I am wondering, idly, thoughtlessly, whether I am going to have a patient to round on in the morning.
Case presentation, O Best Beloved: M is a late-twenties male, morbidly obese, severe Pickwickian syndrome, presenting with respiratory distress leading to respiratory failure. He is currently ventilated via tracheostomy tube placed during this hospital stay; he requires maximum ventilator support with an FiO2 of 100%, PEEP of 17, and sats in the upper 70's to lower 80's on these settings. Oxygen has been unable to be weaned for 13 days. On presentation he was treated presumptively for PE with therapeutic Lovenox but became coagulopathic; he was returned to prophylactic doses and later started on a heparin drip. He has a urinary tract infection with candida species and Levaquin-resistant E. coli, now on renal doses of Vancomycin and Fortaz. He diuresed briskly during his inital days but suffered a sudden increase in creatinine leading to prerenal ARF, unresponsive to fluid hydration, and is now progressively azotemic with a creatiinine of 7. Renal has been consulted and attempts to begin CRRT via subclavian line placed by pulmonology failed. General surgery placed a permacath which is suffering from unacceptably high return pressures, making dialysis sporadic at best. Potassium is mildly elevated to 5.3. Patient was initially pleasant, cooperative, and communicative via writing notes but of late has become encephalopathic, requiring first restraint and finally sedation and paralysis to prevent him removing his tubes. He is on a NE drip to maintain systolic pressures after responding poorly to dopamine; he requires nearly 50 mikes. In family conference, it was decided that he should be made a DNR and comfort measures initiated.
What does it mean?
My first day on service I walked into a room in the ICU and greeted M by name. He is in the special, extra-big bed for extra-big people; his admission weight was something right around 500 pounds. He waved, shook my hand, smiled at me. He wrote notes, asking if we could help him pay for bariatric surgery. He asked if he could go home now that he'd had his trach. We explained, again and again that this was far more serious than that. When he was turned over to me I was told that he would likely never leave the ICU.
It wasn't until his kidneys quit - whether from crossing the fine and delicate line of diuresis vs dehydration or from the steadily decreasing ability of his heart to force blood through his body, we may never know - but when he was told that we were having no luck getting them to work again, I think I saw him begin to understand that he was dying. And he is. We were not made to carry so much weight as he is; it wears out every organ in its turn. But I spent time with him that day, calling his family, explaining the situation, trying to find him some company in his loneliness. When you are awake in the ICU and alone, you can watch TV or you can think dark thoughts. And when the news is dark, there are few thoughts to think.
Over the last five days, I have watched a pleasant and friendly man become first depressed, then determined. He mouthed at me "I'm going to make it" and made a fist. I told him that he had to keep thinking thoughts like that, that it was good for him. And I went to his chart and wrote: Prognosis grim.
We have done everything we can do, O Best Beloved. We cannot do diagnostic X-rays on him; there is too much fat to penetrate for anything but the worst resolution possible. He does not fit in the CT scanner and he is not stable enough to leave the ICU. He nearly died on the table getting a tracheostomy. We called Renal, the computers and mathematicians of medicine, and they did their numbers. Unemotionally, I was told by the rounding nephrologist that we were not doing any favors to him by trying to do dialysis. We're only rearranging how he's going to die. But we have to try.
We have tried everything. We don't know what we're treating; he runs fevers every day and antibiotics have been changed and changed. Cultures and titers are coming back for exotic organisms that he doesn't have; all he has is the most ordinary of urinary tract bacteria and a yeast infection. Sometimes the numbers will say he doesn't even have those. He is dying of his obesity, in the long run: his heart is giving up and his lungs can no longer inflate without a machine to force them open and keep them from collapsing completely. He is requiring norepinephrine - noradrenaline, for the Brits - just to keep circulation to his organs above a critical value. Despite having 100% oxygen forced into his lungs with every breath (try breathing 24 times a minute, O Best Beloved, and see how it feels) his oxygenation decreases every day. It may be that his lungs are crystallizing - oxygen is a potent toxin - but we could not give him less or he would have died long before now. It may be that his very cells are worn out.
Nephrology was dismal, but they tried, and there is a very stalwart and daring surgeon who tried as well, and for a few hours at a time his blood has been strained and cleansed. But there is so much of it. He has a port in for CRRT - a sort of dialysis that I don't completely understand - because without kidneys you must be dialysed or you will slip slowly and inevitably into death. There are, however, worse ways to die than hyperammonemic encephalopathy. At least that way is more like sleep.
The ICU pharmacist rested his hand on my shoulder on Tuesday; he looked down at me. "You reach a point," he said, gently, "where you have to acknowledge that there's nothing more you can do - except to decide what you're going to learn from this case to carry on to the next person you can't help."
It takes me an hour or more to write my note every day; I sit at the desk in front of his glass-doored room and watch him as I write. I cannot tell you if it is self-flagellation or a search for comfort; I find nothing of either. When I came into the room and greeted him one morning, and got nothing more than a twitch and flutter of eyelids, that was the morning that my hope for him broke. I stood, holding his hand, and told him everything planned for the day, not knowing if he could even understand me. I told him we were going to try a surgeon to replace the catheter that didn't work for dialysis. I told him we were still trying, that we hadn't given up on him. And then I went back to the chart and I bit back the tears and I stared at the page until I could wrap my fingers around my pen and see to write.
It has been like that every day. When R found me to turn over for my call, I was sitting in the ICU, staring into space. And he knew, and he understood, and he didn't say much, but he touched me, laid his hand over mine, and that was enough for another day. When I called last night to ask him to round for me today, on my day off, he asked and listened, caught himself up to date on M's condition. That means something, that someone cares that I care.
I have not cried yet over him, no more than tears welling in my eyes and my voice. None have spilled, yet. I am fighting them, saving them, holding them back. Not to deny but so that I will have them left for the end.
Today, O Best Beloved, I am thankful to be alive.