The Family Meeting

A meeting between family members of a sick patient and the various health care professionals taking care of the patient sounds like such a good idea. It may actually be a good idea. But for me it is truly one of the circles of hell. Spending half an hour or fortyfive minutes in a room with social workers, clergy, nurses, patient advocates and a pack of distraught and angry family members..... It's hard to describe the horror.

These meetings are usually set up when it is clear that the patient is not going to survive, yet no one has made the rational decision to withdraw aggressive support and allow the patient to die in peace. The meeting usually starts with me giving my "Grandma is toast" speech, followed by a sermon on the circle of life. You know, to every thing, turn, turn, turn.

Then the family members get to vent their anger at the doctors and nurses caring for the patient. For reasons known only to God, family members are often hostile and angry, rather than grateful for all the hard work and long hours put in taking care of their loved one. I can count on one hand the number of times a family member has said something nice to me. You know, something on the order of "Thanks for staying up all last night and saving my husband's sorry ass". Mostly it's just a litany of complaints. I understand that this is how people sometimes react to the potential loss of a loved one and that I should just stay calm and understanding. The problem is I'm an ICU doc. If I was calm and understanding by nature I would have gone into Family Practice or Endocrinology. Besides, it's easy to be calm and understanding on a full night's sleep.

Anyway, the characters at these meetings can be pretty entertaining. When meeting with family members of an elderly, critically ill patient one seems to run into the same characters over and over again. First, there's the TAD (Totally Annoying Daughter). This is the daughter who has seen a couple of shows on Oprah and reads People magazine and therefore feels qualified as a medical expert. The TAD's main premise is that if the fucking doctors had only listened to her in the first place her mother wouldn't be in this mess. Amazingly, the TAD has usually just flown in from 2000 miles away and hasn't paid the slightest attention to her mother for the last 10 years. Now she wants everything done and won't even discuss withdrawing support. On the otherhand, there's the daughter who has lived locally and has been lovingly caring for her mother, driving her around, making meals for her, taking her to see the doctor, etc. When she can get a word in edgewise she usually says something like "Mom wouldn't want to be kept alive on all these machines. She always told me that when her time came, to let her go join Dad".

Well, in the end the Angel makes his visit. At these times we're more like allies than enemies. I generally just nod hello and go on about my work. Occasionally I flip him off just to let him know where I stand, that next time he'll have to fight for his prize.

Grandma Is Toast

One hundred or even fifty years ago, no one would dream of sending their 85 year old mother to the ICU to die. When my grandmother was dying, my mother sat at her bedside and held her hand until she passed away. I doubt it occurred to her to call an ambulance and transport her to the hospital . She was very old and it was her time. Why die surrounded by strangers sticking you with needles and shoving tubes in various places, when you can die in your own bed, surrounded by your loved ones?

For reasons that escape me, modern Americans seem to have forgotten the natural cycles of life. We are born, we grow old, we get sick and we die. It always astounds me when I go into the waiting room and inform a gathered family that their 87 year old matriarch is dying, and they are shocked and stunned by the news, demanding to know what can be done to save her. Can we operate? What about dialysis? Start the tube feedings and put her on the ventilator!

I sometimes feel like asking them "How long did you expect her to live? A hundred? A hundred and twenty?" It seems we have lost touch with the fact that despite the advances and power of modern critical care medicine, people are not immortal. People grow old and then they die. Each and every one. No one is immortal. While I tend to remember the young, salvageable patients that I save, these are actually somewhat rare. About 80% of what we do in the ICU is help ease the transition from this life to the next.

It is amazing to me how often I get the late night calls from the ER with some 9,000 year old guy from the nursing home with respiratory failure, hypotension, wildly abnormal blood chemistries. The ER doc will proceed with some prolonged presentation of the case, and the whole time I'm thinking "Call the priest for the love of God! There's nothing I can do for this one." They need the Angel, not me. But I have long since stopped fighting that particular battle. If they want me to buy them a few more hours of life, even if it involves painful procedures, needle sticks, various intubations, I come in and do it.

But I can't help but long for a more rational society where our old ones are kept at home to die. How much nicer would it be for the patient when instead of me shoving needles into central veins and tubes into tracheas, their loved ones made them tea, and talked about their lives, joys, memories. Talked and kept them company as they passed from this life to the next.

Instead they often come screaming into the ER and are transported directly to the ICU. Once their I go to work on them, suppressing my feelings about the obvious futility of what we're doing. I don't mind the actual work, the worst thing is:

The Family Meeting!

The Angel Wins One

I returned to the ICU at around 7 am that morning. The patient was back from the OR minus his entire colon. The operative findings suggested a toxic megacolon and the initial path was consistent with C. Dif. colitis. C. Dif. is a bacteria that overgrows the colon when other beneficial bacteria are killed by antibiotics. The C. Dif. flourishes causing illness that ranges from mild diarrhea, to bad, persistent diarrhea, to what this patient had: toxic megacolon with septic shock and multisystem organ failure. That explained the super high white count. The colon had been transformed into a dilated sac, leaking toxins and bacteria into the bloodstream. The surgeon had whacked out the whole thing and transported the patient back to the ICU, back in my court.

I first called up the labs and saw that the metabolic disaster was worse than I anticipated. He had severe acidosis and the potassium was life-threateningly high. I would need to get him on dialysis like right now. I went into the room and did a brief exam, while letting the day nurses, G. and N., know what I would need to put in a dialysis catheter. I also dialed up the extension of the dialysis room and told the dialysis nurse to clear the schedule and set up for an acute run in the ICU.

And then he arrested.

The heart rate slowed, the alarms went off, and then the heart stopped. I yelled something intelligent like "Jesus, Fuck!" and then told the nurse to do what she was already doing, call a code.

We started CPR, took him off the ventilator and started bagging him by hand. The code team arrived and we started trying to flail his heart back to life. What could only look like a circus where the clowns were dead drunk was actually a carefully choreographed procedure. An RT bagged the patient, three different nurses administered the drugs that I and the house officer called out, two beefy orderlies alternated vigorous CPR, and a charge nurse carefully recorded everything we did on a code sheet.

At first things seemed hopeless. Flat-line is the worst thing you can see on a monitor during a code. Remembering the acidosis and hyperkalemia I gave him bicarb, calcium, epinephrine, more bicarb, more epi, atropine.....

Time went by and we were getting nowhere. I could sense the desperation in the nurses, waiting for me to call it. I kept thinking "28 fucking years old, the Angel is not getting this child...". But still the monitor was flat.

"OK, another dose of epi and atropine,,,,"

The nurse looked at me but gave the meds. "Epi and atropine in."

"Stop CPR." They stopped. The room was silent as we stared at the monitor. I looked at the House doc who looked back at me and nodded. The flat line was now a rough squiggle.

"Yes! VFib. Shock him, 300 joules."

The nurses set up the defibrillator. "Clear." We all stepped back and the body arched up. The monitor swerved erratically and then settled back into a coarser vfib.

"Shock him again."

"Clear!" Again he arched. The monitor came back to a smooth line and then a slow rhythm appeared.

"Jesus!"

The nurse looked up at me. "Perfusing. I've got a femoral pulse."

I looked at her. "Thank the fucking Lord. Get me the dialysis catheter." I turned to the dialysis nurse B., "You ready to go?"

He nodded, lines in hand. I harpooned the femoral vein without bothering with the niceties of scrubbing and draping. the line was in and we hooked him up. "How long was the code?" I asked the charge nurse.

"Two hours, 35 minutes."

My mouth hung open. "What?"

She nodded. "We thought we were gonna have to call Security to haul you away from the bed. We've never coded anyone that long."

I turned from her and looked at the ventilator sighing, the monitor beeping out the struggling rhythm and alarming away, the dialysis machine spinning and bucking. "This boy is alive." I turned to the crowd in the room. "Thank you everyone. This boy is still alive."

I left the room and sat with the chart to try and write a progress note. To reduce what had just happened to medical jargon and lab values seemed ridiculous. I felt like writing: "We met the Angel of Death in the field of battle, and remained locked in mortal combat for 2 hours and 35 minutes. The boy is still alive. Do you hear that, Angel? He will not die. Not on my watch you son of a bitch." Of course, writing that might raise eyebrows. In the end I wrote a clinical code note. I signed the patient out to my partner who was coming on service and left the hospital for the office.

That young man died that afternoon.

The Battle Is On

I got to the ICU around 1 am and went straight to the young man's room. C was the night nurse, and I nodded hello, not interrupting her as she continued organizing the patient's care. I checked the monitor, noting the low blood pressure, and then went over the IV drips. He was on high doses of pressors (drugs given iv to maintain blood pressure) and some iv fluid.

"What's he gotten so far for fluids?" I asked.

"The house doc gave him some saline boluses, 250 cc times 2 so far." C replied.

I checked the pressure monitor once more. "Give him a liter of saline over the next hour and chase it with 6% Hetastarch, 500 cc." C nodded and went on about her business. "Let's set up for a central line and A-line as well." I checked the ventilator settings and, satisfied, started washing my hands for the procedure.

A central line is a three-lumen catheter that goes into the subclavian vein, useful in critical cases for giving fluids and meds, as well as monitoring pressures in the right side of the heart. An A-line, or arterial line, is a catheter in the femoral artery that allows continuous blood pressure monitoring and blood sampling. Every doctor does his procedures in quirky and idiosyncratic ways, but C and I had worked for many years together and she knew the particular equipment I needed for these procedures. We worked efficiently, with little needing to be said, and, luckily, all the lines went in quickly and with no complications. Once the lines were in I began to examine the man. His eyes were dilated, but that could be due to the pressor drugs, rather than brain damage. Heart and lungs were clear. I pulled back the sheets to see a distended belly. No bowel sounds could be heard. The belly was ominously quiet. It was also rigid. Ok so now we knew he had an acute abdomen.

"We need surgery to see this guy, like right now!"

"Who do you want?" C asked.

"Probably start with colorectal."

Getting a surgeon to come in in the middle of the night can be tricky. I figured the on call doc for colorectal surgery was more likely to come in than the general surgeon on call that night.

I sat down at the desk and pulled up the labs on the computer. Grim. He had acidosis and renal failure. No surprise there. His white count was astoundingly high at about 60 thousand, evidence of a catastrophic event, most likely in the belly. While I was writing orders and dictating a note the surgeon arrived. Fortunately, he agreed to operate and in minutes the OR techs were wheeling the patient away. I say fortunately, as surgeons come in several types. The best type are the ones who love to operate, night or day. They seem to only truly come alive when they are in the OR cutting someone open. This type of surgeon is like a sophisticated weapon that, when deployed and quided properly, can kick the angel's ass.

The other type of surgeon will start ordering diagnostic tests, consulting other specialties, suggesting medical management, anything they can think of to avoid taking the patient to the OR. When a surgeon starts suggesting medical management you know you're in trouble. A surgeon who doesn't like to operate is about as useless as an unloaded gun.

Well, tonight's surgeon was ready to rock and roll. He agreed that the patient had an acute abdomen and an exploratory laparotomy was in order. I finished up the paperwork and headed for home, knowing I had several hours before the patient would be back to the ICU.

Home, bed, sleep.

The Angel

First note the picture. It's always good to have a face to associate with a voice. This one was taken a few days ago before going out to an orchestra benefit dinner. I wasn't on call and wasn't driving, a rare confluence of events that I used to maximal advantage. The night started early and ended at around 4 am.

Earlier in the week the evenings activities were not so pleasant. I was awoken by the beeper at about 12:30 am. Not yet deeply asleep, but I had gotten a taste and wasn't happy about driving in to the hospital. The patient was an unfortunate 28 year old man who had testicular cancer that had relapsed. He was on the Cancer ward and the Oncologists had been tormenting him with various poisons under the rubric of chemotherapy. Apologies to my Oncologic colleagues, but despite their claims of cutting edge treatments, oncology is so barbaric as to be medieval. They give the chemo and sit back to watch which dies first, the patient or the cancer.

Chemotherapy is also a commercial enterprise that the oncologists do quite well with. They buy the chemo wholesale, sell it to the patient (or more correctly the patient's insurance company or Medicare) retail, plus an infusion fee. Quite a little profit center and the main reason oncologists drive Audi A8's or BMW's, while us humble intensivists are cruising around in eight year old Hondas. They also give the chemo at their "Infusion Centers" during the day and then drive on home. When the poisons do their trick and the patients get deathly ill, the oncologist is nowhere to be seen.

This night the House doc had talked to the oncologist on call, whose only order had been "Consult Critical Care". The patient had been in the hospital for several days with complications of chemo. In particular, his bone marrow was suppressed and his white blood cell count was perilously low. He had been getting antibiotics and narcotics for pain control but had developed a distended, painful abdomen, fever and hypotension. The differential diagnosis included an acute abdomen, sepsis or ileus (gut paralysis) due to narcs.

I got into the car and cruised towards the highway, hunched over the wheel, driving by habit more than active attention. Then I felt a pressure from the back seat, as in a mass of air being displaced. I willed myself not to look in the rearview mirror. A low chuckle emanated from behind me, air moving across inhuman vocal chords.

"Fuck you.." I growled, staring straight ahead at the road.

What might have been laughter, but came out more like a snake hissing. "Alas, I am beyond the pleasures of the flesh."

"Bummer. How about kissing off then?"

Again the low chuckle, a creaking of ancient skin folds. "This one is mine...."

I thought about the case. Definitely sick, but young, possibly with stores of resilience that had not yet been exhausted. "In your dreams, asshole. That's where he's yours."

"Alas, no sleep, no dreams."

"Yeah, well, join the fucking club."

The chuckle sounded again and then it was gone. The pressure dissipated and I was alone again in the car. I reached over and found some music on the radio, cranking the volume to blow away the lingering traces.

Blood

I can remember a time when blood was considered a sacred, life-giving substance. When I was an intern, to get splashed with blood was a part of the job, the only drawback being the need to use hydrogen peroxide to remove the stains from clothing. Now we look upon blood with the same dread we hold for toxic or radioactive waste. Health care providers cover themselves with gowns, masks, eyeshields and gloves, and tremble at the thought of getting sprayed with the stuff.

I did get hepatitis B when I was an intern, presumably from blood exposure, but after 4 or 5 weeks spent laying on the bathroom floor vomiting, I was good to go. Nowadays the risks are greater: Hep B, Hep C and HIV. I used to get stuck with a needle two or three times a year, anyone who does a lot of invasive procedures will. Lately I will admit to being more cautious. Knock on wood, but I haven't been stuck or sprayed in at least 6 months.

The patient was an unfortunate young woman who, as we say, was behind the door when luck was being handed out. She was in her twenties, she was HIV positive and had end-stage renal disease. She was on dialysis at one of the local units. Besides practicing critical care medicine, I am also a nephrologist, or kidney specialist. This woman was one of my partner's patients and was admitted in the afternoon with a fever and a tender swollen arm. The infection was in her vascular access for dialysis, basically an artificial blood vessel connecting an artery and vein under the skin in her right upper arm. Three times a week it was stuck with needles and she was hooked up to the artificial kidney to clean the blood. Her access vessel was obviously infected.

I evaluated her, put her on antibiotics and had vascular surgery come see her and do their thing. The surgeon set her up for an operation to remove the infected vessel in the morning and we all went home.

Unfortunately in the early morning hours the infection eroded through the access and she cut loose with a gusher of arterial, HIV-infected blood spraying all over the room. She rapidly developed shock, acidosis, respiratory arrest and basically crashed and burned. I was called in to see her upon transfer to the ICU, and can only imagine the scene with the brave nurses and house doc trying to control the bleeding while terrified of getting exposed to the blood that was flooding the room. They basically had to call a Haz-Mat team to decontaminate and clean up.

In the ICU I had to place a central line, arterial line and a dialysis catheter. Her labs showed severe acidosis and increased potassium, such that she was only minutes away from a cardiac arrest. With great trepidation I approached the patient, double-gloved, eye shield in place, gown on. I cleared the nurses away so no one accidently stuck me and placed the needed lines. When I finished with each needle I dropped it into a sharps box and tried not to make sudden moves or grabs, but blood was everywhere and by the time I was done and the patient was running on dialysis I was drenched in sweat and drained.

The patient needed frequent blood draws, cleaning, suctioning of the ETT, and I was amazed at how the nursing and technician staff calmly went about their jobs. Brave souls indeed. The family was also calm and accepting of the complications and treatments. I think they had been through a lot with this woman already. They seemed to realize that her days were numbered and each time the Angel of Death was beaten it was only a temporary reprieve, a rear-guard action.

Home, bed, sleep.