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A Death in Hazen and my thoughts afterwards


When we first moved to Hazen, I rented an office downtown that had been previously occupied by another doctor several years ago; it was small, with a glass front door, a lobby, and three side rooms, one of which I used as an office. The two side rooms up front were my exam rooms, and a big old enclosed table was my front desk, cordoning off an alcove where the secretary sat.

We moved in to a third floor apartment across the highway from the hospital; rents were inflated because of the construction project going on 20 miles northwest of town. A coal-gasification plant was underway, with two billion federal dollars behind it. The facility was gigantic and used the anthracite coal which everywhere around lay only twenty feet below the wheat and sunflower fields which surrounded town.

The process of conversion was arcane and complex, and it was performed on an enormous scale.  Coal, hard, low quality anthracite, was input into a rotating furnace without oxygen, and methane, propane, other gases, and rocky slag were output.  Enormous cooling towers were used for the cooling water which relieved the thousand degree heat of the process.

The facility was so large that it employed a full-time biologist to monitor the microbial population of the cooling water in the towers.  She became one of our patients early on, a lovely woman who had been recruited from a university back east.

We were immediately very busy; my wife, acting as receptionist and nurse, just couldn’t keep up so we immediately hired two medical assistants, one of whom was about sixty and the wife of a high level engineer at the plant.  We received important tips from this woman, whose husband kept her well informed about plant activity.  The other assistant was a young girl who got poison ivy by lying in a thicket by the river; she was incompetent and lasted only a few months.

Our apartment was on the top floor of a three story building with four flats on each floor. It had been newly built the previous spring to accommodate some of the construction workers. The roof was flat, which I thought was a novel design feature in this climate. In late September it started to get very cold, below freezing every night, and it snowed a little bit, just enough to stick to the roof. In October it really started to get cold, staying below freezing all day, with the same light, intermittent snow. By late December, serious cold took over; every night it was at least 40 below zero, and it never got above zero during the day.

Besides approaching the records, cold below 45 below zero is problematic because the propane everyone uses for heat begins to become slushy at this temperature. Fortunately, it never got that cold.

One day a man came in to our office with his wife; he complained of stomach pain and generally not feeling well. He was a Baptist minister, a very obese yet well muscled man of about forty, and his wife was equally obese.  He had been in good health until a couple of weeks ago, and was very active in his local ministry. I examined him but he was so obese that I couldn’t feel his abdominal organs. He had relatively mild generalized tenderness.

He looked ill but the light in the rooms was so poor that I couldn’t see any jaundice. Even mild obesity totally obscures the outlines of the abdominal organs and makes accurate palpation impossible, and most of the white people that I saw here in this rural Northern state were fairly obese. I was unable to pin down what organ within his abdomen was causing distress.
I ordered blood tests, and when these came back (that afternoon) I went over them with him and his wife. His liver enzymes were off the scale, but at first I didn’t notice them. His blood sugar was about 220, so I felt he obviously had diabetes, but that was expected given his obesity.

It took me a while to realize that his liver enzymes were so abnormal that they registered on the graph only as a pegged line (this was the now obsolete line graph that came with sequential multiple automated blood chemistries (SMACs) at that time.

This graph was confusing and pointless as there was little relationship between the tests on the x axis, thus no logical reason for lumping them together in one graph; this made the pattern drawn on the y-axis completely arbitrary and essentially meaningless, just one more thing to memorize in the mistaken impression that it was important.)  Nowadays, each test in the SMAC gets its own simple one dimensional graph that is easy to understand: it is high, low, or normal by about so much.

I didn’t at first realize the significance of what I held in my hand: this man’s death sentence, prescribing when and how he was to die.  The numerical value of his serum gamma amino transferase (SGOT) and serum gamma peptidyl transferase (SGPT) was undefined; it was too high to accurately measure with the reagents in the SMAC machine.

Finally, as I stared at the paper, I began to realize that there was something seriously wrong.  I asked him to let us order further tests on his blood. Fortunately, we already had enough blood, thanks to my wife’s thoroughness and sagacity as a laboratory technician. We sent out for quantitative determinations of his liver enzymes and added hepatitis A and B antigen/antibody tests for the definite possibility of acute viral hepatitis.

The next day, his wife called back for the results; I told her that we had found hepatitis B and we didn’t know how he had gotten it. She said he was feeling very bad and I told her I would admit her to the hospital. I usually admitted patients who were acutely ill, even if nowadays we wouldn’t put them in the hospital, because everyone lived so far apart that I felt they were safer in the hospital. This was understood by all the patients and staff.

Another factor that argued for early admission to the hospital was the weather. In the depths of winter it was often difficult to keep a vehicle functioning. At temperatures of 40 below zero, a car battery only retains about 5 % of its rated power. This is enough to start the engine if the oil isn’t too stiff from the cold; 5w-20 weight oil is usually used, and small electrical heaters are attached to the engine block to keep it warm overnight.

The day I admitted him, his bilirubin was sixteen. This was about as high as I had ever seen it in acute viral hepatitis. He continued to be ill but his spirits seemed good at first. I didn’t tell him he was going to die because I didn’t know, but I was worried. I called a specialist in the capital to discuss his case and ask him a few questions. He offered to take the patient if I felt it was too serious, but I thought he could stay here as there was little to do for him but give him IV’s and keep him comfortable. The specialist warned me not to give him any benzodiazepines as his liver woouldn’t metabolize them at all and he would be extremely sensitive. He didn’t warn me that the patient would develop uncontrollable restlessness a few hours before lapsing into a coma from which he would not wake up, no matter what I might do.

Every day, I checked his bilirubin and every day it went up by two points. His liver enzymes, reported out at astronomical levels initially, dropped day by day as the necrosis of his hepatocytes dwindled off; there were literally no more hepatocytes left to die. Despite the toxicity and enormous amounts of bilirubin and ammonia in his blood, he remained conscious and functioning. He conversed with his wife and children, and they kept up a continuous vigil at his bedside.

The last few days were a parade of other organs shutting down as the toxic effects of bilirubin and ammonia in his blood began to take hold of his system: kidneys, adrenals, gastrointestinal, cerebral. The last couple of days, he began to be extremely restless and confused. His bilirubin was 40.  For twenty four hours, he tossed and turned continuously in bed, exhausting himself and the nurses. Finally I succumbed to their sufferings, pleadings,  and ordered a tiny dose of a benzodiazepine.   I decided on a minimally metabolized form, one that would flush out in the urine,  perhaps 15mg of Serax.  I gave him just enough  to calm him down. Within an hour, he lapsed into a deep coma. Within four days, he would be dead.

My first reaction when he collapsed was “Oh my God, I’ve killed him.”  For some reason, I still had not processed the fact that his disease had been fatal from the beginning.  I began to feel terribly guilty.

When he became comatose, I called the family together and told them that his liver had completely failed him and that, without his liver, he could not survive. The family got together around the bedside, and I joined hands with them in intense prayers. That was around ten PM. The prayers lasted perhaps twenty minutes. Afterward, I hugged his wife and eldest son.

A couple of hours later, I called my colleague at the hospital in Bismarck. I told him the patient was failing and could I please send him to the medical center?  There was nothing anyone could do, but I just couldn’t accept it.  I still felt, more and more, that I had killed him with the tiny dose of Serax.

I transferred the patient, in a coma, to Bismarck, where he died two days later. The local public health workers were extremely interested in the case. It seems I had forgotten to inform them that there was a case of a reportable disease in my hospital.  A couple of months later, they told me that they suspected he had been taken by a variant of hepatitis B which was especially deadly.

None of the people from the public health service or any of the doctors said anything negative to me about all the terrible things I had done in this case which had obviously killed the patient and endangered the community.  Apparently, they didn’t notice what I had done wrong, much less that I had done anything wrong at all.  Or maybe they were just too nice to say anything to my face.

I gave hepatitis B immunizations to all the nurses who had been in contact with the patient; the vaccine was relatively new, and looked like it was guaranteed not to carry AIDS, that scary new virus that everyone was afraid of at that time.

I went to the patient’s funeral, held in the largest church in town. It seemed that there must have been five hundred or a thousand people there; in any case, the rather large church was packed. The ceremony was long, and it seemed, everyone had heartfelt sorrow at his passing. One of the other attendees recognized me; he had seen me as a patient. He came over to me and asked why I had come to the funeral, seeing as I was already known never to go to church or attend local Lions meetings. I told him, “I had to come.” I don’t know if he realized I had been this man’s doctor too.

I began to think about this man after he died, at first in a guity way, then later in a more obsessive way since no one had bothered to indict me.  There was nothing I really knew about him.

Not having known him from before he walked in to my office that day, about a month before he died, I couldn’t say that I had any personal knowledge of  him. I felt that he was a man with a fat wife at his side, a rather fat man to be sure, and coincidentally a preacher or parson of some sort, but a completely responsive and cooperative forty year old who laid out his symptoms clearly and simply, and had an enlarged and tender liver when I first examined him, if I had given any thought to his examination, despite his obesity, and showed on his first blood test ten times the level of liver enzymes that he was supposed to have.

But all that time he never told me what his life had been like, what his work was like, what his wife and children were to him, how he felt about them, if he had any ambitions, what his hopes and dreams and fears were.

I  thought of him as a generic, ordinary man, and he had brought me his death papers and he had shown them to me. It was as if he had opened his shirt and had shown me his dying insides.  There was nothing I could do about it, this sentence of death, its weight and size were beyond reversal.

The ineluctability of death rends your life’s perceptions like claws. You can’t get around it, you can’t get over it, and you can’t get under it. He died, and there was nothing I could do to stop it; everything I did was useless, a waste of effort.  Worse, I had killed him a few hours early, just to quiet him down and relieve the nurses.

In the months after he died, I began to order more blood tests on patients, on their first visit, if they had any kind of distress, even if it was vague. Nausea, diarrhea, vague abdominal pain, fatigue, weakness, all vague symptoms but all harbingers of impending mortality.

I never found out what caused his hepatitis B. This virus is characteristically transmitted from one person to another by blood or extremely close contact. We were never able to locate someone who had hepatitis B who would have given it to him. His wife and children had no evidence of exposure to the disease. He had never had any blood transfusions.

We had no reason to suspect that he was sexually active, even with his wife. The only history we got from his wife was that he had visited someone who was dying of hepatitis six months ago; but even if that person had had hepatitis B, which we weren’t able to ascertain, transmission by casual contact is thought to be impossible.

A person from New York City, even in 1983, when this patient died, would suspect that this parson had a secret homosexual love life through which he was exposed to hepatitis B. This patient, to my knowledge, was never asked if he had ever had sex with another man by anyone other than myself, and he denied it to me. How could he possibly do otherwise.

There has been a significant change in practice, encouraged by insurance companies, who pay for the procedures. A patient who comes to the doctor for the first time will now be expected to have a blood and urine test regardless of whether he or she has any complaints. This change came about partly because it was discovered that these patients frequently had not seen a doctor in a long time and often minimized or denied symptoms because they were so embarrassed.

In areas where there is expected to be a high risk of, say, HIV/AIDS, all patients will be offered the relevant tests on their first visit. For example, at a clinic that treats young men and women with sexually transmitted diseases, it may be routine to test all patients for the presence of the viruses that cause cervical and penile cancer.

Back in Hazen, North Dakota, in 1984, it was early spring, and the ceiling of our apartment in the bedroom closet began to dribble water. The traces of snow that had been falling all winter began to melt and immediately penetrated the flat roof. Soon water began to dribble down the walls.  Two weeks later, My wife and I, and our kitten, and our finches, found a much nicer place to live on the other side of town.

2 Comments leave one →
  1. Stephanie permalink
    2012-11-02 21:23

    That was quite a sad but thoroughly engrossing story.
    I followed your link here from Retraction Watch.


    • 2012-11-11 22:02

      When I discovered that someone had read my story, I was impelled to change it slightly… so perhaps you should read it again.


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