The Doctor Will See You Now [Non-Fiction]

Chapter 28: Gastroenterology

It's been the breaking bad news week this week. I've only done two shifts, courtesy of having done night shifts over the weekend (so I get the days back).

On shift 1, a middle-aged man gets admitted and becomes unresponsive (drops to GCS 3) overnight. CT'd his head: multiple massive bleeds in his head with lots of brain swelling (multiple intracerebral bleeds with midline shifts and mass effect). No neurosurgical intervention possible, given severe alcohol-related liver disease. Likely bleeding due to decompensated liver disease. Liver makes clotting factors. Diseased liver struggles to make clotting factors. Super prone to bleeding. (Fun fact: liver also makes clot-busting factors, so you're also super-prone to clotting. Not fun.) He has kids in their teens. Their mum died when they were young. I had to break the news to two teenagers that their father will likely never wake up and will die in the next few days. There is nothing we can do.

On shift 2, another middle-aged man, also alcohol-related liver disease, gets admitted with abdominal pain and also becomes unresponsive. CT head did not show bleeds, but his clotting factors were sky high (PT 64, INR 5) so his blood was super runny. We reversed it with Vitamin K and plasma. Plus his haemoglobin dropped to like 40 from his baseline of 80; we suspect an upper GI tract bleed because of his funky clotting (coagulopathy). We transfused him. Plus his kidney tests went off (AKI); we suspect hepatorenal syndrome or sepsis-driven acute kidney injury, although the infection markers were unremarkable. We gave him albumin solution and antibiotics. Hepatorenal syndrome is basically when you get liver failure, the kidneys get a knock-on effect. He is also comatose, presumed hepatic encephalopathy (liver processes a lot of toxins as you absorb stuff in the bowels. A failing liver means the toxins go into your system and into the brain). Multiple organ failure. I broke the news to his siblings that he will also likely never wake up and will likely die in the upcoming days. There isn't much we can do, although we will persevere (for now) with the antibiotics and fluids in case it's an infection that triggered the decompensated liver disease in the first place. With his poor reserve, even if it's infection, he will probably not pick up. But we'll try.

It's not been a good week. Don't drink excessively, guys.

Both patients died in the subsequent 48 hours.