A Family Affair

“Dad, where were you this morning?” my daughter inquired as I returned home late one night. My absence had been noteworthy. She and I share several physical and behavioral traits courtesy of our common genetics, one of them being the tendency to rise early. We are the larks of our family, and as her owl siblings sleep, we typically bond in the early morning hours—but not on this morning. Instead, I had been awakened at 5 a.m. by our intensive care unit fellow to review an admission. A 48-year-old patient with multiple myeloma, who had had an allogeneic bone marrow transplant 6 months earlier, was now presenting with multiorgan system failure. As my fellow recounted the details, I struggled to grasp the relevant issues; even larks sometimes have trouble focusing at 5 a.m. Upon hearing the ventilator settings, pressor requirements, and blood pressure, it became clear that my presence was required at the bedside.

As we headed toward the intensive care unit, the fellow and I were met by a multitude of worried visitors spilling out of our patient's room. Apparently, we were not the only early risers that day. We introduced ourselves, requested privacy at the bedside, and assessed our patient. Intubated, he was hypoxemic despite high-flow oxygen, hypotensive despite multiple vasopressors, and acidemic despite bicarbonate. The presumptive diagnosis was severe systemic inflammatory response syndrome, with pneumonia as the source. We identified the organ dysfunctions, established a …