Thread by @TheRealDoctorT

The patient is a relatively young man. He is confused, mumbling nonsensical phrases. I ask him what his name is. He stares at the ceiling with glassy eyes and says “cookies and cream.”

His kidney function is normal. I have been asked to see him for acidosis. 1/

He has just been admitted to the ICU from the ER. The working diagnosis is alcohol withdrawal, and possible aspiration pneumonia. He was found unresponsive by a neighbor.

Head CT was negative. Bloodwork showed normal kidney function, but low bicarbonate (high acid). 2/

Test results are still coming in. An alcohol level was checked and was undetectable. Urine drug screen was negative. An arterial blood gas is sent and shows that despite the lab results, the patient’s blood is significantly alkalotic. He is markedly hyperventilating. 3/

This combination of (anion gap) acidosis on bloodwork and an alkalosis on the blood gas is highly suggestive of a specific poisoning...

On exam he is clearly hyperventilating, but his vital signs are stable. He remains confused. He has a catheter draining clear urine. 4/

A salicylate level is sent and comes back extremely elevated: aspirin overdose.

His kidney function is normal, and he is making urine, but he is showing signs of neurotoxicity.

The scales will soon be tipped if his acidosis becomes overwhelming and he starts to seize. 5/

While also initiating supportive measures, I decide to dialyze him in an attempt to clear the aspirin from his blood.

He is increasingly agitated. A suggestion is made to sedate him. This isn’t a good idea, as the last thing we want to do is suppress his respiratory drive. 6/

I anesthetize him with subcutaneous lidocaine, and place a 16cm dialysis catheter into his right internal jugular vein. Four nurses assist me with calming him and making sure he doesn’t break the sterile field or suddenly twist his neck.

I am sweating heavily. 7/

During the line insertion he starts to go into brief runs of unstable rhythms, non-sustained ventricular tachycardia. I call for a crash cart, and request 2 amps of sodium bicarbonate to be pushed STAT.

Is this the prelude to a terminal seizure and irreversible arrhythmia? 8/

Mercifully, his irritable myocardium settles down.

Dialysis is initiated emergently.

He doesn’t seize.

I keep checking and rechecking bloodwork every 2 hours until his aspirin levels are consistently undetectable and his acidosis has resolved. 9/

I don’t sleep much that night, between repeated calls on his lab results and updates on other patients.

When I finally drift to sleep my dreams are fragmented, filled with accusatory ghosts and lingering regrets.

I wake up early and shower. The steam is soothing. 10/

As I walk in to the ICU to see him the next morning, a transformed patient greets me. He is bright and cheery, his gaze sharp and alert. Gone is the confusion and agitation.

He has survived a potentially fatal toxic ingestion.

He doesn’t remember much of what happened. 11/

I have to reintroduce myself. He has no recollection of overdosing or any intention of overdosing. He sheepishly admits to taking a “fair amount” of aspirin for hangover headaches.

As I get ready to leave his room a family member asks to speak with me. 12/

They introduce themselves as “in the medical field.” I don’t ask for clarification. They want to know why I dialyzed the patient when the kidney function was normal. They say it was “unnecessary” and expensive.

I try to explain my rationale as clearly as I can. 13/

They give me a shrug when I finish explaining. “Agree to disagree” they say, and turn away.

For a moment I feel a surge of fury, a white-hot warmth spreading up my spine, to the base of my skull.

I was up all night making sure your loved one was okay.

I want to scream. 14/

Instead I take a deep breath as I leave the room. I use the hand sanitizer and close my eyes as I feel the coolness of the evaporating liquid on my hands.

Someday, perhaps, my resentment will evaporate that fast.

Someday, those accusatory ghosts will have nothing left to say.