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Quiet time in the ICU... - Nobody wears a white coat any more... — LiveJournal
...a tribute to becoming a doctor.
Quiet time in the ICU...
There is not much snow on the ground right now, but what there is seems to be dividing itself between ground and air. We decided not to go to family thanksgiving; we made a turkey breast and mashed potatoes and green bean casserole and dressing right here instead. Too much driving, once you factor in the additional travel time due to snow.

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.

Tags: , ,
now feeling:: sad sad

7 whispers echo . o O ( ... ) O o . whisper a word
deadrose From: deadrose Date: November 25th, 2005 03:31 am (UTC) (etched in stone)
I sympathize, and in a small way, I understand. I still carry around the memory of a patient I often cared for, back when I was an aide in a large nursing home years ago.

He was 42 when I met him. Successful businessman, lovely wife, sweet kids; had an MI and the aid car got lost in the cul-de-sacs of the wealthy suburb. By the time he was resuscitated, the physical damage was done. Brain damage, spasticity, I'm sure you can imagine. Then the emotional damage hit: his wife put him in the nursing home, didn't bother to unpack his things, just left the cardboard boxes and walked out of his life. Neither she or the kids ever came to the home after that.

So there he was, warehoused in a nursing home where most of the staff treated him the same way they did the moribund Alzheimers patients. He quit speaking, just stared at the tv all day.

I tried, despite the horrible patient loads we had (and this was supposed to be one of the really good places) to take enough time with him at meals, to be patient as he fought to swallow.... and just to talk to him, to treat him like a fellow human being. One day though, I just couldn't go back in there again. The place had pretty much eaten me alive.

He died a few weeks later of aspiration pneumonia. I've always felt guilty that I couldn't hack the job, couldn't stay there and try to look out for his needs (I suspect my cousin with severe CP has a lot to do with this), that I couldn't singlehandedly change the lack of treatment from the staff, or the attitude of his wife.

Anyway, that's why your story brought a lump into my throat and a major wave of empathy. I'm still thankful to have met that patient, but I'll always regret that I couldn't do enough.

PS: Wish my dad luck, he's having to sit his boards again next week, and having a hell of a time getting up to speed on all the specialties (such as OB and surgery) that he hasn't practiced in years. He can't afford the malpractice insurance, but he still has to know every new treatment, every new drug. You know, just in case he's walking down the street and someone grabs him and throws him into a fully-equipped hospital with no doctors and a woman in labor with a placenta previa. *snort*
ayradyss From: ayradyss Date: November 25th, 2005 11:03 am (UTC) (etched in stone)
Best of luck to him. Recerts are wicked.
From: (Anonymous) Date: November 25th, 2005 04:23 am (UTC) (etched in stone)

from your anonymous sister

we missed you today, and love you, and I know I'm glad that you got a chance to relax and be with Matt (even if we missed you). I'm looking forward to seeing you on Saturday.

and, just a note in response to a posting someone else made. It was taking me time to be a victim-- my apartment had been broken into, and taking care of all of the necessary things (locks, a new frame, etc.) was taking up my time. To complicate it, everyone wanted to hear the story, and that was also taking up my time, and I was done with it. The people who did that don't deserve and will not get the power to control my life in that way. Being a victim is (sometimes) a choice as much as it is an uncontrollable event. Choice is all I get, and I choose not to be controlled in that way.

Loads of love, and I got a call back from the head start people--- it sounds positive!
daimones From: daimones Date: November 25th, 2005 12:40 pm (UTC) (etched in stone)

Re: from your anonymous sister

I am sorry to hear that and fervently hope you don't have to go through it again.
ellisande From: ellisande Date: November 25th, 2005 01:07 pm (UTC) (etched in stone)
*hugs gently* Hang in there, lady.
From: silmaril Date: November 25th, 2005 07:37 pm (UTC) (etched in stone)
fyrfitrmedic From: fyrfitrmedic Date: November 25th, 2005 08:20 pm (UTC) (etched in stone)
Very evocative stuff; I'm reminded of my own feelings from several weeks ago, both as a provider and as a family member.
7 whispers echo . o O ( ... ) O o . whisper a word