GETTYSBURG MEDICAL NEWS
The Clinical View
By P. E. Hoffsten, M.D.
27 February 2008

HIGH TECH MEDICINE

            The lady was 56-years-old and, as far as she knew, was in perfect health.  But she had developed a fever to 103 degrees, she had diffuse aching all over, and she was coughing up a clear sputum initially.  She was self diagnosed as a case of influenza, but on the third day when her sputum turned yellow-green and she was feeling sicker, she came to the clinic for evaluation.  There it was seen that she had a pneumonia on her chest film and blood tests consistent with a severe bacterial infection.  She was hospitalized, started on an antibiotic, and in three days time had recovered enough to return home and “live happily ever after.”  She didn’t require any specialized medical care and had there been someone at home to help care for her she might not had have had to even be in the hospital.  The methods and concepts in which her care was based aren’t different than those in the 1950s.  But things aren’t always this easy. 

            The second case to talk about is a gentleman in his 50’s with a long history of diabetes.  He had lost one eye to the diabetes and had difficulty with vision in the other eye.  His kidneys were badly damaged so that he only had about 15% of the normal filtering capacity of his kidneys.  The nerves in his feet had long since ceased to function at all and he had no sensation from the mid-calf down.  Unfortunately, he is still a pack-a-day smoker with quite significant emphysema.  He took medications to control his blood pressure, which was too high, and his cholesterol, which was also too high.  He also came to the clinic with a temperature of 103 degrees, a cough productive of a yellow-green sputum, and aching all over, just like the lady mentioned above.  But his influenza test was negative and his chest film showed diffuse abnormalities throughout both sides.  His ability to oxygenate his blood was severely impaired requiring oxygen supplementation.

            But now comes the high tech part.  Within a few hours of his admission, it became obvious that he was not able to support his own respirations any longer.  He had become too weak to breathe and his lungs had become too wet in order to get adequate oxygen into the body.  He required an intubation where a tube is placed into his trachea and connected to a machine to breathe for him.  This type of care requires highly-skilled pulmonary technicians to monitor the machine to make sure the settings are correct and to communicate with the physicians, the nurses, and the patient to provide the greatest comfort possible. 

            At the same time, the physicians caring for him needed to arrive at a very potent antibiotic combination that would cover a broad spectrum of possible infecting bacteria.  In order to know what type of pneumonia the gentleman had, we have to first grow the bacteria from his sputum and then characterize it in regard to its sensitivities to different antibiotics.  This takes two days in the best of hands.  In those first two days, antibiotics to cover the broadest range of bacteria need to be administered.  The truth is that the battle regarding his pneumonia is won in those 2 days without their definite knowledge of what the infective organism is, so the broadest range of antibiotics needs to be used.  This was done and his fever tended to come down in those 2 days.

            But as often happens with severe infections, now his kidneys failed.  They had been badly damaged before, but with the bad infection that he had, his blood pressure dropped and his kidneys ceased to function at all.  Now he needed to have artificial kidney treatments.  Fortunately, preparation for this had been started months before in anticipation and he had a well-developed “arterial venous fistula” in his left arm that could be used to connect him to the artificial kidney.  This requires a very special skill from nurses who are trained to deliver hemodialysis care.  They removed approximately a 10 ounce quantity of his blood from his body each minute and replaced that blood after it had been through the artifical kidney machine and purified.  The nurses on our dialysis unit perform this skill on 12 different patients a day, six days a week in the dialysis unit at St. Mary’s Hospital.

            So now there is a person with an artificial kidney treatment and also on an artificial respirator with a bad pneumonia being treated with antibiotics.  As though the situation isn’t complicated enough, remember that he has an endotracheal tube down his throat.  He is not able to eat and has to be provided nutrition through a feeding tube threaded through his nose, down through the esophagus, and into the stomach.  The dietician needs to balance his caloric requirements and all the extra nutrients that a person needs in a time of severe illness.

            And as though that isn’t enough, remember that this gentleman is diabetic so he has no capability to balance his blood sugar appropriately.  It has been shown through years of research that crucially ill individuals such as this do better if their blood sugar is carefully controlled in the 100 to 125 milligram percent range.  The physicians and nurses caring for him need to monitor his blood sugar very frequently and provide enough insulin intravenously to balance the tube feeding, his illness, and his blood sugars.

            This is all of the problems in the first two days, but then the care really gets high tech.  Specifically, a person’s immune system effectively deals with a large number of bacteria and fungi that are in the air.  Usually fungi such as Candida and Aspergillus (that black mold that grows in the nooks and crannies of your bathroom) are normally not a life-threatening infection for humans.  But when a person becomes clinically ill, such as this gentleman, and the normal natural bacteria in his throat and intestine are modified by the antibiotics that he takes, these fungi and other organisms can become pathogens.  Approximately 10 years ago, the first effective practical antibiotics to use against fungus such as Candida became available.  One of these called Diflucan (fluconazole) was started on this gentleman with the thought that his continued pneumonia was really secondary to fungal overgrowth.  Things initially got slightly better, but then by the seventh hospital day he was beginning to deteriorate again.

            By this time, his fluid and electrolyte abnormalities had been corrected with the dialysis care, he was extubated and breathing on his own without the artificial respirator, but his fever curve continued to be slightly high, and he remained very short of breath.  He was receiving all of the antibiotic that our hospital usually used, but was simply not getting well.

            So the next step of high tech medicine was utilized.  Through the wonders of our computer systems and televisions, this gentleman received a “telemedicine consult” in which he was placed in front of the camera and his situation and case particulars were told to an infectious disease specialist hundreds of miles away.  After reviewing all of the care the gentleman had had, the specialist suggested using a new antifungal antibiotic that we really had not needed up to this time.  When this was started, the gentleman’s care reversed very quickly and his fever came down, his appetite began to return, his breathing improved, and recovery now seems a potential reality.  We can’t reverse his kidney failure to the point where he will get off of artificial kidney treatments, but we did get his pulmonary status reversed to the point where he is breathing comfortably on his own and the infections that caused his pneumonia are dealt with. 

This summarizes a two week ordeal in the care of this gentleman, but the technology including the artificial respirator, the artificial kidney, the telemedicine, along with the use of new and unusual antibiotics, are all high tech medicine that are available right here in central South Dakota.  No, we don’t have a neonatal intensive care unit, or the ability to do heart surgery, or brain surgery, but there is quite a remarkable capability to take care of very sick people here in central South Dakota.