July 29, 2024 - Transfer to Seattle

279 miles in the back of an ambulance, strapped to a gurney, and unable to move! The beautiful sunrise was the only thing carrying me through the pain, the tears and the overwhelming fear! It was what felt like the longest road trip of my life and would become the most important trip I’ve ever made. Today began the journey that would become the rest of my life!

Around 11:00 p.m. on July 28, 2024, the hospital received communication that a bed opened up at Swedish Medical Center in Seattle. Over the next several hours, I was prepared for an estimated departure at 5:00 a.m. on July 29, 2024, via ambulance. Initially I was supposed to be transported by air, my mom even secured me life flight insurance, but for some reason they couldn’t take me by air anymore. I recall them telling me that it was too dangerous to fly over the Cascade Mountains, but as I thought about it later down the road that made absolutely no sense. They fly people over the Cascades all the time! This just goes to show my mental state during these initial days, first thinking I was in the hospital for 3 days when it had only been a few hours and then this. Nonetheless, I was prepared for departure and at the time of discharge from Sacred Heart Hospital my vitals were:

• Temp: 97.4

• Pulse: 92

• Resp: 20

• BP: 129/78

• O2: 90%

I was discharged in serious condition with the following diagnosis:

• Acute liver failure without hepatic coma

• Endometriosis

• GERD (gastroesophageal reflux disease)

• AKI (acute kidney injury)

• Hyponatremia

• Hypoakalemia

• Sepsis

• Lactic acidosis

• Anemia

• Coagulopathy

• Urinary retention

After an extremely uncomfortable trip in the ambulance, I arrived at Swedish Medical Center in Seattle, WA around 11:00 a.m. on July 29, 2024, and I was immediately evaluated from a team of individuals. I was extremely lethargic from the ride, and I didn’t get any time to rest. The number of individuals that were doing different things to me and asking me millions of questions was incredibly overwhelming. I was all alone and terrified!! I had no idea what was going on half the time and didn’t understand exactly what they were evaluating, because all I knew was the diagnoses I received in Spokane. They took me down for an additional CT, an US and the relaxed part of a stress test and the results were as follows:

Ultrasound

1. Hepatomegaly. Echogenic liver with poor visualization of the parenchyma and central vessels.

2. Peripheral portal veins are patent. The MPV and Porta hepatis are poorly visualized and may only contain thready minimal flow.

3. Patent hepatic arteries.

4. Poorly visualized hepatic veins, but suspect patency based on Doppler waveforms.

CT Maxillofacial without Contrast

1. No evidence of paranasal sinus disease.

2. Right second maxillary molar periodontal disease.

I was ordered to have no caffeine and be NPO at midnight for stress portion of stress test the next day. In the meantime, I underwent Hepatology and Nephrology consult as I waited for my mom to arrive in Seattle. I needed her voice throughout the process because I was still very much in shock, overwhelmed and didn’t understand everything that was happening to me.

Hepatology Consult

• It was discovered that during a visit to the ED for abdominal pain in October 2023, I had elevated AST at that time and my CT showed hepatic steatosis.

  • I have never been told that I have hepatic steatosis until now. What is hepatic steatosis? How long have I supposedly had it? Why did no one tell me if this was showing up in imaging? Should have I seen this on my own when reviewing my visit summary despite not being explicitly aware of it?

• Hepatitis likely superimposed on NASH.

  • Hepatitis? How did everything go from liver disfunction to liver failure, to steatosis and now hepatitis? What is the underlying cause of hepatitis? Why are they ignoring the seemingly obvious underlying concerns I have? Is it related to the medication I was taking? Can Endometriosis be a factor? Is it related to the autoimmune disorder discovered below?

• Echo overall unremarkable, RVSP 29.

• Will need 2-person breast exam in lieu of mammogram.

Nephrology Consult

• History of GBS and Endometriosis

  • GBS (Guillan-Barre Syndrome) - a rare autoimmune disorder where the body’s immune system mistakenly attacks the nerves outside the brain and spinal cord. This attack can lead to muscle weakness, numbness, and tingling, often starting in the legs and spreading to other parts of the body. In severe cases, GBS can cause paralysis and breathing, swallowing or speaking difficulties.

• On presentation to OSH was hypotensive (low blood pressure) and labs showing acute liver failure on top of chronic liver disease - unclear if related to recent medication use or gradual decompensation.

  • Chronic liver disease? I have never been told that I have liver disease!

• Patient is alert and conversing despite low Na suggesting possible interference of bilirubin with Na assay, so her hyponatremia is likely better than it is. There was an order for hypertonic saline, but it was never started, nor would it be indicated at this point in her current mental status. She desats (drop in oxygen levels in the blood) sitting up, suggesting platypnea/orthodeoxia syndrome.

  • Platypnea-orthodeoxia syndrome - a rare condition that causes shortness of breath (dyspnea) and low blood oxygen (hypoxemia) when standing or sitting. Symptoms improve when lying down.

  • This explains why I have felt dizziness/faint for the past several years periodically that had significantly worsened over the past few months.

• # AKI stage 3 (crt >4) (baseline creatinine 0.5 4/2024, presenting creatinine 3.6) trending down from 4.4. Pending urine quantification. Multifactorial, ATN from hypotension induced renal hypoperfusion (reduced blood flow to the kidneys), tubular toxicity and cast nephropathy with hyperbilirubinemia (damage to the tubes that filter out waste therefore leading to excess of bilirubin), altered renal perfusion associated with hepatorenal physiology of hepatitis (change in the normal flow of blood to the kidneys), cannot r/o hepatorenal syndrome (life-threatening complication of advanced liver disease that causes acute kidney injury) given acuity UA with turbid urine (milky) and pyuria (high levels of white blood cells), r/o UTI.

• No evidence of renal obstruction per last imaging.

• Hypervolemic with ascites needing paracentesis.

• Severe life-threatening illness and/or secondary multi organ failure as per assessment above.

By the time they finished my initial intake, I finally had a chance to catch my breath until my mom arrived. There were so many questions and so much information being thrown at me and I was having a hard time understanding it all. I needed my mom to help me answer questions, help me make decisions and fight for the care I needed. They often pushed back when I would refer to my mom for an answer, they wanted me to answer the questions and me to make the decisions, but my brain was not comprehending even the simplest things. I would attempt to read the information they were giving me, but it wasn’t registering. I became entirely reliant on my mom again, for the second time in my life!