Mr. Icterus is well-known to our team. In the 6 short weeks I’ve been on Internal Medicine, I’ve seen him twice. He is one of the jolly (as opposed to crabby) alcohol abusers and has pretty severe cirrhosis with a classic presentation: jaundice, abdominal ascites, caput medusae, hemorrhoids, asterixis, bilateral pitting edema, hyponatremia, you name it. We drained his belly last time he was in and I got to observe my first paracentesis. His electrolytes righted themselves and his edema resolved. He was looking worlds better and ready to go home. We obliged.

A week or so later, Mr. Icterus was back. He had pancreatitis, his abdomen was again full of fluid and he picked up pneumonia somewhere. We grew MRSA in his sputum and he developed an acute change in personality over a day or two. The overnight nurses started giving me reports of him refusing to cooperate. He kept taking his oxygen mask off and tried to pull out his foley and IV fluids. They had to sedate and restrain him. This was very unlike the Mr. Icterus I knew and we gave him lactulose to treat the suspected hepatic encephalopathy, possibly set off by hypoxia.

Yesterday morning when I went to round on him, Mr. Icterus was shivering in bed with the sheets pulled up to his chin. I asked him what day it was and he told me the time. I asked him where he was and he rolled his eyes like I was an idiot, but couldn’t name the hospital. His blood glucose was 43 by lab, 65 by finger stick and 35 by finger stick an hour later. We gave him an amp of glucagon and checked his finger stick blood glucose every hour until it was over 100 for two hours in a row.

Later that afternoon, we were rounding on another patient when a fellow student heard the code. “Isn’t that your patient?” he asked and we both rushed down 4 floors of stairs. Sure enough, his room was overflowing with people and a crash cart. His pneumonia and ARDS had caught up with him. Mr. Icterus was intubated and delivered to the ICU. It was my first experience in a code and I have to say I was less than impressed. It’s not like TV.

In the ICU, we started a propofol drip. We listened to lung sounds to ensure the endotracheal tube was in the right place. There is a disposable stethoscope left in his room so that we don’t spread MRSA throughout the hospital around our necks. But it’s worse than the pink toy ones we gave away as favours at our weddings. My inexperienced ear can’t hear a dang thing. We ordered a chest x-ray. ET tube is 4cm above the carina. The nurses re-inserted his foley.

Not once in the entire time of his two admissions have I seen a single family member. Since he’s been slapped with the MRSA contact precaution sticker, even fewer people enter his room because when we do, we have to suit up in gowns and gloves and masks. If he wasn’t in the propofol-induced coma, I’m sure he’d still be trying to sneak out for cigarettes and Reese Peanut Butter Cups. Mr. Icterus may not make it through this. And we’re not entirely sure who to inform.

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photo: Sunrise at the front entrance of The Hospital. Taken with my cell phone. Fellow students have commented on how much the welcoming statue looks like a uterus.

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