Head Bleeds

I was on call last weekend, working the Saturday morning to Monday afternoon shift (Yeh, tell me about it). The ICU was hopping and the battle with the Angel was fully engaged. The theme was head bleeds. Specifically, intracerebral hemorrhages in middle-aged, previously healthy men.

The first was a 48 year old who lived with a roommate, worked various constructions jobs, and whose hobbies consisted of smoking, drinking and otherwise abusing his body. He hadn't seen a doctor in decades (a policy I approve of wholeheartedly) and likely had undiagnosed, untreated hypertension. He called his buddy to tell him that he didn't seem to be able to move the left side of his body. His buddy, rather than calling 911, drove over, and by the time he got there the patient was unresponsive and on the floor. By then the friend figured out that calling 911 was probably a good idea. In the ER, the blood pressure was 220/110 and the CT showed a huge, essentially fatal brainstem bleed. The surgeon looked him over and admitted him to my service to prepare for organ donation.

The next one was 52 years old, had also ignored his high blood pressure, and was found on the floor of the Men's room at his job, unresponsive and with a gash on his forehead where he had hit the sink on the way down. The CT showed an occipital bleed (back of the brain) and not too much else. The neurosurgeon took a look and again admitted him to my service in the ICU for blood pressure control and observation. We gave him IV fluids and administered several intravenous blood pressure meds, and he stabilized pretty quickly. Within a few hours he was semi-awake and communicating with slurred speech. I told him what was going on and went out to the nursing station to write a note. Five minutes later his wife was in my face very irate.

"My husband is very upset. I want to know why you told him he had a stroke?"

I looked at her.

"I don't know, I guess because he had a stroke."

It took me a while to explain what the word stroke means, that it is not just for old people who develop sudden paralysis, and includes various types of head bleeds. We talked for some time about his prognosis (doctor speak for how he's going to do) and the need for careful control of his blood pressure in the future, and she went away somewhat calmer.

The third patient had complained to his wife about a real bad headache and she had brought him promptly to the ER. His CT showed a big intracerebral bleed with a shift or compression of the rest of the brain. Bad news. I got the call from the OR where the surgeon had buzzed open his skull, scooped out the collection of blood and put in an intraventricular drain to monitor the pressure. He was on a ventilator and the plan was to keep him sedated, control his blood pressure and give him IV fluids and nutrition. We would let him wake up in a few days and see what his brain function was like.

The fourth patient presented with a sudden loss of consciousness, hypertension and a bleed on CT. By this point it was getting a little repetitive and a little ridiculous. It was like the Angel was jacking me around. Unfortunately, this one died before he could even be brought to the OR.

Final Score: Angel 2
ICU doc one definite win, one tie.

A Knight of the Road

One of my partners has a black cloud.

Which is to say, whenever he is on call he gets hammered with consults and admissions of super-sick patients. It couldn't happen to a nicer or more consciencious guy. He never looses his temper or dresses down the nurses, as opposed to your's truly who has on occasion been known to lose his temper. Dr. B. is truly a saint, and has been cursed with a black cloud.

My last two call nights have definitely been black cloud material. I worry I may have acquired a black cloud of my own. Maybe I should do some ritual or ceremony involving the burning of a clump of sage.

Friday night could have been a fluke. Three ICU admissions after 9 pm! Going from room to room, physical exam, iv's, central lines, arterial lines... Just a fluke. Then came Monday night.

Now, if I can have dinner with my family and even do some bedtime reading to my youngest while I am on call, I feel like life is good. So last Monday, when I got the page to our second ICU, about 25 minutes drive into the southern suburbs of Minneapolis, I wasn't too upset. The patient was from California, and had apparently driven to Minnesota to take part in a contract job that involves industrial waste removal. The police pulled him over for erratic driving, but somehow discerned that he was not drunk, just confused. They brought him to the ER where his blood pressure was 200/120 (normal about 130/75). The high blood pressure was cooking his brain, what we doctors call "hypertensive encephalopathy", which technically means cooked brain.

He told us his feet and legs had been swollen for about two weeks and he was weak and short of breath. He also had acute renal failure and severe anemia, and it turns out he was most likely bleeding into his lungs. Believe it or not, but this whole picture is a well recognized syndrome (syndrome = running together of symptoms) called Goodpasture's Syndrome. Dr. Goodpasture described the syndrome of pulmonary hemorrhage, acute glomerulonephritis (say it 5 times fast) due to an autoantibody attacking the blood vessels of the patient. A classic autoimmune disease in which the body's immune system loses the ability to distinguish friend from foe.

He needed plasmapharesis, which is a procedure sort of like dialysis. We place a large-bore, dual lumen catheter in a central vein and hook him up to a machine that separates the plasma and red blood cells. We give the patient back his cells and replacement fresh, frozen plasma, and pitch the plasma we removed. It's a way of removing toxic antibodies that apparently cause Goodpasture's Syndrome. Actually, the scientific rational is not too far removed from blood letting or leeches, dressed up in scientific jargon. Basically removing evil humors. I also added high dose steroids and planned for some cytoxan later in the day. Basically shutting down the immune system and the evil antibodies.

I set about placing the central line, and while I scrubbed, prepped, harpooned, the patient told me about his life. He lived in California, to the extent that he lived anywhere at all, with his girlfriend of twenty years. He traveled the country doing contract industrial waste removal and had done his share or drinking, carousing, smoking, etc. He was tall and tanned and wiry. He had the hard muscles of a guy who had never seen the inside of a gym or health club. When I harpooned his femoral vein his only acknowledgement of pain was a grimace, and a slight pause in his story of life on the road.

It was late and I was focused on work. While I was talking care of him I had two more patients roll into the ICU in various states of disarray that promised to take me the rest of the night to sort out. Black Cloud Central. But I wish I had had a tape recorder running. The Knight of the Road was telling me his life story at 2 am in a suburban Twin Cities ICU, a story that needed telling. I got the line in, the pharesis nurse did her thing, and I moved on. The next morning, one of my partners took over. Once I catch up on some sleep I plan to check up on him, see how it all works out.

At the End of the Day

As the saying goes, in the long run we're all dead.

I wonder then what is it I really do in the ICU? A carpenter finishes his job and has something to show for it. A house, a remodeled kitchen. A tile layer can go back and look at his work which will last until the next owner of the house decides to tear it up and start again. But in the mean time, the owners can walk on his work and admire its beauty.

In the ICU it seems like an endless battle that we are certain will eventually be lost. In the long run we're all dead.

I got called in after dinner last Friday night to see a 77 year old nursing home patient who was found by the nursing home staff unresponsive, with respiratory distress and an unmeasurably low blood pressure. He was in the nursing home because after years of heavy smoking he not only couldn't breath without supplemental oxygen, but the vessels to his feet were so clogged that ulcers were developing and spreading, not healing because of poor blood supply. He would never walk again, and would clearly never return to independent living at home.

And yet, the ER doc duly intubated him, put him on the ventilator and sent him up to the ICU. I wandered in and asked the HUC where the new patient was.

"Which one, Doctor? You have three new ones to see."

Great. In the fifteen minutes it had taken me to drive in there was an 87 year old woman who had just had part of her colon wacked out and was febrile, hypotensive and tachycardic. She would be in the ICU shortly.

There was also a 60ish year old woman in the ER who had recently had abdominal surgery with the discovery of a widely spread adenocarcinoma throughout the abdomen. Rather than close her up and tell her the truth- which would have been "Sorry, there's nothing we can do, and you should get your affairs in order." - The surgeon had done an aggressive surgical resection and the oncologists had given her the first course of chemotherapy. Predictably, now ten days later, she was in septic shock and being sent directly to the ICU.

I spent the next 6 hours going from room to room- physical exam, review the drips and vital signs, adjust the vent, write orders for iv fluids and antibiotics,.......

I basically wrote the same order set for all three patients and then after rechecking to see that things were pretty stable, I went home. I got to the house at about 1:30 am and was woken up about every half hour subsequently with questions and updates from the Unit nurses.

At the end of my work day, Saturday morning, what did I have to show for my work, other than exhaustion? There were three patients who were still alive, but not for long. The Angel was making rounds right behind me, taking notes and planning his schedule. What was it I had really accomplished? My job is to keep these patients alive, and I had done it to the best of my abilities. But, even in the short term these poor souls were dead.

I told myself it was the fatigue talking. Ours not to reason why and all that. I got dressed, went outside and spent a few hours in the August sun chopping brush, pruning trees and pulling weeds. Simple work, physical, without much need for conscious thought. A Zen experience. And when I was finished I could walk around the garden and see my accomplishments. Well, by evening I would be feeling philosophical and by Monday ready to start again.

Rejuvenation

Memo to Angel of Death: Bad luck! I'm back.

A week in the saddle in the mountains of southwest Montana. No phone, no television, no computer, no email, no voice mail. Each day spent loping on horseback through alpine meadows, along rushing streams, surrounded by snow-capped peaks. The only tough question each day was which wine goes with elk?

But now I am back. Fortunately, my first week is being spent on outpatient responsibilities, dialysis rounds, outpatient clinic, reviewing labs and charts. I'll be on call Friday night and then have the weekend off to recoup. Not too shabby a schedule. I do miss my horse though.

Riding is a very Zen experience. When you first start going fast, loping or galloping, the natural reaction is to grip tight with your legs, knees and hands. Wrong move. You immediately start bouncing all over the place. To find your seat on a loping horse you have to let go. One hand on the reins, the other in the air. You need to lengthen your legs and drop down the heels, feeling the horse but not gripping. You lean back but keep your posture upright, moving from your center in synch with the horse's center. You don't master the horse, you blend with it, until you are one creature, running flat out up mountain trails.

When you find that sweet spot, the world and all it's troubles falls away. The Angel evaporates into mist.

If people still rode horses for transportation I am convinced the world would be a better place. No air pollution, no global warming, certainly no road rage. When was the last time your Lexus nuzzled you after a long ride? The only waste product of the horse is reprocessed hay that would provide valuable fertilizer for farmers.

From a ICU doc's point of view the advantages are amazing. Just think, no one ever got drunk, left the bar at 1 am, and ran their horse into a bridge abutment at 70 mph. Just throw the reins over the horse's neck and let him find the way home.