Thread by @TheRealDoctorT

It starts with a subtle unease.

She can’t describe what’s wrong with her because she isn’t even sure there’s anything wrong.

Something just feels ... “off.”

Maybe she’s a little tired. Maybe she’s a little stressed. Maybe her college classes are too much.

Who knows? 1/

As the weeks pass, the vague unease coalesces into a sinking fear.

Something is definitely wrong.

She’s tired, all the time. Her appetite is gone. She withdraws from her social life, and her grades start to dip.

Deep inside her, an illness is beginning to take hold... 2/

She goes to see her primary care doctor. Tests are run and everything is normal. By now she has a cough, and sinusitis. She is started on antibiotics.

Despite the antibiotics she feels worse.

She has low grade fevers. Her joints ache. Her cough won’t go away. 3/

She goes back to her doctor. More tests are run.

Her platelet count is a little high, but things don’t look too bad. Then a marker for inflammation is checked (an “ESR”), and it is very high.

She is started on empiric steroids and referred to see Rheumatology. 4/

For a while, she feels great. The steroids make everything better.

She starts eating again. She is able to go to class. Her fevers subside.

But the improvement is short-lived.

Her cough comes back with a vengeance. She goes to the ER, and is diagnosed with pneumonia. 5/

She is discharged with another course of antibiotics. She takes these dutifully, but she has a feeling they’re doing nothing.

Days pass.

She notices a rash.

Her urine is looking red, almost rusty.

Deep inside her, the illness is progressing rapidly now... 6/

She’s scared. She knows something is deeply wrong. She calls her primary care who tells her to come in tomorrow to be seen, or go to the ER.

In tears, she calls her mother.

She’s short of breath on the phone.

As she hangs up, she starts coughing.

Her sputum is bloody. 7/

The human body has a remarkable ability to hold the line - to compensate, and compensate, and compensate.

There are backup systems, and backups to the backups.

But once the tipping point is reached, things can fall apart devastatingly fast.

I am asleep when my phone rings. 8/

When I see her for the first time, she is already on a ventilator. Her family is at the bedside.

Inside her body, an avalanche of organ dysfunction is taking place, stemming from an immune system run amok.

Blood vessels are under attack. She is bleeding internally. 9/

Untreated, she will die, soon.

The working diagnosis is a pulmonary-renal syndrome, a vasculitis, a disease of the immune system.

Together with the Pulmonary / Critical Care team, we begin treatment.

Dialysis. Plasma exchange. Steroids. Immunosuppressive therapy. 10/

There is a stillness that comes over a room where the greatest battles of life and death are being fought.

We all sense it instinctively, the weight of it.

It is a battle that has been fought since the dawn of time.

The only sounds are monitor beeps and ventilator hisses. 11/

She lies motionless, tethered to the machines.

There are only the faintest signs of life. The rise and fall of her chest. The delicate flutter of the jugular venous pulsation.

The tracings on the monitor that remind us that a heart still beats, that signs are still vital. 12/

I get to know her better in the days that follow, through her family.

Her room is covered in photographs, and I look into each one. Her mother explains them, often laughing, sometimes crying.

They tell the story of a life filled with a gentle love, and a burning purpose. 13/

One photo in particular sticks out to me.

A photo of her, as a young girl. She is kneeling beside a pond, reaching out to a toy boat.

It’s raining. The little toy boat is being battered by the raindrops.

She offers it shelter from the storm, and holds out her hands. 14/

The worst of her storm passes, in time, as her immune system is finally held in check and pulled back onto the rails.

She wakes up, as her sedation is weaned. She smiles at her family, as their tears stream down.

She offers a thumbs up.

She is a fighter, and I am awed. 15/

Eventually she is successfully extubated. Her kidneys start working again, and we stop dialysis. She is transferred out of the ICU.

She asks me what happened to her, why did she get so sick.

As I try to explain, I see a clarity in her eyes, a wonder at her own unraveling. 16/

A year later, and the young woman I see in clinic looks nothing like the weakened patient who was in the hospital for so long, and needed weeks of physical therapy.

She is doing well in college.

She is upbeat, and happy. 17/

Her father accompanies her to every clinic visit. He rarely says anything, just smiles and listens and thanks me at the end.

Today, however, he has something to say. He waits until his daughter has left the room, and turns to me.

“Doctor T, what were her odds?” 18/

“Her odds?” I quirk a brow.

“What were the chances that she could have died from this?”

“Ahh... it varies. She’s young. She’s a fighter...” I trail off.

He looks at me and nods, an understanding passing between us.

Unexpected storms, toy boats, and safe harbors.