Phillip

Phillip Kennedy woke up later than usual on Monday, January 27, 1997. He had a headache and fever, and he planned to stay home from work. I awoke at 5:45 AM, tired after a weekend on call. As I dressed in the dark winter dawn, I looked forward to coming home early. But, Phillip Kennedy was to die that day, and I was destined to share in his death.

Phillip was 54 years old with diet-controlled diabetes and alcoholism in recovery. I had cared for him in my internal medicine practice for seven years. Phillip usually saw me three times a year for routine visits and his annual physical. He was a gregarious, affable man with red hair and a ruddy complexion. Our interactions were friendly, natural, affectionate, and at times, playful.
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Phillip came to see me for his annual physical on Wednesday, January 22. He felt good and had no specific complaints. Phillip told me that, over Christmas, he had married June, the woman he had been living with for the past 12 years. June was 20 years his junior. Phillip said that there were parties surrounding the wedding and that he had started to drink again. He said that he was just celebrating with friends, not drinking excessively. Everything was under control.

Phillip’s exam was normal except that his liver was firm and moderately enlarged. I told Phillip to stop drinking and ordered a complete blood cell count and a chemistry panel including liver studies. I called Phillip the next day to remind him to abstain from alcohol and to tell him that his lab tests were normal.

I was on call the following weekend—the nights were particularly brutal, with multiple phone calls and time spent in the intensive care unit until the early morning hours. I rearranged my schedule on Monday the 27th so that I could be done by 3:45 that afternoon and possibly stop by the gym or take a late afternoon nap; probably the latter.

June called Monday morning to ask for an urgent appointment. She said that Phillip had been sick all weekend and needed to be seen. Phillip was double-booked into the 1:00 PM slot. After returning from lunch, I brought Phillip and June back into the exam room. I hadn’t met June before. Phillip and I joked briefly about his new, young bride as he introduced us. After he got undressed, Phillip said that he felt “generally lousy” with a headache, a fever, and no other specific symptoms. Although Phillip and June both initially reported that he hadn’t had any alcohol for the past two days, June later acknowledged that Phillip had been drinking much more heavily than he had previously owned up to.

On exam, Phillip had a temperature of 103° F, the same hepatomegaly noted five days previously, and a faint, yellow tint to his ruddy complexion. No other part of the exam was remarkable. He had no tremor or confusion and was definitely not experiencing alcohol withdrawal. I sent Phillip downstairs to the hospital for a chest x-ray and some blood work, feeling that he probably had a viral syndrome, an occult pneumonia, or possibly alcoholic hepatitis. His recent normal lab test results and relatively normal exam reassured me that his condition was probably a benign process.

Thirty minutes later, the lab called me with several panic values. Phillip’s platelet count was 30 thousand/cc, white blood cell count was 19 thousand/cc, bilirubin was 13 mg/dl, and his serum glutamic-oxalocetic transemi-nase was 560 U/liter. While I rechecked Phillip’s lab data from the previous week, I asked the lab tech to make sure that the results she had given me were for Phillip. She confirmed that the results were Phillip’s from today even though the same lab tests had been normal five days earlier! I asked the lab tech to send him back to my office immediately.

When Phillip and June returned, he was acting confused. He had lost control of his bowels while waiting in the lab. I told them that he needed to be admitted to the hospital. Phillip insisted on cleaning himself up in the office rest room before going to the hospital admissions office. He seemed to take an awfully long time in the bathroom. Occasionally, I would peek in and tell him to hurry. After several minutes, I checked on him once more and told June that I was going to see a couple of other patients. I asked her to get me when Phillip was done so that we could get him down to admissions.

While I was with the next patient, June knocked on the door. Crying, she said she needed my help. The strong odor of feces was present as I approached the partially open rest room door. Phillip was now completely naked; mottled and markedly jaundiced; unconscious and smeared with feces; still on the toilet but slumped against the wall. The stench was overwhelming.
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Phillip had no pulse as I slid him off the toilet. I began CPR by myself while my office staff called a “Code Blue.” Phillip recovered spontaneous respiration and pulse as the code team arrived. Before accompanying Phillip down to the emergency room (ER), I tried to reassure June that he would be all right. Phillip looked somewhat better in the ER. He was talking and said he felt okay. Yet he appeared to be in septic shock with hypotension, warm mottled skin, and anuria. I re-examined Phillip; ordered pressors, fluids, and antibiotics; arranged for an intensive care unit ICU bed; and returned to my office.

By that time, it was 4:00 PM and the rest of the afternoon’s patients were still waiting for me. Neither I nor my office staff had thought of rescheduling them. My next patient, Mrs Trumble, a lovely, 84-year-old woman with multiple medical problems, was one of my favorites. As I entered the exam room, she asked, “Are you all right, doctor?”

Christ! How could I answer such a question? How long could I keep up the conceit that everything goes along according to plan, and I’m captain of the ship? I told Mrs Trumble that I had been caring for someone who unpredictably had become quite ill, and that I was disturbed, distracted, and saddened by it. I excused myself to check the roster of patients for the rest of the day. I asked my office staff to reschedule all but the most urgent patients and then returned to finish my visit with Mrs Trumble.
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I finished in the office around six that evening and went to the ICU. Although Phillip’s blood pressure had stabilized and he was no longer mottled, Phillip was still anuric and only minimally responsive. Before going home for dinner, I reviewed Phillip’s care with the nurses and spoke to June. I checked out with my colleague who was covering, but told the answering service to call me for matters related to Phillip Kennedy.

By the time I got home, our two older boys had had dinner, and our infant had gone to sleep. I shared a glass of wine with my wife, telling her about Phillip. About halfway through dinner, the answering service called with the ICU on the line. The nurse, Candy, said that they couldn’t keep Phillip’s pressure up despite maximum doses of dopamine. She also said that Phillip was starting to have runs of ventricular tachycardia as well as some profound bradycardia. I told Candy that I’d be right in and asked her to get June on the phone for me.

I told June that things didn’t look good for Phillip. June gasped and started to cry. I told her that I was coming into the hospital and would be there in a few minutes. Just then I could hear, “Code Blue ICU” coming over the hospital loud speaker. June screamed, “Oh, shit! It’s Phillip,” and dropped the phone.

When I arrived at the ICU, the code team was still working on Phillip, but he was already dead. The head of the team looked at me, and I told him to stop. I walked back to a room behind the nurses station where June was sitting with a couple of nurses. I sat down next to June and took her hand. She sobbed, “I can go along with some tests, but I can’t lose him. I can go along with a few days in the hospital, but I can’t lose him.” I sat quietly with June as she spoke. Finally, I said, “It’s bad, it’s very, very bad, June. And it’s not fair—sometimes terrible things happen.” June looked up at me, her eyes open and wild, “He’s not dead, is he?” I looked at June, still holding her hand, “Yes, June, Phillip’s dead.”
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“Ahhhhhhhhh no!” June wailed as she fell to the floor, rolling around, shrieking uncontrollably. After a few minutes, I tried to touch June, but she pulled away. “No! Don’t touch me!” She sat on a chair and rocked back and forth. “I want to see Phillip.” June’s parent’s arrived as I led her to Phillip’s room.

June’s parents and I sat down in the room as June climbed into bed with Phillip. She lay with him for a long time; at first quietly, then caressing him, kissing his hands and face, and then laying her head on his chest. I left the room and waited for June at the nurses’ station.

When June came out, we hugged each other and wept. I told her that I would be available for her when she needed me. June agreed to my request for an autopsy. We both needed to know just what had set off this horrific storm of events. I left the ICU, overwhelmed with emotion, and stopped in the hospital chapel on the way to my car. Kneeling at the prie-dieu, I rested my head on my folded arms and cried for a long time. “God, why do you do these things?”

Phillip’s autopsy showed that he had died of an hepatic abscess, possibly secondary to diverticular disease. The mortality for hepatic abscess, if antibiotics are started after the onset of sepsis, is reported as greater than 30%.

Death is no stranger to me. I have spent much of my career treating people with HIV, and I serve as a medical director for our local hospice. The thousands of deaths I’ve been involved with have given me the false sense that I somehow understand death; that death has a pace and a rhythm; that I don’t always know when death will happen, but that I know it is happening when it is happening. I am familiar with the physical, emotional, psychological, and spiritual phases people go through as they die. Many of us in the hospice world refer to death as a birth-like event. We often refer to ourselves as “midwives to death.” In this model, death is an unfolding. It’s a process we can watch, anticipate, ride . . . surf. canada pharmacy mall

Phillip’s death was not an unfolding. It was not a birth. It was a miscarriage. There was no guidance in this event. June and I took a horribly unpredictable ride into hell. In the days that followed Phillip’s death I began to ask myself, “Why did this have to happen in my office? Why did I have to be involved?” After all, if Phillip had stayed home two more hours before coming in, if his appointment had been at 3:00 PM instead of 1:00 PM, he would have died at home. It would have still been horrible for June, but I would have been spared. Why did I have to be part of Phillip Kennedy’s death?

My deep spiritual belief is that things don’t happen by accident. I had to partake in Phillip’s death. I had to be present for June, during and after this horrific event, which has inextricably bound us together. Bad things happen in our lives that we cannot control. Phillip’s death could not be prevented. My role was not to prevent Phillip’s death, but to soften its blow for June and her family. June needed me to share Phillip’s death as a witness, a mirror in which to search for meaning. My professional experience with death as well as some tragic deaths in my own life prepared me to participate in Phillip’s death as a physician, a friend, and a fellow mortal. I thank God for the strength gained over the course of my life to help people in need. And, I pray that I won’t be called upon again for a good, long time.

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