ICU:Mortal Combat with the Angel of Death

The Ravages of Alcoholism

2008-03-06T08:17:00.000-08:00

The patient was 44 years old. By the time I got to see him he was already on the ventilator. He was also on levophed (commonly referred to as "leave em dead") and dopamine, both to support a faltering blood pressure. I stopped to review the labs. What a mess! His bilirubin was 22 (normal around 1.5) and his other liver function tests were off the wall. He was anemic and his blood chemistries were not compatible with mammalian life. His ammonia level was 144 (normal less than 40). Ammonia is normally detoxified by the liver, and high levels seen in liver failure are thought to contribute to a depressed mental status known as hepatic encephalopathy.

The patient was indeed comatose and so my only history came from reading the chart.The patient had reported drinking about a quart of vodka a day, while smoking 2 packs of cigarettes a day. You would think that this was a combustible combination, but apparently he had not exploded and was simply found down on the kitchen floor.

I entered the room only to feel the shifting air pressure, to catch the flitting shadows in my peripheral vision. The Angel was already on the job.

"Hey!" I said, "Give me a chance to examine the guy."

The laughter was unnerving, as usual, and the voice still scared me a little.

"Don't waste time on this one, I am here to collect him."

"How do you know I can't save him? Some times the liver can heal once you stop the booze."

Again, the rasping laugh. "Yes. You could save him so he could live to drink again."

He had a point. I went about my exam, first checking the drips and the monitors. Pretty grim. Max doses of pressors, vitals marginal. He was a deep yellow bronze, jaundiced from his liver failure. His belly was distended and tense, filled wih the fluid of ascites. His feet were quite swollen, when I squeezed, my fingers left deep imprints. At this point the family, sister and mother, came in.

I introduced myself and then reviewed his condition with them. I closed my remarks by stating that his condition was terminal and that he had no chance at all of survival. I braced myself for a hostile argument, but it didn't come. They were both exhausted, undoubtedly by years of cleaning up the mess left by an alcoholic son or brother. What I saw was mostly relief. They asked a few questions and then agreed to withdraw support. We stopped his IV fluids and pressors, and he died within 5 minutes.

I scanned the room for the Angel, but felt nothing. I went outside to write a note. This man was only 44, younger than me by ten years, but he had drank himself to death. It appeared that he had also tortured his family along the way. Now maybe all involved could move on. I tried to picture myself in their situation, one of my beautiful sons dying in an ICU at only 44 years old, but the images wouldn't come, it just didn't compute. I did resolve to appreciate my good fortune, and cherish every minute I had with my children.

I finished my note and left the ICU, already dialing my wife's cell just to say hello.

When Viruses Attack

2008-02-23T09:17:00.000-08:00

One of the occupational risks of being a doctor is exposure to infectious diseases. This can come in the form of accidental needle sticks, of which I've had my share, or exposure to infectious agents through contact. Yes, I wash my hands very frequently, but the risk remains. We have recently had a mini influenza breakout, with two patients ending up in the ICU on ventilators. It may or may not be related, but last Tuesday I began to feel a little sick. Nothing major, just a scratchy throat, cough, some congestion. I figured it for a standard cold (or in doctor speak, viral URI), but by Wednesday morning I knew things very more serious.

I started to spike fevers, developed a headache and started chilling and shaking. Getting out of bed to make the ten step trip to the bathroom took all my concentration and willpower. I actually called in sick.

You might think that a group of doctors would understand that people do get sick and should stay home, but in my group we all pretend that we are invulnerable to the diseases that affect mere humans. We have no system in place to fill in for a sick partner. In eleven years with my current group I had never taken a sick day. Not once. But on Wednesday I had no choice.

I was in bed for 36 hours, miserable with cough, headache, drenching sweats, chills. It finally dawned on me that I most likely had real influenza. I contemplated taking a course of tamiflu but in the end didn't have the energy to phone in a prescription. I talked to my father on the phone and mentioned my illness. Before retiring, he was a pediatrician which is almost like being a doctor (just kidding, Dad). He asked if I had been to see my doctor. I told him no, that would be a sign of weakness. After we finished laughing, his only comment was "Jackass."

On Thursday I attempted to work, but only lasted a few hours. Friday, I was in the whole day, and appear to slowly be getting better. It's a little scary how weak I've gotten. It's like that episode in "Buffy, the Vampire Slayer" when she temporarily loses her super powers. I'm normally a very vigorous, athletic person- someone who thinks of spending an hour on a gigantic thoroughbred horse, jumping fences, as a light workout. Now I was having trouble walking up a flight of stairs. Scary indeed.

Saturday was one of those glorious, sunny days that makes you give Minnesota another chance. After weeks of temperatures below zero it was now in the twenties and the snow sparkled. I took our Labrador for a long walk, letting her run in Kenwood Park. When I got home, a few hours later, I was exhausted.

It has finally sunk in that doctor or not, athlete or not, a virus is a virus. It doesn't care, This one hit me like a steamroller and knocked me flat. I will have to work each day to increase my endurance and strength, just like anyone else. I'm just thankful the Angel of Death didn't see the need to take an interest.

Influenza

2008-02-16T18:43:00.000-08:00

I was taught in medical school that pneumonia is the friend of the elderly.It helps ease the transition from this life to the next.

She was 94 years old. The family insisted that she was living independently at home. Apparently her independent living did not include eating, as she appeared to be a thin-skinned bag of bones. By the time I got to her in the ICU she had already been put on the ventilator. Why you would put a 94 year old on the vent escapes me. Her respiratory failure would have been a perfect way to die: progressive obtundation, coma, death. The ER doc had talked to the family, who I guess was impaired in some way, and wanted "everything possible done". Of course, the fault is ours. As her doctor of the moment, the ER doc should have said "I'm sorry. There's nothing we can do. It's her time to die."

The ICU room was darkened and I saw no need to turn up the lights as I examined her. Her bones stuck out everywhere. She had very little hair but still had her teeth. She did not respond during the exam. As I leaned in to listen to her heart I felt the now familiar shift in air pressure and heard a rasping laugh.

I pulled one of the earpieces of my stethescope out of my ear and without turning to see what would only be a shadow at the corner of my vision, I said "Yeah, yeah. I know. She's all yours. But not for a little while. Have some respect."

His voice had too much air whistling over ancient, inhuman vocal cords. "Why do they fight it so? Is life in this small, dreary world so precious?"

"It has its moments."

The presence shifted closer for a moment and then seemed to recede to the edges of the room. "Her moment is gone. You work on her body but she has already left it."

I put the earpiece back on and listened to her heart. The rhythym was regular, but the blood flowing over her 90 plus years old, calcified valves made a roaring sound with each beat. A systolic murmur, likely from the aortic valve.Her neck veins were flat, suggesting that she did not have fluid overload and that her respiratory failure was not from congestive heart failure. I shifted to her lungs and heard the whistling, prolonged expirations of inflammed, swollen airways. I made a note to myself that she would need iv steroids and inhaled bronchodilators. When I took off the stethescope and stood up I heard the rustle of robes, the creak of leathery skin.

"You still here? No famine or pestilence somewhere else in the world that requires your attention?"

"I am everywhere.Waiting."

"Yeah, well, fuck that. You'll have to wait a little longer on this one."

The laugh again and then gone.

I sat by the computer and checked her labs. They had swabbed her nose for culture and the rapid antigen for influenza A was positive. So we had an explanation for her lung problems. A classic case of real influenza. People toss the word flu around, most often referring to a viral upper respiratory tract infection or viral gastroenteritis. But this was influenza. The same disease that had allowed the Angel of Death to harvest souls wholesale during the pandemic at the beginning of the 20th century, and intermittently over the decades.

The ER notes said she hadn't been to a doctor in several years and that meant she hadn't had the flu vaccine. Might not have mattered much as it seems that this year's vaccine was an antigenic miss, meaning it didn't prevent the strain of virus currently making the rounds. I wrote orders for tamiflu twice a day down the feeding tube and sat down to dictate a note. It was late and I figured I'd save the inevitable family meeting for the morning. I couldn't imagine the type of dysfunctional psychopathology that would result in tormenting the family matriarch during the final hours of her life.

The car barely started, having been out in the minus 15 degree weather of a Minnesota February night, but eventually fired up after several tense tries. I hunched over the wheel, and drove with muscles clenched, waiting for the engine to generate some heat. And then the Angel was back. The soft laugh, the thickening of the air.

"Fuck you." I ventured half-heartedly.

"You did well tonight." came the rasp. "She lives yet."

"Gee, I'm touched by your compliment, but could you kiss off for awhile. Someone might see me talking to my self."

"I am here. You are not alone. We are two sides of a struggle, two sides of a border. A struggle that you will always lose and I will always win, sooner or later. Sooner or later they are all mine."

I reached down to turn up the radio. "I fight the fight as long as they want me to. I don't decide who lives or who dies, but if they want to hang on to their sorry ass lives a little longer, I try and make it happen."

The Angel's presence faded and my shoulders relaxed. Maybe it was the heat finally coming on, or maybe I get a little tense in the presence of death incarnate.I took the exit off the highway and turned into my street, controlling a small skid with the nonchalance of a northerner driving in February. The tires crunched up the driveway and through the opening garage doors.

Upstairs, bed, sleep.

The Week Begins

2008-02-03T20:48:00.000-08:00

Monday morning I start the week long ICU rotation. I will be on call one week night, Monday this time, and the weekend. Monday morning I start a work day that lasts until Tuesday at 4:30 pm. Saturday morning I start a call weekend that ends Monday at 4:30 pm. We recently recruited a new partner. During the interview process some of the candidates asked if you got the day after being on call off, to which we responded "In your dreams, that's where you have the day after call off."

Non-medical people often think this is crazy. How can you work for 36 to 48 hours, during which time you may or may not get any sleep. My first response is that I have been doing just that since I was in my early twenties, and it's the difference between a doctor and a civilian. Patients don't get sick at convenient times, and if you don't like staying up at night, working holidays, going without sleep for a day or two at a time, then find a different profession.

Residency training programs now have time limits on work periods and require that residents go home by 1 pm after being on call the night before. Basically, instead of doctors, modern residency programs are producing skilled laborers who work shifts. Upon finishing training they will be ready to go to work for health care corporations. We have seen this most clearly in the shift to hospitalists, who are employees of whichever corporation owns the hospital, and cover the inpatients and new admissions, working defined shifts of 6 to 8 hours. Although they are all well rested, patient care responsibilities turn over several times a day as shifts end and none of the doctors really gets to know a given patient well.

My view is that the one big advantage of being a doctor is that you don't have to work for anyone else, ever. As a highly educated and skilled professional, you can open your own practice, run your clinic however you see fit. I love that part of being a partner in a small private practice. I have no boss to impress, no supervisor who can judge me. My patients are the only ones I answer to, and my practice is based on a professional obligation to provide them the best care possible.

Rat Poison 2

2008-02-02T11:34:00.000-08:00

I went about my rounds, eventually leaving the ICU and doing ward follow-ups. In truth, I almost forgot about the case until about 4 in the afternoon when it kind of struck me that I hadn't heard anything about her lately. I wandered down to the ICU and sure enough there was a lot of commotion in her room. The Flying Squad was back and they were getting the patient organized, giving report to the ICU nurses, getting her hooked up to the ventilator and monitors.

I walked in and caught the flutter of a shadow in my peripheral vision, the rustle of robes of heavy cloth. No one else seemed to notice. Not a good sign if the Angel was taking interest. "What happened in IR (Interventional Radiology)?" I asked, as soon as I caught a nurse's eye.

"They found a bleeder, in the splenic artery. They coiled it with a good result and she seemed to stabilize. For a while at least."

I looked at the monitors first. The A-line was reading about 75 systolic with a pulse of 130. Not good. "Labs?"

"Just drawn. Nothing back yet."

I set her up for two more units of blood and some FFP as well on spec and started examining her. Her extremities were cool and she had a purplish mottling of the skin that is called livido reticularis. It's seen in patients with shock from various causes. Her abdomen was still rigid and she was obtunded (doctor speak for totally out of it). The labs began to trickle in: her INR was now 1.25 and her platelets were ok. The hemoglobin was low but not terrible and would improve with transfusion, but her blood pH was markedly decreased implying severe acidosis. I heard the rasping, huffing laugh and turned around only to see a shadow disappear. The Angel would get this one. We had waited to long to intervene.

Maybe it wouldn't have mattered anyway but I felt that we had had a window of opportunity and missed it. Medicine is a team sport. I need the surgeons and the radiologists, and they need me. They each have to make their own decisions and we all live, or die with them. I reluctantly went out to talk to the family. This would be a tough one: relatively young, abrupt onset of a lethal event.

About an hour later we had an order for DNR/DNI, and later in the evening they agreed to withdraw support. She died in the early morning hours the next day without ever waking up.

Rat Poison

2008-01-31T20:09:00.000-08:00

Well. Where, indeed, did that last post come from? Maybe I was channeling Che Guevara or something. I get a little passionate when it comes to exploitation of the proletariat in America.

Back to the ICU.

It was Sunday. Bright and sunny and absolutely freezing in the way of Minnesota in January. I was on call for the weekend, slogging through morning rounds when I got the "5141" page. I thought "So it begins." The ER doc was somewhat frantic. The patient was a 60 year old woman who fell at home and couldn't get up. EMS was called and noted a blood pressure of 60 systolic. They put in an IV, started some saline and transported her to Red Room 1 in the ER.

Once there the ER doc noted a rigid, distended abdomen. The labs showed a hemoglobin of about 5 (normal is around 14), meaning she didn't have much blood perfusing her vessels, probably because most of her blood volume was in her belly. She was also on coumadin.

Coumadin is rat poison. The rats eat it. It thins their blood, preventing the blood from clotting. The poor rodents bleed into their heads, get dizzy and crawl outside to die. Ok, I made up that last part, but you get the point. People are put on coumadin for a variety of problems such as blood clots, cardiac arrhythmias, artificial valves- situations where you need to prevent blood from clotting. The problem lies in the fact that coumadin has what we doctors call a narrow therapuetic window. That's doctor speak for a drug where beneficial treatment levels are very close to lethally toxic levels.

In order to monitor therapy in patients on coumadin we monitor a lab test called the INR, which stands for International Normalized Ratio. Whatever that means. The goal is for the INR to be between 2 and 3. Less than 2 means risk of clotting and when you get greater than 4 or so it means increased risk of bleeding. Monitoring the INR and adjusting the dose of coumadin is a major headache with the dose being adjusted just about every week. This patient had an INR of 7.5. When the ER doc relayed that to me I responded with something really intelligent, on the order of "Yikes!"

She arrived in the ICU and, along with 3 nurses, I set about stablizing her. We basically poured the blood bank into her, to correct her anemia. We also gave her a lot of fresh frozen plasma and vitamin K to try and reverse the coumadin-induced anticoagulation.I put in a femoral arterial line for real time monitoring of blood pressure. Her blood pressure came up and her heart rate came down and we got a chance to sit back and catch our breath.

The first thing I did was have the HUC stat page the surgeon on call. Wherever she was bleeding from she was going to need someone to go in and fix it. The surgeon came by and had a look but felt we should temporize and focus on correcting her high INR and transfusing her. I had to agree that at the moment she looked relatively good, although deep down I wondered if now was the time to operate, when she was indeed quasi-stable.

Well, you fight the Angel of Death with surgeon you have.

Needless to say, about an hour later, when I was just finishing my orders and dictation she crashed. I ordered more blood, but our peripheral IVs weren't up to the task, so I went for the big guns. In a patient who needs massive infusions of blood and fluids you want a central line that's short and fat, and therefore has less resistance to flow. I favor a Cordis introducer in these cases, so I had the nurse set up for the line. Not only was the INR still elevated making line placement risky, but this patient weighed in at 100 kg, meaning no landmarks were available to guide my needle home into the internal jugular vein. Once more I rolled out the Site-Rite portable ultrasound and, fortunately, with only a minimum of flailing about had an introducer in place in short order.

By now the surgeon was back, but he opted to turf the patient to Interventional Radiology. The goal was to have the radiologist do a mesenteric angiogram, locate the bleeding artery and, if possible, embolize or otherwise clot it off. The Flying Squad came and trundled her off to Radiology and I went off to try and see some of my other patients. For the next few hours at least, she would be a SEP (Someone Elses Problem).

The Dialysis Patient

2007-01-23T19:44:00.000-08:00

I got the call at 3 pm as I was back at the office, feet up on my desk, lightly sleeping. The nurses used to tease me about this activity, but now are protective of my nap time. I can sometimes hear them whispering or moving quietly near my desk so as not to wake me up. The 3 O'clock nap is one of the high points of the day. The rounds are done, but you can't go home yet as you are responsible for any new admissions or consults until 4:30. You're exhausted from the grueling days and nights on call. A twenty minute nap at the desk is pure bliss.

The call came from Interventional Radiology. Hmmm. A call from IR can be routine, a question about a vascular access procedure on a dialysis patient, fro example. Or it can be a disaster. The IR guys do some incredible things, snaking around the arteries and veins, using the blood vessels of the body like a highway. They get to where the trouble is and then dilate arteries with balloons. deploy stents, embolize bleeders. But they can also get into horrendous complications. Sometimes they dilate the vessel a little too much and it bursts. They call the surgeon first and me second.

This call was a complication, but not too bad. They were draining fluid off the lung of a dialysis patient, a procedure called a thoracentesis. During the procedure the initially clear fluid had turned bloody, and the patient had complained of pain and started coughing. This is when the doctor starts to sweat. The follow-up chest xray had showed a partially dropped lung or pneumothorax. Since I was the nephrologist covering I got the call.

The patient was, at best, a trainwreck. He was a former smoker with obstructive lung disease. He had congestive heart failure with a left ventricle that twitched and quivered rather than pumping. He also had end-stage renal disease and was on dialysis. The reason he accumulated fluid around the lungs and in the belly was that he had a bad heart. Whenever we tried to take off fluid with the dialysis machine his heart couldn't compensate and his blood pressure dropped. We never were able to get him to his dry weight and he progressively swelled up with fluid.

He also had the angry wife syndrome. When I began to take the history she jumped right in with a tirade about his last hospitalization and how the doctors had screwed everything up. You see, his problems were not the result of 60 pack years of smoking, coupled with bad diet and lack of exerecise, It was because the doctors had let him sit in the ER for 10 hours before ordering the right xrays, blood tests, blah, blah, blah. Since that hospitalization he had been in a nursing home, being fed through a tube, transported to dialysis three times a week. He didn't walk and it quickly became obvious to me that he was relatively out of it as well.

Ok. So what the hell are we all doing here with the dialysis and invasive procedures in Radiology? I mean here is this poor loxed out guy: laying in bed, can't walk, can't talk, can't eat. I mean really, what the fuck?

I soothed the wife as best a possible, ordered some pain meds so a least the old guy wouldn't suffer, and admitted him to the ward. She asked me if I planned on surgery for his dropped lung. Yeah, lady, totally, I'll call the OR right away, because they love operating on cadavers.

My plan was to make him comfortable and see if the lung re-expands. At most he'll get a chest tube, but even that could be trouble. Hopefully I can get him back to the nursing home and he can live the rest of his days in peace.

The Friend of the Elderly

2007-01-16T19:32:00.000-08:00

A wise physician once told me that pneumonia was the Friend of the Elderly. Being a young, naive med student, I didn't understand. As a battle-hardened ICU doc I understand perfectly. Pneumonia is the friend of the elderly because it helps ease the transition from this world into the next.

This last two weeks we had a veritable Quaker Meeting of the Friends of the Elderly. In the space of 2 weeks we had four cases of severe pneumococcal pneumonia, the classical pneumonia. The patients ranged from about 60 to 85 and presented with severe fulminant illness requiring ICU management, including mechanical ventilators, central lines, multiple pressor drugs, broad spectrum antibiotics... the whole show.

One recovered well, two died within a couple of days and one lived to transfer out to the medical ward, but has severe complications, will likely lose one or both legs to gangrene (a complication of fulminant sepsis), and at best, will live the remainder of his life in a nursing home. ICU Doc one, Angel of Death 3.

Pneumococcal pneumonia used to be easily treated with simple penicillin, but now resistant bacterial strains have emerged and we have to use new wave antibiotics. Despite our best efforts, some 25 % of these patients die. This sounds bad, after all, why can't we cure a simple bacterial infection? The thing is, everyone dies of something. Overwhelming pneumonia isn't a bad way to go, and is often pretty quick. As I said, the friend of the elderly. If I can help some poor patient leave this world in relative comfort then I feel I have done my job.

Maybe the Angel is my friend.

Physician Heal Thyself

2007-01-02T20:01:00.000-08:00

Got back the day before New Year's Eve. Off in Utah skiing for a week. We go to Alta, which is an alternative type ski resort: no snowboards, ancient lifts, limited number of lift-tickets sold each day. When there, we stay at the Alta Peruvian Inn, an alternative type ski lodge. I highly recommend it if your tastes run to mellow funkiness, with a Soviet-era design theme to the rooms. However, the snow is the best in the country and the mountain rocks. Seven days of skiing lift-open to lift-close, great food, great wine, nice company. Life is good.

Got home in time for a New Year's Eve party with the Russian crowd at the St. Petersburg Restaurant (my wife is an immigrant from Kiev, Ukraine), but as I got off the plane I rapidly developed sore throat, nasal congestion, headache, cough and sneezing. It was like somebody smacked me with an axe-handle and I was down for the count. No way could I get out of the celebration, but as long as I was deathly ill, I volunteered to be designated-driver. I am often on call during dinners and parties and so can't drink anything. The other guests took my sobriety in stride. I'm sure half of them think I'm in AA anyway. We went to a neighborhood pre-party and a 2 am post-party, with me barely able to breath, but driving well. The post-party was with a great crowd of friends, but we got there late in the process. Half the guests were in the hot tub naked, and the other half were relatively incoherent, but very affectionate and carrying water bottles.... hmmm.

Finally got home, paid the baby-sitter off and crashed. I woke up feeling like hell. Now can you imagine anything more unfair than not drinking and waking up feeling worse than hung-over? My wife asked me if I should go to see a doctor. As if. What would they say other than "Probably a virus"? I began a regimen of sleep, green tea, multivitamins, light eating, and by the next morning was improved but not yet well. It was off to work anyway.

One problem with our practice is that we are very tightly scheduled in our rotations and we don't really have a mechanism set up to compensate for a sick doctor. In the last ten years of practice I have been out sick on 2 days when I had viral meningitis. Even then I got grief from the other partners. One of our partners once went to the Mayo Clinic to have neurosurgery. Since the surgery was on Friday we told him to feel free to take the weekend off, as long as he was back to work on Monday. None of us takes seriously the idea that we could become ill or incapacitated, even though we see obvious examples every day at work.

Fortunately, tonight I am feeling better. I went to the gym for a light workout this morning at 5 am. Nothing serious, just a wake up call to the body, a shot across the bow, notice that we would be returning to full action mode soon. True to form, when I stepped on the scale I was down four pounds. Every time I get sick, fortunately a rare occurrence, I drop a bunch of weight. It's like the "Virus Diet".

When meeting the Angel of Death on the field of battle you have to be in good health. By tomorrow, I'll be ready to fight the fight.

Valve Job

2006-10-22T20:20:00.000-07:00

People don't get sick at convenient times of the day. This is the hardest lesson for young doctors to learn. The transformation of a medical student to a doctor has something to do with knowledge and experience, but in the end comes down to an acceptance of the need to care for patients at night, on holidays, on Christmas Day or Thanksgiving. For the Angel, a holiday is just another day. For the ICU doc, there is no let up, ever.

I had fielded some calls during the early evening and, optimism triumphing over experience, gone to bed at around eleven pm. At 1:15 am the beeper went off and I pushed the backlight button. I scrolled down to the message, and moving the screen in and out to find a place where my middle-aged eyes can actually focus, finally saw the number. "5141". Fuck.

The ER doc was nervous. An 80 year old, previously healthy, never hospitalized before except for childbirth. She had gone to bed, but subsequently gotten up and walked to the den. She then called her husband to help her. He found her drenched in sweat, unable to get her breath, complaining of chest pain. The ER doc figured it for a run of the mill MI, but it didn't fit. First set of enzymes negative, EKG unremarkable. Then her lungs began to fill up with fluid, despite a lack of evidence of total body fluid overload. Her chest xray was whiteing out, and by the time I got in to the ICU she had been tubed and was on the vent.

I talked to the husband, checked the xrays, reviewed the labs and what little medical records this octogenarian had generated over her lifespan so far. Then I went to examine her. The legs were not swollen, the heart sounds from the front of the chest were pretty bland, but when I listened to the left chest from behind she had a loud, harsh, systolic mumur. Hmmm.

An echo tech was summoned and did her magic with the echo machine: severe mitral regurgitation. The mitral valve, which usually directed blood from the left atrium to the left ventricle was bad. Putting it all together, she had acutely blown a mitral valve tether and blood was not moving forward through the chambers of the heart. Her lungs filled up with fluid and her blood pressure was plummeting. We started dopamine to raise the blood pressure and I bit the bullet and gave her some iv fluids to pretty good result. Then I called in the A team.

I'm an Internist, a nephrologist and an intensivist, but to give this patient a chance of survival I was going to need a cardiologist and a CV surgeon. I asked the HUC to get me the cards guy on the phone and began the process of mobilizing doctors in the middle of the night. By now it was about 3 am and none of them were too excited about coming in, but that's life. As I once told a complaining resident, who was upset about working all day after having been up all night: If you don't want to take care of sick people find another profession.

Patients don't get sick at convenient times. When you say the Hippocratic oath you commit yourself to battle with the Angel of Death. You give up the quaint notions of sleeping at night and sitting with your family on holidays that civilians take for granted..

The next morning the cavalry was in full charge: trans-esophageal echo confirming a flail valve, cardiac cath with placement of an intra-aortic balloon pump, trundled off to the OR for mitral valve replacement. The whole nine yards. Our role as intensivists was to sit back and watch it all unfold, making sure someone was keeping the overall picture in view.

She made it back to the ICU, but when I went back into the room I felt the air pressure shift, heard the rustling of robes. A shadow lingered at the edge of the ceiling light and then vanished. "Yeh, yeh, I get the picture." I grumbled to the departing Angel. I checked the monitors, looked at the screen for the balloon pump, reviewed the iv drips and then went to the desk to sit at the computer and see what the labs were showing. Satisfied that we were doing everything we could I went back to my rounds and eventually back home.

Sometime in the night she faded out and died. She had had eighty years of good health and then died within 48 hours of falling ill. We had done what we could, and now she walked with the Angel.

Late Night Conversations

2006-10-03T21:14:00.000-07:00

I woke up with a start, reaching down to the floor next to my bed for the beeper. Only it wasn't there. It was still pitch black out, so I figured it wasn't the alarm clock. Normally, when I am not on call I sleep like a rock. If I am not on call, the sheer pleasure of knowing they can't hurt me is almost beyond description, and I sleep with an inner peace usually found only in young children. But this night it wasn't the beeper or the clock, so what was it?

The answer came in a shifting of weight on the end of the bed and a soft rustling of robes and leathery flesh. I came fully awake, feeling that now familiar pressure, displaced atmosphere.

"Hey, I'm off tonight. You need something, call the answering service, just like everyone else."

The rasping laugh, again a shifting of weight. "I have no days off.... Even now I will soon be at work".

"Yeah, well, don't let me keep you." For a moment, I wondered at my calm responses. Did I no longer fear death incarnate? Maybe it was true. Maybe I had been at the Critical Care business so long that I felt the Angel was more an annoying colleague than my mortal enemy.

It seemed to stand up. "We both do our part, in the end someone must guide them from this life to the next."

"Sometimes, my friend, but timing is everything. Sometimes you come too soon, and then the battle is on."

"Sooner, later, does it matter so much? In the end they are all mine. Their time on earth is so brief anyway."

"Well, you know, short but intense."

I lay back, settling my head comfortably on the pillows. "I gotta sleep, Buddy. We can discuss philosophy another night. And next time skip the Grim Reaper bit on the end of the bed. Use the beeper."

The presence faded and disappeared.

Ars longa. Vita brevis. I had it straight from the Angel's mouth.

Head Bleeds

2006-08-18T17:52:00.000-07:00

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

2006-08-08T20:11:00.000-07:00

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

2006-08-06T12:53:00.000-07:00

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

2006-08-02T18:54:00.000-07:00

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.

Burn Out

2006-07-22T09:38:00.000-07:00

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.

DOA II

2006-07-20T20:48:00.000-07:00

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.

DOA

2006-07-15T15:00:00.000-07:00

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.

The Bleeding Whale

2006-07-09T20:03:00.000-07:00

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

Ending it All

2006-07-06T20:07:00.000-07:00

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.

The Family Meeting

2006-06-25T20:15:00.000-07:00

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

2006-06-13T20:29:00.000-07:00

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

2006-06-11T20:02:00.000-07:00

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

2006-06-06T20:31:00.000-07:00

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

2006-06-05T19:47:00.000-07:00

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

2006-06-03T13:19:00.000-07:00

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.

Sugar: Day 2

2006-05-31T20:19:00.000-07:00

Again the disorientation of being pulled from a deep sleep. Again grabbing the wrong device. Pressing the button on the beeper does nothing to the grating noise and I eventually realize it's the alarm. I so wanted to sleep. Just sleep.
The rule post-call is "Keep moving".

Brush teeth, keep moving. Shower, keep moving. Any pause, just sitting for a minute with a cup of coffee, can cause a resurgence in the barely suppressed need for sleep. I drive in to the doctor's lot and shut down the car. For a moment the battle is lost and I go out in the driver's seat. A door slamming across the lot brings me around and I head for the hospital.

Up the stairs to the third floor and into the unit. I greet the HUC (stands for unit coordinator or some such) with the standard "Good morning! Who died?". '
"None of yours, Doc."
I slide into the chair before a computer and log in to the clinical information site. While my list opens with impossible slowness I glance into Room 355. The young diabetic is still there, restraints on the arms, endotracheal tube (ETT) in place, vent sighing and alarming, monitor traces blinking and alarming.

The labs have gone from incompatible with life to just grossly abnormal. That's a start. I go to the room and begin my exam. Still unresponsive but the pupils are reactive and C, the nurse, tells me he's been agitated at times. Actually a good sign in this case as it suggests he hasn't totally cooked his brain. I check the drips and their respective pumps, and review the flow sheets. Things look pretty good in fact and I can feel the weight of the Angel fade. Always that low, non-human chuckle and the feeling of shadow passing. It talks to me sometimes, but not today. I smile as I write my progress note and new orders. "Get over it Angel! This one is not dying, not on my watch."

The family files in. Today they seem less hostile, even sympathetic; perhaps in recognition of my being here again bright and early this morning despite an obviously sleepless night. Perhaps also in recognition that things are better and their boy will live. The mother is smiling a little, her questions more gentle. I sense the father wants to hug me and so begin sliding from the room.

The scene as I leave is orderly. The boy is still critically ill but the Angel of Death has given up. Orderly.

I have often felt that practicing critical care medicine is about creating order out of chaos. The ICU doc is compulsive and repetitive, checking again and again, not because he's neurotic, but because it holds back the darkness, holds back the Angel of death, creates order where once chaos ruled.

Sugar Sugar

2006-05-30T20:51:00.000-07:00

He was young, 26 years old. In the ICU that's young and it ups the ante. It's one thing to lose an ancient patient whose time has come. Quite another to lose a young man who should have a full life ahead of him. If you don't screw up that is.
The beeper woke me up from the deepest levels of REM sleep and I was momentarily disoriented. I picked up the alarm first, pressing the snooze control to no effect. Finally, wakefullness intervened and I lit the beeper up. The ER number flashed and I groaned, knowing that my night's sleep was done.

ER speak: 26 yo, type I diabetic. Last heard from 2 days ago. Found down by concerned girlfriend. EMS transported. Intubated in the ER and placed on a mechanical ventilator. Labs barely compatible with life. Blood sugar 1657 (a personal record in my experience), blood pH 6.8. Acute renal failure, coma, hypotension. Blah, blah, blah. I was already tuning it out, planning my counter-attack.

What it all meant was that my night was screwed. Diabetes has many manifestations, but one of the worst is diabetic ketoacidosis or DKA. An absolute lack of insulin sets off a cascade of metabolic disarray that if not diagnosed early and managed carefully resuilts in death. This boy was a late presentation to say the least. Down for two days with blood sugar levels so high I'm suprised his blood didn't crystalize. His blood was dangerously acidotic, his brain wasn't working and his blood pressure was failing. The Angel was definitely in the room, if not sitting on the bed laughing at me.

When I arrived at the Unit, a crowd of family members were wringing their hands in the room. I chased them away with my doctor-on-a-mission mode and got to work: physical exam, check the labs, attempt to decipher the illegible notes of the ER doc, place lines (arterial line, central venous line), adjust the vent, order iv insulin, iv fluids, lab monitoring.

Two hours later I was heading home. The sky was lightening and the birds were beginning to sing. For the now the Angel had been chased out of the room, but it would be several days before the battle was decided. The most difficult part was dealing with the family members after seeing the patient. It was the usual cast of characters: mother who was a nurse with some medical knowledge asking detailed questions, belligerent sister who wasn't going to let any goddam lazy doctor not give her loved one the best of care, silent and distraught father looking on in disbelief as his little boy, the one he taught to throw a baseball just the other day, lay near death, tubes in his lungs, veins, arteries, bladder. Eventually I managed to convince them that I knew what I was doing and that they were going to have to trust me.

Home, bed, wait for the next call.