor to the head of the bed. The patient’s face was totally obscured by a tangle of IV tubing and monitor wires. The endotracheal tube dipped down between the sheets and disappeared.
“Mrs. AM was in good health until thirty-four years of age when she was partially paralyzed following a stroke. Over the next fifteen years she had seven heart attacks, three episodes of gastrointestinal bleeding, and a ruptured abdominal aortic aneurysm,” Ferguson spoke slowly. He did not mention the previous cancer surgery or the occasional amputation of an extremity.
Phillips wondered if Mrs. AM was the famous old Mulligan whose husband never returned from Cuba after the war with Spain.
“In January, cardiac catheterization demonstrated significant narrowing in all coronary arteries, and the patient was prepped for bypass surgery.”
The division director expressed surprise that she had any arteries left to narrow. No one smiled. Therefore he decided not to ask why anyone would catheterize a lady who was born while Grover Cleveland was still the struggling mayor of Buffalo.
“Following surgery the patient could not be weaned from the ventilator because of pre-existing chronic obstructive lung disease,” Ferguson continued. “Two days later, AM had a cardiac arrest. She was successfully resuscitated and has been unresponsive since then.”
The Snodsmith Professor pointed out the often imprecise definition of success while squinting at the lumpy, quivering form under the covers.
“The patient subsequently developed pneumonia and sepsis. Following several courses of antibiotics, the patient’s urine output deceased, and, on August 14th, we were called to evaluate the situation.”
Everyone, except the professor, smiled.
“All studies were consistent with acute renal failure, and we started dialysis on August 16th.”
The chief turned toward the bed again. The bumps and mounds were covered by the blanket, and he could not find the dear old face. “Did anyone consider withholding treatment?” he asked.
The renal fellow shrugged his shoulders. No, frankly, nobody mentioned that. His deep voice became deeper, “The BUN was very high, 149, and the potassium was above 7 with EKG changes. All the studies demonstrated that treatment was indicated. Is Dr. Phillips suggesting that we withdraw the patient from hemodialysis?”
Phillips asked what the family thought.
“Family? They are all dead. She has a great nephew in Peoria, but we couldn’t reach him. The social worker thought that he might be in a nursing home.”
Ferguson, a bit chagrined, had selected this case, not to philosophize, but to discuss management of electrolyte problems and fluid overload in post-operative acute renal failure. He quickly asked Dr. Phillips what he thought of the rapid acid build-up. While it was interesting, the chief thought that it was irrelevant and asked what real benefit of treatment the team had expected.
Ferguson’s face reddened, and his lips tightened. He pulled out a stack of lab reports pointing out that, according to these results, the situation had significantly improved. Ferguson suggested that the chief could look at the reports himself.
In thirty years the chief had looked at enough reports; he again turned toward the head of the bed. The only movement under the sheets paralleled the bellows of the respirator and the pumping of the aortic balloon. He tried again to the see the dear lady’s face.
“Dr. Wilson,” he asked, as he looked at the name tag on the chest in front of him, “if this patient were your mother, eh, your great-grandmother, would you want her to continue dialysis?”
Wilson, with all due respect, thought that she would rely on the opinion of the specialists. “The surgeon, the cardiologist, the pulmonologist all thought that treatment would improve her clinical condition,” she insisted.
“The specialists? Didn’t you notice that each one is just looking at his own organ?” Phillips asked. The student blushed. “The heart is stronger, the lungs are improved, the infection is under control, and the blood studies are better. But the patient seems about as full of life as an old, vinyl garment bag.”
The professor, who seemed disinterested in the BUN or potassium, wanted to discuss judgment, compassion, and quality of life in this high-tech age, but suddenly the ventilator alarm blasted, the cardiac monitor clamored, and a large, red stain spread across the sheet.
Bodies went flying, and books and clipboards went sailing into the air. Dr. Phillips ran to the head of the bed as the bulk of students darted out of the cubicle to make room for the inevitable, sweaty, foul-mouthed cardiac arrest team.
As Phillips ripped the sheet back, his head jolted forward, and his eyes leapt from his face. Ferguson’s jaw fell, and he turned white and sweaty.
The bed was empty.
“Donna, get in here!” Phillips called to the head nurse. “What the hell is going on?”
The chief, with more than 30 years of clinical experience, had seen almost every conceivable problem, but this was the first patient problem where there was no patient.
Everyone who had remained in the room agreed: there was no body in that bed. The mattress was littered with a series of balloons, tubes, bottles, and jars. A bag of blood had burst. The breathing tube led into a plastic bag from the Shop-Quick Market. The pulsating aortic balloon was jammed into a squeaking, bouncing Dairy Barn mayonnaise jar, the large economy size. A piece of paper was taped to the jar.
“Donna,” Phillips called again. But the head nurse always left the floor during renal rounds.
Ferguson looked at his reports and printouts. He could not explain the disappearance. According to his records, Agnes Mulligan was still there. The laboratory reports kept coming.
“They came out of the bag of blood that burst?” Phillips suggested.
“We had no problem with today’s treatment,” Ferguson added as he wiped his face and nose with a yellow handkerchief. “The patient must have left after dialysis.”
The professor wanted to know if she had departed on roller skates or had flown out the window.
Although he couldn’t answer that question, Ferguson did not think that this was a complication of dialysis, “Just look at these lab reports.” And there was no window.
The nurses who were unable to escape were called into the room.
Mrs. Mulligan had been there for her morning bath, but she weighed only 57 pounds—they surmised that it would be pretty easy to sneak her out of the hospital. “She could have traveled in a small suitcase,” suggested one nurse.
“I’ve always enjoyed renal rounds,” a wide-eyed resident mentioned to Dr. Phillips as he walked across the room, “but today’s were the best.”
The chief appreciated the praise. The student inquired whether or not Dr. Phillips would write the case up. The good doctor replied that he was fairly sure that the Garfield Herald Examiner would take care of that.
Inquiries over the next few hours were not helpful. Phillips was certain that the little lady had been present for dialysis. To the best of his knowledge, no one had ever reported adequate dialysis of a mayonnaise jar.
“Why wasn’t anyone aware of the patient’s absence before or during rounds?” Dennis Lipsink, the hospital president wondered—clearly not understanding that no one was going to check on a patient if all the monitors, controls, and alarms remained silent. “And we’re only at 97 percent occupancy,” he sighed, upset at having a profitable client stolen.
“Was this a kidnapping?” Lipsink speculated. The chief of security, brought into the inquisition, indicated that they focused on people who come into the hospital and not those who leave. And, besides, he noted, old Mrs. Mulligan wouldn’t likely command much of a ransom.
“And why did the thief go to the trouble of setting up a mechanical replacement?”
No one knew the answer to that question.
No one had any idea until Phillips, absent-mindedly, looked at the wrinkled note on the back of the mayonnaise jar:
HASN’T AGNES ELSPETH MULLIGAN SUFFERED ENOUGH?
DOCTORS—PLEASE—THERE IS A TIME TO LIVE AND A TIME TO DIE.
(An old Spanish-American War Vet)
JOEL L. CHINITZ, MD, MPH practiced nephrology in Philadelphia for 20 years, directed the Hahnemann University College of Medicine nephrology curriculum, and then completed an MPH program at Temple University. Pursuing a second career in public health and community medicine, he was a primary care physician at the Hunting Park Health Center and Medical Director of both the Philadelphia University Physician Assistant program and the Visiting Nurse Association of Greater Philadelphia. As Community Health Coordinator at Philadelphia Physicians for Social Responsibility (PSR) he developed training programs in domestic violence and firearm violence for clinicians. His greatest achievements include completing six marathons after age 40 and being tolerated by a wife and three exceptional daughters.