Saturday, July 22, 2006

Burn Out

I need a vacation. I mean, really need a vacation.

The onslaught of patients just never ceases. You fix one up, transfer him to the ward and in the meantime the ER's called with three more admissions. The families are inexplicably hostile, leaving angry messages on my voicemail at regular intervals. If I answered every voicemail and met with family members of sick ICU patients each time I was asked to, I would literally not have time for anything else, like, I don't know... patient care?

The patients seem to get more and more hopeless. Yesterday, my three new consults were a young (44 years old) man with disseminated cancer and renal failure; a 73 year old with metastatic colon cancer and renal failure; a 55 year old male with multiple myeloma (hematologic cancer) and renal failure. No matter what I did, and despite the chemotherapeutic antics of the oncologists, not one of them would live out the next three months. As I was preparing to leave I got the final straw of a consult, a 97 year old woman, transferred from the nursing home with weakness. Ninetyseven years old. She was getting dialysis as an outpatient and over the last few months had developed "failure to thrive", a term borrowed from the pediatricians.

OK.

A full day's work and nothing to show for it. Yes, I know, you treat the patient in front of you and don't think about the long term philosophical issues. In the long term we're all dead anyway. Like I said. I need a vacation.

I'm off for a week of horseback riding in the Rocky Mountains of western Montana. If the past is any guide I will return ready to fight the angel with style and pananche.

Later.

Thursday, July 20, 2006

DOA II

I got into the ICU at around 1:30 am. I checked the wall mounted computer screen to see if I could figure out where the patient was, but due to the privacy restrictions now in place (I believe the regulations are called HIPPA or some such bureaucratic nonsense), we can no longer write the patients' names on a board displayed on the wall, so that the doctors can actually find their patients. The screen had a bunch of room numbers and initials next to them. Useless.

I found the HUC and grumbled "Where's the new one. From the ER."

HUCs are ever cheerful and polite, and for some reason all named Heather. She responded "Oh, Hi Doctor! Your new patient is in 371!"

I grumbled some more and walked down to the room. The patient was indeed ancient, pale, thin... and tilted on her head.

Seriously.

This is a patient position called Trendelenburg. Some doctor, named Trendelenburg of course, realized that if you tilt a shocky patient head down the blood drains out of the capacitance veins in the legs and into the central circulation. This auto-transfusion raises the blood pressure to a certain extent. The nurse had put the patient into Trendelenburg because her BP was around 60 systolic despite high doses of two pressor drugs.

I walked in and started to examine this poor old lady. The nurse was highly agitated about the abnormal labs and started frantically reciting them to me. Without looking up I raised a hand in the universal symbol for "Shut-the-fuck-up". She mistakenly thought that this was a medical care situation when in fact it was simply medical ritual. The ICU doc examines the patient, reviews the notes from the ER and the labs, talks to the family and then allows the patient to die. There was nothing we could do or should do for this woman whose time had come. The Angel was waiting.

I finished my exam, checked the drips and the ventilator and went to the station to sit in front of the computer. I reviewed the labs, wrote my note and then got a cup of coffee before calling the daughter. She was in another state and mercifully agreed to withdraw support once I explained that the situation was clinically hopeless. Sometimes reason prevails.

We stopped the infusions and took her off the vent, removing the tube from her trachea. A few minutes later she stopped breathing and the monitor went flat. I returned to the station and dictated an admission note and a death summary.

I sat for a moment and listened to the sounds of the unit. Nurses chatting, phones ringing, monitors alarming. I took comfort in this background noise and a job well done. We had helped our patient leave this world and enter the next, with a minimum of pain and discomfort.

Home, bed, sleep.

Saturday, July 15, 2006

DOA

I know it sounds paranoid, but I really think there is a light sensor in my room. If I'm on call, as soon as I turn out the lights, the sensor activates and alerts the ER that an Intensivist is attempting to sleep. This alarm triggers immediate pages and demands that I drive in to the ICU. Sometimes when it's time to sleep, I lay in bed with the lights on and a book on my chest, pretending to be awake, just so they don't call me.

The ICU doc is by nature superstitious. I never, ever, not once, say that the night on call is going well. Such a statement would anger the Gods and bring on several emergent consults. The only time you can say the night went well is the next morning when you're sipping coffee and signing out to the partner taking over.

Against my better judgment, I turned off the lights at around 11:30. They waited about half an hour, just so I could get a taste of deep sleep, and then set off the beeper. There's always the hope that it's just some ward nurse calling with a question, just part of the nightly competition for "Stupidest Nurse Call." This competition is especially acute in the early morning hours when the labs start coming back. I'll answer the page and get "This is Dolores. Bed 17 has a blood pressure of 175/95."

And then silence. You know, I'm supposed to wake up from deep sleep and know not only who's in Bed 17, but what their history is and what the significance of that blood pressure is. Usually I say something like "Well, Delores, can I have some more clues, perhaps even a name?"

Or else they wake you from deep sleep and tell you that Mr. Jones' hemoglobin is 9.7 and yesterday is was 10.0. They drag you out of some wonderful dream and start reciting labs that you'll be reviewing in a few hours on rounds anyway. Here the proper response is "Thanks. I'll alert the media."

Anyway, this was not a nursing call, stupid or otherwise. "5141". The ER. I called in, knowing it was hopeless, I would not be sleeping any time soon. The ER doc answered, and was way too cheerful. "Hey, Thanks for calling back!" ER docs work shifts. When their shift is over they leave. No beeper, no call. Lots of sleep. No wonder they're cheerful.

The patient was an 87 year old nursing home resident. Found unresponsive, brought to the ER by the paramedics. Blood pressure next to nothing, not breathing. The ER doc proudly told me that he had started a central line, volume resuscitated the patient, put her on dopamine to bring up the pressure. He was in the process of getting her intubated and on the ventilator. He then read me her labs: sodium 120, potassium 7.1, pH 6.9, creatinine 4.0....

I interrupted and said : "You know, she sounds sort of... I don't know.... Dead?"

There was that sort of buzz-kill silence and then he rallied his enthusiasm, "Well, as far as we know she's full code."

"Great, I'll be in."

I figured it would be 30 or 40 minutes until they got her up to the ICU, if she lived that long. I lay back down and closed my eyes. The bed shifted and I felt that pressure, air displaced. A soft rasping laugh came from the foot of the bed.

"Please. Spare me the whole Grim Reaper bit."

Air rasping back and forth in the simulacrum of a laugh. A soft voice, inhuman, but almost gentle. "Don't bother going in for this one. I'll have her soon enough."

I sat up and threw the covers back. "You will indeed, but forms must be followed, rituals carried out. " Then a bit of bravado, "You'll get her when I say you get her."

Again the rasping, the settling of robes, creaking of ancient flesh. "I am patient. I have nothing but time."

Then gone. The pressure released and the room empty. I heard the wind whipping the leaves back and forth, the rumble of a distant thunder storm. Stand up, keep moving, brush teeth, keep moving, dress, keep moving.

Into the car and gone.

Sunday, July 09, 2006

The Bleeding Whale

The patient was admitted to the Hospitalist service, but by late afternoon on Sunday they were well over their heads. What is a Hospitalist? This is a new practice of Internal Medicine that basically involves a group of Internists who manage patients in the hospital. This way the primary care doctors (other Internists and Family Practioners who see patients in clinics) don't have to bother with inconvenient things like sick patients in the middle of the night. It is a division of Internal Medicine into clinic based practice and hospital based practice, and I am wholly unconvinced it is a good idea.

I moonlighted for the Hospitalist service at our hospital when I was young and hungry and the service had just begun. Basically, I covered for the weekend, admitting general medicine patients, dictating H & P's, discharging patients, dictating discharge summaries. By the end of the weekend I was bored to death. I concluded that I would rather drive a truck than be a hospitalist.

At any rate, the patient was in his sixties and had come in with shock and respiratory failure. In the ER someone put down an NG tube (a flexible tube that goes from the nose, N, to the stomach, G for gastric) and got back a lot of fresh and digested blood. His hemoglobin was down to 6 (normal around 14) and he was getting lots of transfusions. The GI doc had called in the endoscopy team and was preparing to pass a scope down his gullet, but they wanted the patient to be more stable first. Having a patient arrest during endoscopy can be such a bummer.

The Hopsitalist decided to call in the Cavalry and there I was... better late afternoon than three in the morning. The first order of business was a central line. When someone is critically ill you want a big tube going into either the subclavian or internal jugular veins so that if they go south quick you can give them meds, fluids, blood. Usually you just find the landmarks on the neck and get a needle into the vein so that you can pass a wire through the needle into the central veins near the heart. Then you slide the actual IV catheter over the wire and pull the wire out. Sounds complicated but it gets easier after the first thousand or so.

The problem was this guy was a whale. I'm talking 200 kilograms (2.2 pounds per kilogram, you do the math). Locating a neck was tough, and finding any landmarks hopeless.This scenario is becoming more and more common in the hospital. While obesity certainly causes lots of morbidity, it also makes the patient very difficult to care for. Just to turn this guy over in bed took four nurses. He needed a "Big Boy Bed" with extra weight capacity and controls to maneuver his mass.

Well, what to do? The Endoscopy nurses were looking at their watches, thinking about Sunday dinners going down the tubes, while I poked and prodded. Solution? Bring out the Site-Rite. This is a little ultrasound machine mounted on an IV pole. You cover the probe with a sterile condom-like sheath and use it to guide the needle stick. It was amazing, I could see the round pulsatile carotid artery and flat compressible internal jugular vein clear as day. I could watch the needle dive through the neck and enter the vein, all the time watching a little screen on the pole rather than the patient. Blood return, thread the wire, done.

Next we needed an arterial line. This is a catheter threaded up the femoral artery and hooked up to a transducer that allows continuous measurement of blood pressure, and sampling of arterial blood to do blood gases on and help manage the patient's ventilator. Normally, the femoral artery can be felt in the groin area, but in this case two nurses had to retract the patient's massive gut and hold it back just to see the groin. Every time I pressed in to try and feel a pulse, mounds of fat pushed back at me. Occasionally I convinced myself that I felt a pulse, but the flab would shift and I would lose it. In the end I used the Site-Rite again, saw the pulsing, round femoral artery on the screen and plunged a large needle into his groin. Fortunately I was soon rewarded with a geyser of bright red arterial blood spurting across the sterile drapes. Thread the wire, pass the catheter, done.

Once the lines were in I could manage his fluids and drips, and we had his blood pressure stabilized in short order. In fact, they started the endoscopy while I was still in the room so I stuck around to watch. They have a big video screen on a cart and you can see the whole thing. His blood filled stomach was actually pretty gross to see, and I couldn't tell what was what, but the GI specialist confidently located a bleeding ulcer and injected an artery with epinephrine to close it off.

I sat to review the chart, pull up the labs on the computer, write my consult and dictate. About half an hour later I walked back into the room for a last check. What had been bloody chaos was now a scene of neatness and tranquility. The patient was clean, sedated and laying still in bed. The tubes and lines snaked off to their pumps and monitors and no alarms were sounding. The blood pressure was steady and, if not normal, at least at an acceptable level.

Home, bed, sleep

Thursday, July 06, 2006

Ending it All

In summer, the passions of the young run strong. To the young and inexperienced, breaking up with a lover can seem like the end of the world. Teenagers and those in their twenties, have yet to acquire the experience to realize that if the sun still rises and you are there to see it, then life is good. Like Woody Allen said, 80% of life is just showing up. If your girlfriend dumps you, the sun will still rise the next morning. And you know what? When you stumble outside to get the newspaper, more than likely there'll be another young gal walking by, and you can say something intelligent and suave like "Hey." And she will smile back at you and say "Good Morning!"

You get the idea.

The problem is that when you're 16 to 25 years old you have no perspective on life. Being dumped by a girlfriend can seem quite literally like the end of the world, and why wait around for the final moments? Why not just end it all now? And if you happen to live through the suicide attempt, maybe your old lover will find out and come to the hospital and......

Saturday night, July, hot. Call from the suburban ER. Twenty-something male went into his parent's garage and drank a lot of windshield wiper fluid and antifreeze. I know. This sounds totally gross. I'm told that windshield wiper fluid is actually pretty tasty. Tart and tangy with a subtle nose. He was clinically okay but the labs showed mild acute renal failure and metabolic acidosis, both signs of a serious, potentially lethal ingestion. I talked to the ER doc and we started fomepizole, an inhibitor of alcohol metabolism that prevents the metabolism of the methanol and ethylene glycol he ingested into toxic metabolites that can cause severe metabolic derangement, acute renal failure and, worst of all, blindness. We used to give them enough booze to keep them legally drunk, which would competitively inhibit methanol and ethylene glycol metabolism and prevent generation of toxic metabolites. Now we use the antidote, fomepizole. We had a few doses sent down from the county hospital by taxi and got the boy loaded up.

Six hours later he was doing okay clinically, but the methanol levels were still sky high. After wringing my hands for a while I called in the troops and organized treatment with acute hemodialysis, the artificial kidney. This type of treatment removes the abnormal alcohols from the bloodstream and in conjunction with the antidote can save the patient's sorry life.

To do dialysis acutely you have to place vascular access. This means placing a big, thick, long iv tube into a major vessel. Since we only needed one treatment I chose the femoral vein, due to ease of placement. The nurses gathered all the equipment and I started setting things up. Of course there had to be some nurse-beaurocrat who wanted a op permit signed to place the line, something I rarely bother with. Do you really need to ask permission to save someone's life. Anyway, I went through talk, expecting a quick signature and getting on with it. Unfortunately, this guy had a bunch of questions, on the order of "Do I really need to do this? "

To which I answered "No, unless you have a problem with hanging out with seeing-eye dogs."

We finally went forward and I harpooned the femoral vein with great alacrity. Soon we had the dialysis machine spinning and humming, filtering the poisons out of the blood. The kid's parents came by and had a bunch of questions, but were mostly relieved that the child they had put so much time and effort into raising was not going to die tonight.

I wrote some orders for Psychiatry to see the patient in the morning (psychs don't do night work) and headed for home. I thought about my own kids (four at last count) and shuddered at the thought of one of them taking his or her own life. You just have to get them through the phase of teenage asshole narcissism and selfishness, bring them to the point of appreciating the intrinsic beauty and worthiness of life for it's own sake. I got home to the darkened house and walked through the kid's rooms, listening to them breath, before heading for bed and sleep. Waiting for the next call.