Black Friday

Thanksgiving week is the busiest time for travel in the United States. Students who are in distant colleges and universities, family members who have moved away from their parents, and most people who have wandered far, all journeyed back to the place they call home to be with their family.

For a day the family gathered around the table with a spread of bountiful food and gave thanks. For a day the family was one again. Unless you have no family, or you don’t like your family, or you hate food, it is hard not to like this holiday.

Of course for some people this time is for vacation and some time off work. For some it is about parties. For some it is about parades. For some it is all about watching football. And yet for some they make this holiday time all about shopping – the Black Friday event. But primarily, this time is for families and about giving thanks.

I am in charge of the hospital’s ICU this week. I know there’s no good time to be sick and be admitted in the ICU, but being sick during the holidays is terrible. It is particularly difficult for the families involved.

We have one patient who was admitted in our ICU about 10 days ago. He is in his mid 50’s and he got really ill. He has multi-organ failure. Despite all the efforts, he did not get better. He is on mechanical ventilator, on continuous dialysis, and on several medications to keep his heart pumping and blood pressure up, yet he is sliding away. More concerning still is that he is not waking up.

His family would like us to continue our intensive management until many of his family, especially his children, who are in other states could come and see him and then they would say their goodbyes. For one more Thanksgiving, they gathered, though not in front of a bountiful dinner table, but in an ICU room, as one family again. Then today, Black Friday, they decided to transition to full comfort cares and let their father passed on after a final farewell. It’s kind of hard to give thanks in such circumstances.

Sadly to say, that story is not unique to that family.

In another ICU room, a mother who is only 40 years old, has metastatic breast cancer to the brain. She failed all surgery, chemotherapy and radiation therapy, and is now having frequent seizures. Family would like to keep her in the hospital until Thanksgiving day. Last night they took her home with Hospice to die.

In yet another ICU room, a man who is in his 70’s suffered a large intracranial hemorrhage a week ago. Even after surgery to the brain to evacuate the blood, the patient remains comatose and is in continued vegetative state. The family also would like to have family members from far away places to come on Thanksgiving to see him. Today, they took him off life support.

The saddest of all is in another ICU room. The patient is in his 60’s who had cardiac arrest and prolonged CPR four days ago. We cooled his body down (hypothermia protocol) to try to preserve any brain function. However after we rewarmed his body temperature and discontinue all sedation, he’s not waking up. There is no family members around and we cannot find any one except for a friend that said they don’t know any family of his, and perhaps he is estranged from his family. Both the cardiologist and I felt that continuing life support is medically futile given his significant anoxic brain injury. We let him passed on peacefully, with nobody around him except our ICU staff.

To many, today, Black Friday means bargain sales and wild shopping spree. But in this frantic place, inside these ICU walls, it has a different meaning. It is the solemn color of mourning.

For those of you celebrating this holiday time, may you cherish each moment you have with your family, and commemorate this season in it’s true essence.

(*photo taken with an iPhone)

Bad Night

We’re sleeping in the hospital now. It started this year. Our calls are now in-house as the hospital wanted us to physically man the ICU 24/7. This is besides the resident-on-call who is already in the ICU. Sleeping in a call room of the hospital about once a week, makes me feel like I’m a resident or a doctor-in-training all over again. But I understand, the times are changing, the practice of medicine is changing, and the liability of this profession is changing. We have to adapt.

Few weeks ago, I walked in at 5 in the afternoon to take over the call for the night. The moment I walked in, I was called by my partner who was in charge of the ICU all day, to meet her in the cardiac catheterization lab (cath lab) so she can sign out to me the patients.

When I came down there, I found out that there were two patients currently in the cath lab that were both going to the ICU.

One was a man in his 40’s with severe pancreatitis and was having multi-organ failure, including severe respiratory failure that was not improving even if he’s on mechanical ventilator. So large-bore catheters were being inserted in his neck and groin, so we can place him on Extracorporeal Membrane Oxygenation or ECMO (see previous post about ECMO).

The other patient in the cath lab was a man in his 70’s that had a cardiac arrest. He required prolonged resuscitation. The cardiologist was putting an Impella device in his heart, a device placed inside the left ventricle of the heart to help pump out blood. When that’s done, the patient would be transferred to the ICU. He was already on ventilator as well.

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Impella device (photo from Medscape.com)

Then my partner told me that there were two more patients already in the ICU that she was called to evaluate, but did not have the chance to see yet, as she was stuck in the cath lab for the last hour or so, assisting in this patient that require ECMO.

One patient in the ICU was a transfer from another hospital, he had fever with very low blood pressure. He also has advanced esophageal cancer and on chemotherapy. He has no immune system to fight the infection. After the initial work-up, he turned up to have Influenza A.

The other patient in the ICU to see was a trauma patient, who was in a vehicular accident. He had several broken ribs and a collapsed lung. The Trauma Team has admitted the patient, but they were having difficulty oxygenating him despite being on a ventilator, thus they were consulting us for assistance.

She also told me that we have 21 other patients in the ICU that were relatively stable at the moment, but can turn volatile anytime, besides the four new ones that needed my immediate attention.

Lastly, she said that she declared the patient in room 15 as clinically brain-dead, hence, legally dead. Patient was a young lady in her 20’s who overdosed on drugs, and unfortunately was not found immediately. When she was brought to the hospital, she was too far gone. The patient’s family agreed to have her organs donated, so she’s still on life support until they can harvest her organs. The Transplant Team wants us to do a bronchoscopy to assess if the lungs and airways were normal and appropriate for harvest.

Hearing the long laundry list, I thought to myself, this would be a long night. That’s not even considering more new patients that may come.

Shortly thereafter, I got a call from the Transplant Team asking me when could I do the bronchoscopy in room 15. I told them that I would take care of some more pressing issues, and when I get free, I’ll do it, but I already contacted the endoscopy nurse to come and set up for the scope. I thought, let me take care of the living first, before I deal with the dead. But I didn’t tell them that.

When I came up to the ICU, the patient from the cath lab who had a cardiac arrest and got the Impella device, also arrived in the ICU. I evaluated the patient, and it was obvious he was doing poorly. He was requiring 3 IV drips (1 drip is a poor sign already, let alone 3!) to keep his blood pressure up. This was despite the device in his heart to pump blood. He already looked dusky and gray.

I sat down with the patient’s family, and told them that the odds were not in our favor. I don’t believe he would survive the night. I also told the cardiologist that I felt bad for him as well, as all his efforts may be all for nought.

The patient died less than 2 hours after he came up from the cath lab.

While I was working on this patient, I got a call from the Emergency Department about a new patient that needed to come to the ICU. The patient was in her 80’s, with advanced dementia, and was from a nursing home. She was septic, perhaps from a urinary tract infection. I may think that she was not the best candidate to spend my limited time and resources at that time, but who am I to say who lives and who should not. A life is still a life. So I sent my resident to evaluate and admit the patient.

When the ECMO patient came up to the ICU from the cath lab, that was where I spent most of my time and effort. We even consulted Nephrology to start the patient on dialysis too. However, despite all intervention, with ECMO, dialysis, mechanical ventilator, and several IV medication drips, the patient continued to deteriorate. I felt like we’re just spinning our wheels without gaining any traction. I noticed that the patient’s heart rate and blood pressure were drifting down. Definitely an ominous sign.

I gathered the patient’s family and brought them at bedside to the patient. I honestly told them, there’s nothing else we could do.

The patient died 5 hours after he was hooked up on ECMO. I felt defeated and deflated with these events.

In between the deaths of my 2 patients, I was able to squeeze time to do the bronchoscopy on room 15. It looked healthy, so I relayed to the Transplant Team, they can perform their harvest.

After midnight my night quiet down a bit. I caught up and was able to see all the patients I needed to see. When I had some down time, I reflected on what I accomplished and those I failed to accomplish.

At least I was able to stabilize the elderly patient from the nursing home, right? She will get better from the infection, then she’ll go back to the nursing home in a few days, and spend the rest of  her existence in bed with very poor quality of life due to her advanced dementia. How about the patient with metastatic esophageal cancer? He’ll get better from the influenza. But he still have to deal with his cancer and more chemotherapy with bleak hope of a cure. And the sad list just goes on and on.

Nights like this, make me question if it’s really worth doing this. I got several more pages through the night, but I survived to see the morning.

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A couple of weeks after that disheartening night-call, I received a letter. It was from the Organ Donor Network. They were thanking me for my effort in assisting to obtain donor organs for transplant. Because of this, they informed me that a young man was given a new lease in life as he received new lungs. There were other patients too that received “gifts of life” with their transplanted heart, kidneys, cornea and so on.

I then realized that even in patients who died under our care, we can make a difference. It still worth it after all.

(*photo of dawn, taken with an iPhone)

Last Walk of a Fallen Jedi

(It’s Christmas season once again. Also in 10 days the new Star Wars movie will be out. I would like to re-post a story of one of our ICU patients. The original article was posted in December 2015, “When You Wish Upon A Star Wars.”)

I entered the room and stood silently at the foot of his bed, watching him breathe. He was hooked to a small ventilator that is connected to a mask covering his face with straps around his head, that he looked like a jet fighter pilot. Beside the bed was his father and his mother who were obviously distraught, yet trying to hold off tears.

Luke* (not his real name) was one of our ICU patients. Even though he was only in his 20’s, he had his fair share of surgeries and hospitalizations than many patients in a geriatric floor combined.

He had a genetic disorder that prevents the development of various organ system. This affects the skeletal system giving them a peculiar look and stature, that some people coin the term FLK syndrome: Funny-Looking Kid. Though for me, there’s nothing funny at all. This disorder also causes heart defects, and can involve other organs like the lungs, liver, gastrointestinal tract, lymphatic and blood system. Even so some people with this genetic disorder could live to adulthood, some would succumb to this disease early in life.

Luke had a number of surgeries to fix his heart problem, and other procedures too many to recall. He had been treated in well-known hospitals like Mayo Clinic, for his disease. But despite of all the technology and medical interventions, his body continued to betray him.

For the last several months he had been in and out of the hospital, usually staying for several weeks at a time, including ICU stay. I have taken care of him a number of times in the past.

In spite of his illness, Luke tried to live his life as “normal” as possible. His family gave him the opportunities and the best care they could. His mother, who was a patient of mine too, had the genetic disorder as well, albeit with a milder manifestation, thus I knew the family well.

One thing I learned, was that Luke likes Star Wars, even though the first Star Wars movie came out more than a decade before he was born. Perhaps he envisioned himself as a Jedi Knight. Yeah, he was a fan of this movie genre, just like the rest of us, I guess.

In this last hospital admission, Luke came in with a lung infection causing respiratory failure, requiring intubation and mechanical ventilation. He came on Thanksgiving Day.

After several days in our ICU, we were able to extubate (take out the endotracheal tube) him, only to place him on a non-invasive positive pressure ventilator (NIPPV) with a face mask, as he cannot breathe on his own. This is like a CPAP machine. At least he can stay awake and not be sedated on the non-invasive ventilator, and he can speak as well. He can only tolerate a limited time off the NIPPV, and had to be hooked right back on it. He would not survive without it.

As I watched him with his “jet-fighter mask” with his bed as his vessel, what came to mind was that in a cruel twist of fate, this kid who likes Star Wars, now breathes like Darth Vader: whoooh….poooh, whoooh…..poooh, whoooh…..poooh. Every breath, there’s a gush of pressurized air coming out of the ventilator and through his mask.

After one holiday, another one is approaching. Christmas is just around the corner. And Luke remains in the hospital, ventilator-dependent, with no clear sight that he’ll get better. He knows it, and his family knows it. Luke’s days here on earth is numbered.

With wishful thinking, maybe he can linger a little longer to see the new Star Wars movie which he was looking forward to seeing for the longest time. But how? Him in the hospital? On a ventilator?

But wait, isn’t it Christmas season after all?

Wish granted!

After making elaborate arrangements and collaboration, Luke and his family will be going to a movie theater, to be accompanied by some medical staff, for a special private showing of the “Star Wars: The Force Awakens,” when it opens this weekend.

After that trip to the theater, Luke will be going home for Christmas with his family, on hospice care. No more hospitals. No more ventilators. No more pain.

Perhaps he could stay home until Christmas. But if not, Luke could soar into the heavens and once and for all, walk on stars. His final home.

********

Post Note: Luke made it through Christmas. He eventually lost his battle few months later.

Barriers

He was always there.

Constantly standing outside the ICU room, that is closed by a sliding glass door. He looked worried. The expression on his face was if he was begging for any news or information to any hospital staff that goes in and out of that room. Except that even when we tried to talk to him, he does not comprehend any word we say.

He does not speak English. Yet I believe he had a sense of what was going on. I think he somehow knew that something very bad was going on. Except nobody can really confirm it to him in a language he can understand.

His wife was inside that ICU glass room. Lying in bed hooked to several monitors and to a life-sustaining machine. Infusing into her veins were several liquid medications in upside down bottles hanging from poles. Coming out of her body were several tubes and catheters – some in natural body orifices, and some in surgically made openings.

The room was a negative air-pressure isolation room. Meaning, that all air droplets were being suck out of that room to a special outlet to prevent from spreading. And all personnel that go into that room needs to don a gown, a mask or a respiratory hood, and gloves.

As he stands outside that glass room looking in, several barriers are separating him from his sick wife, and from the world.

First is the physical barrier of being in an isolation room. This is being done as we suspect she has a highly contagious disease that can spread not just to the other hospital patients, but also to the hospital staff. If only he can be constantly at her bedside. Of course he is free to go inside the room, as long as he wear all those protective gear.

Second is the language barrier. Being a new immigrant to this country and not understanding its language can be very isolating. Not able to communicate even the simplest of questions is already difficult, how much more understanding a very complex situation.

Perhaps he and his wife came to this country to escape hardship or persecution. Perhaps they came here to pursue a dream and to begin a new life. Then, this happened. Which leads me to the biggest barrier of all, the barrier of the unknown tomorrow. What will happen to his wife? To him? To their dreams? And their future?

For the past two days we have been talking to him only through a phone interpreter. Due to the circumstances’ limitation, most of the conversation with him was to explain a procedure or a test that is needed, and to obtain his consent. Consent for blood transfusion. Consent for the CT scan and MRI. For the spinal tap. For chest tube insertion. For percutaneous abdominal drainage catheter. For bronchoscopy. And other more. But sitting down and explaining to him every nitty-gritty details of his wife’s illness and its prognosis, we have not done yet.

Finally, the social worker was able to get an interpreter to come to the hospital. Being an obscure dialect of a certain language, it was hard to get an interpreter in person.

So I sat down with him, and with a live interpreter, explained in as much as I could, the gloomy situation. I explained to him the severity of his wife’s condition: with overwhelming still-to-be-determined infection, plus the ravaging systemic lupus affecting almost every organ including the brain, the odds were plainly against us.

As I converse with him through the interpreter, I learned that he has no relatives and the only family he had here in the US is his wife. I also learned that at night he still goes to work at a meat-packing factory so he can keep his job, and then come and stay in the hospital all day. Somehow he just tries to sneak some naps in the ICU waiting room during the day. No wonder he looked so haggard. Life can be tough at times.

Then he asked me the crucial question, “Would my wife get better?”

I gave him my honest answer, “I don’t know.” I told him that there’s a possibility that his wife may die. Even though she’s only 22 years old.

His face became more saddened. Perhaps that’s an information that he was afraid to learn. Now through the interpreter, he fully grasps the gravity of the state she’s in. Sometimes I think, that not knowing is better. Perhaps not understanding, is bliss.

Two more days passed, and he was there most of the time. Outside the glass door. Looking. Pleading. Hoping. I almost wanted to avoid him, for there’s no comforting words I can say, with or without the interpreter.

But today is different. I cannot wait for the interpreter to arrive so I can talk to him. I needed to tell him the news. I think we have found an answer. I think she is slowly getting better.

I needed to tell him, that I believe she will live.

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(*photo taken with an iPhone)