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 her 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 her 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.

IMG_5491

(*photo taken with an iPhone)

Death Snatchers

During our ICU morning rounds, the medical residents were presenting the patients’ cases to me as I was taking over care from another attending physician.

One of the patients came in with fever and worsening shortness of breath. After work-up he was diagnosed with Legionnaire’s disease, a severe infection by a water-borne bacteria . He had complications with multi-organ failure, requiring mechanical ventilator and dialysis, among other life-sustaining support. After more than a week, he improved.

So as the resident was presenting his case with such bravado, he concluded with the statement, “we snatched him from the jaws of death,” with matching clawing action, like the arcade game of claw crane.

I kind of smiled with his presentation. I know he was half-joking, just to lift the morale of the ICU team. Taking care of very sick patients in the ICU where mortality is quite high despite of all the efforts, can be depressing.

I know this resident is a smart guy. In fact he is finishing his Internal Medicine residency with us in another month, and will be continuing his training in Hematology-Oncology Fellowship at Mayo Clinic this July. Maybe he’ll be “snatching” more patients from the jaws of death.

But there may be some truth in his statement, as we are literally snatching people out of the jaws of death. But are we really? Or are we just kidding ourselves?

That afternoon, there was a Code Blue (medical emergency) that was called overhead and my ICU team ran to respond to that call, which was a little ways out, as it was in the annexing building at the outpatient Cancer Center. The Intern (1st year resident), the most “inexperienced” of my team was the first one to arrive at the scene. He immediately took helm and directed the resuscitation efforts. Of course he was more than able and certified to do so.

By the way, even though some may say that residents (doctors-in-training) can be inexperienced, in a recent study published last month in the Journal of the American Medical Association, it reported that patients’ mortality rate is lower in teaching hospitals, than non-teaching hospitals.

Back to my ICU team, after more than half an hour of furious CPR, a stable heart rhythm was finally attained. The patient was then admitted to our ICU. I commended the Intern for doing a great job with such poise and calm, even in the midst of chaos during the Code Blue. Borrowing the words of my other resident, I told him in a jest that he “snatch” one out from the jaws of death.

I know from my experience, that even though CPR was “successful,” it was only temporary. Given the fact that this particular patient has advanced cancer, and was receiving chemotherapy when she had the cardiac arrest, tells me that the prognosis was poor.

I spoke with the patient’s son and explained to him the situation, that even though we were successful in reviving her mother, still the odds of her surviving through this was slim. But the son wanted “everything” done including doing more CPR if in case her heart stops again and does not want to hear about the poor outcome. But I understand, it is hard to let go.

The next morning, I learned that our cardiac arrest patient died. She died a few hours after I left for the night. So much of snatching people from the jaws of death.

Before we can start our ICU rounds that morning, my ICU team was called to the Emergency Department (ED) for a CPR in progress.

When I came to the resuscitation room in the ED, I saw a patient with the Lucas device on him (a machine that do the automated cardiac compression). I was told by the ED physician, that they were trying to resuscitate the man for about an hour now. He would temporary regain a heart beat, only to lose it again.

1234

Lucas device (photo from web)

They called me to assess if we should place the patient on Extra-Corporeal Life Support (ECLS), a “heart and lung” machine, as a temporizing measure to save him (see previous post). I suggested we call the cardiologist too.

Shortly thereafter the cardiologist arrived, and as soon as he walked in, the patient regained a stable heart rhythm again. So the Lucas device was shut off temporarily. After a brief conference with the cardiologist, we decided that the he would take the patient to the Cath Lab and see if he can open any blocked coronaries. Then we’ll decide if we need to hook the patient on ECLS.

Less than 10 minutes after we hashed our plan and as we were preparing to take the patient to the Cath Lab, the patient’s heart stopped again. We turned on the Lucas device once more. Our resuscitative efforts was now close to an hour and a half.

That’s when we all agreed, the cardiologist, the ED physician, and me, to call off the code. This patient was too far along from being snatched from the jaws of death.

We turned off the Lucas device, unhook him off the ventilator, and stopped all the intravenous medical drips that were keeping him “alive.” The ED physician then went out of the room to speak with the patient’s family, while me and my ICU team went to start our morning rounds and take care of our ICU patients.

It was grim start of our morning. Definitely my team was feeling down again.

Two hours later, I got a call from the ED. On the other line was the cardiologist, and I cannot believe what I was hearing. He was asking me to admit to the ICU the patient whom we pronounced dead earlier that morning!

Apparently after we unhooked the patient from all life-sustaining device, he regained a stable heart beat, and he started breathing spontaneously. They were waiting for him to die for the past two hours but he did not.

When I told my team that we were admitting “Lazarus,” which was what I called the patient, they thought I was just joking to lighten the mood. It took me a little more convincing for them to realize that I was telling them the truth.

That tells me enough of this “snatching people from the jaws of death.” Some of them can get out, even if we already dropped them. It just show who is really in charge. Definitely, it’s beyond us.

 

********

Post Note: “Lazarus” eventually died 12 hours later.

 

 

Illusive Hope

During my last weekend call, one of the many admissions I had to the ICU was a man in his 70’s, who was found unresponsive in his home. Since he lives alone, he probably have been lying on the floor for a couple of days before he was found.

After work-up in the emergency room, it was determined that he had a large stroke. As he was very sick and unstable, we were consulted to admit him in our ICU.

The next day, after providing supportive measures, his vital signs stabilized and he became more responsive, and even following simple commands. Yet he still has significant neurologic deficits due to the devastating stroke.

The patient’s son who was the power-of-attorney, talked to me and showed me his father’s living will, which specifically detailed that in case he had an “irreversible condition,” he does not want to be on any form of life support including artificial nutrition, like tube feedings or even intravenous fluids.

I assessed that with the severity of the stroke, the likelihood of “good” recovery was doubtful. My projection was that he would never live independently again, would most likely be nursing home-bound, and definitely would not be the same person that they know. In addition, he could even get worse as the swelling of the brain increase. No question, I painted a grim scenario.

After hearing my assessment, the patient’s son and family, were ready to call hospice and just make the patient comfort cares. The son told me that his father, for sure would not like to live a life with such a poor quality as I have projected. Though I told them, that the neurologist whom I consulted have not seen the patient yet, and perhaps they should wait on what he has to say.

Not long after, the neurologist came. He extensively reviewed the CT scan of the head, and he made a careful and detailed neurological examination of the patient, as he tried to evoke even obscure reflexes that I can only read in the medical textbook. After his evaluation, the neurologist, the patient’s son, and me, went in a room for a conference.

The neurologist explained that with his estimation, even though the stroke was large, since it involved the non-dominant side of the brain and mostly the frontal lobe, he believes that the patient can still have a “meaningful” recovery. In addition, since the acute stroke was a few days ago, he thinks that the swelling was on its way down, and perhaps we were already past the worst phase. He backed this with his expert knowledge of brain anatomy and function.

Thus the neurologist believed that at best, though it may take months of rehabilitation, the patient can talk – though with a funny accent, walk – but with a limp that he even demonstrated, and maybe could even live independently later on. He definitely painted a more rosy picture than the gray picture that I have painted.

Hearing the neurologist’s opinion, it was obvious we have a “slight” difference of opinion. Perhaps slight was an understatement.

After considering the neurologist’s evaluation, the son and the family changed their mind and decided to defer calling hospice and instead support the patient as much as possible, including tube feedings and all.

To be honest, I was a bit perturbed that I gave such a bleak prognosis than what the other doctor gave. Have I given up on that patient too soon? Have I killed the embers of hope prematurely? Perhaps I have become so pessimistic in my view of things. Perhaps I have seen so many prolonged sufferings and bad outcomes despite our best intentions and efforts in my ICU experience. Perhaps I was just saving the family from the heartaches of clinging to unrealistic optimism. Or perhaps I become more cynical and have lost my faith in hope.

In my defense, maybe I just see the front end and the acute catastrophic courses of patients in the ICU, and have limited exposure to the success stories of patients’ wonderful recovery after prolonged and extensive rehabilitation.

But even though I felt betrayed by my negativism, I felt relieved that I have heard a differing opinion, and perhaps gave a chance to a life that we almost gave up on too soon. Even though I felt embarrassed and almost apologetic for my opinion, I was thankful that we gave hope a chance. Everybody deserves that chance.

The following day, when I rounded on our stroke patient, he was more obtunded and unresponsive. He now have labored breathing and had to be placed on a ventilator. I then requested a repeat CT scan of the head.

The CT scan showed what I was afraid would happen: a further extension of the stroke and more swelling, displacing the structures of the brain beyond the midline and even herniating down the brainstem. This was unquestionably a grave condition, and most likely fatal. No more differing opinions.

The family decided to transition to comfort cares, and the patient expired a day later.

I did not kill hope. It died.

IMG_3659

The End Of A Miracle

(I am reposting an article from December 26, 2010, “My Christmas Calling.” I wrote it after being on-duty on Christmas day.)

Christmas morning. Freshly fallen snow was on the ground. It was a White Christmas after all.

Bah, humbug!

I forced myself to get up from bed. My throat was sore. It felt like somebody stuck a fork in my throat and scraped it raw. My body aches like I just ran a marathon. I caught a Christmas bug, you know. No, not the “joyful feeling” of the holidays. A real bug.

I don’t want to go to work, emotionally and physically. But I have to. I am on-duty for Christmas. Our patients in the hospital, especially in the ICU, needs my care. (But who will care for me?) On days like this, I just have to suck it in, take a couple (or make it a handful!) of Tylenol and will myself to go.

I left home with the kids still sleeping and the gifts under the tree unopened. Maybe I would be able to come home early and we can open the gifts together.

In the hospital I greeted people with perfunctory “Merry Christmas,” though I was not feeling the “merry” part. In fact was in a Scrooge-mood.

It was a busy day: 32 total hospitalized patients I rounded upon, 2 hospitals I went to, 19 ICU patients, 12 ventilator-dependent, 2 carbon monoxide poisoning that needed hyperbaric oxygen treatment, 1 chest tube insertion, 1 endotracheal intubation, 1 arterial catheter placement, 2 central venous catheter placement……. and a partridge in a pear tree.

As I dealt with the very critically ill patients and talked with their families, I knew that I was not the bearer of good tidings and joy, but rather of grim news most of the times. As the families broke down into tears and came to term to the gravity of the condition of their loved ones, I thought that these people were experiencing far worse Christmas than me. At least I am going home tonight. My patients will not. Some of them will not come home, ever. And for these families, Christmas will never be the same.

Slowly my “Grinchy” attitude peeled off and was replaced with a sympathetic spirit. I then realized my purpose for this holiday: that is to give my compassionate care for these unfortunate people, in this supposed to be joyful occasion.

The last patient I admitted to the ICU on Christmas came late afternoon. He was 32 years old. When he was 7, he received a life-giving gift, when he became a recipient of a heart transplant. His “miracle” heart had kept him alive for all these 25 years. However, for the past few years, his existence was less than joyful. Complications after complications have developed, and one by one his organs started failing. Including his borrowed heart.

Today he was brought to the Emergency Department barely alive. After transferring him to our ICU – placing him on a mechanical ventilator, putting tubes and catheters in his body, and flooding his system with medicines – his condition did not really improve much.

I spoke with her mother in the ICU’s waiting room. She quietly, but boldly stated, in between sobs, that she was ready to let go of her son who have suffered enough. She indicated to me that she just wanted his “boy” to go gently into the night.

Somehow, the ‘miracle’ heart will be resting this Christmas night.

Did the miracle ended?

I don’t think so. For the miracle of love persists. Love that is shown here by letting go. Letting go in some occasion, is more selfless than holding on.

There is another 7-year old boy who is waiting for his gift. That boy is my son waiting at home. He may be anxious to open his gifts. Or maybe he’s anxious just to see me come home.

IMG_0607_2

A Somber Celebration

Last week, we had a patient in the ICU who was unwell. Unwell, is perhaps an understatement.

He was of an advanced age though, as he was in his 80’s, and maybe has already lived a full life. Yet he was still active, lives independently with his wife, and was in relatively good health, until he got sick and got admitted to the hospital.

He came down with a bad bout of pneumonia. So bad that he went into respiratory failure and had to be placed on mechanical ventilator. This was complicated as well, as he suffered a mild heart attack too. Furthermore, he also developed brisk bleeding in his stomach, but fortunately we were able to stop that bleeding, when we did the gastroscopy.

After several days of intensive support, surprisingly he got better. He got better enough that we were able to take him off the ventilator. He was going to pull through this. So we thought.

But less than 24 hours later, he was placed back on mechanical ventilator. His blood pressure dropped as results of overwhelming infection. He went into congestive heart failure. His kidneys also started to fail. His condition got worse than ever.

We sat down with the patient’s family and discussed with them the dire situation. They decided that they would like to continue the aggressive support and hang on for two more days. I thought it was kind of odd to have so specific timeline in their request.

Why two days?

Two days later, as we’re going through our morning rounds, I was told by my staff that we will be having a party later that day. A birthday celebration right there, in the ICU.

I learned that the family of our elderly patient have called all the family members that can come, to be there and visit the patient. They brought balloons and a large birthday cake. They even brought in the patient’s dog to the ICU! But of course they have to get a permit and confirm all the vaccination records of the dog.

I also learned that the family was planning to take him off life support that same day. They would like to transition to full comfort care, and let nature take its course.

The ICU staff got a birthday card that they passed around and asked us all to sign it. Honestly, I was stumped on what to write on the card.

Do I write “Happy Birthday,” knowing that it may not be really a happy event? Or do I write “May you have more birthdays to come,” which I know would not be true at all? Or should I write “Have a good last birthday?” But that sounds morbid! Or do I write “May you have peace on your birthday,” which I think is very appropriate, but it is as if I’m foretelling death before it actually happen?

Never did I have so much difficulty in writing a simple greeting on a birthday card before.

When the family were ready, we lightened the sedation and have the patient wake up, so he will at least have the chance to witness his own birthday celebration.

The ICU staff came and crowded inside his room and sang “Happy Birthday.” Though I guess, many of us we’re feeling rather sad than happy while singing that song.

We then extubated the patient and took him off the ventilator. He was able to speak after that, though very weakly. The family gave him a piece of his birthday cake which he tasted, even if it was just the frosting.

After a while, he started to show signs of discomfort. He was obviously struggling even just to take a breath. So after the final embraces from the family and a pat to his dog, we gave him medications to relax him and made him more comfortable. He slept the rest of his birthday celebration.

He later slept on into the eternal night.

********

P.S. I wrote on his birthday card, “May you have a meaningful birthday.”

 

Tortured Soul

She was a tortured soul.

In spite of all the medical interventions and having a supportive family, she still was always extremely depressed. It seems that she cannot get rid of her demons and the tormenting voices in her head. The desire to kill or hurt herself consumed her every day.

She has been on different anti-depressive medications and was regularly being followed by her psychiatrist. She even had several admissions to the inpatient psych unit. Yet nothing really alleviated her condition. For a person who is barely in her 30’s, she already had a fair share of misery.

8850-munch-the-scream-e1336013995741

She has attempted suicide a number of times in the past. Though all of those times it was not serious, resulting no grave medical consequences. It was mostly cries for help.

But this time, it’s different.

Her family found her unresponsive in her room after presumably overdosing on a bunch of different pills. Emergency responders were called and upon their arrival, CPR was performed. They were able to establish a stable heart rhythm and patient was brought to the hospital where she was subsequently admitted to the ICU.

She laid there in our ICU, hooked to several monitors and life support. Her chest would rise and fall as the ventilator bellows air into her lungs.

Three days have passed since her admission, yet she remained unresponsive. In addition she had this intermittent jerking-like activity, which I believe was an ominous sign of severe anoxic brain injury. I called the neurologist to assist in her care.

Then few hours ago, something happened.

Her vital signs became more labile. The continuous EEG monitoring which the neurologist requested showed a significant change. The jerking-like activity have quit. Her pupils were now fixed and dilated.

My suspicion was that she now is brain-dead.

Brain death is a complete and irreversible loss of brain function. Unlike in a vegetative state which could have some autonomic or brain stem functions left, brain dead means cessation of all brain activity.

I updated her family of this recent development. Then I proceeded to do my confirmatory exam for brain death per protocol.

After my evaluation, I determined that all her neurologic functions were gone. I even performed an apnea test, which involves taking the patient off the ventilator for 8 full minutes, while providing oxygen through the endotracheal tube. If there was no respiratory motion for the entire time, and this is associated with an appropriate rise in the blood carbon dioxide level, then this is one verification that someone is indeed brain-dead.

The neurologist independently performed her evaluation as well, and also arrived at the same conclusion.

When one is declared brain-dead, it is an indicator of legal death. Different from a person who is in a continued vegetative state, who can be sustained on life support indefinitely (which is controversial in so many levels), a person who is declared brain-dead is officially dead. All life support should be discontinued. Even if the heart is still beating. No argument. No controversy.

I gathered the family and told them of my findings. They were obviously distraught, but accepted the news without any questions.

I also told them, that based on the patient’s driver’s license, she indicated that she was an organ donor. I asked the family if they would like to honor the patient’s wishes.

The family said, that they totally agree to donate the patient’s organs per her wishes. That despite of the patient’s several mistakes in her life, this may be the best decision she have ever made, according to them. And despite of her cloudy and troubled mind, she have decided on this selfless act.

I called the donor network.

I know that somewhere out there, another person will be set free from the shackles of dialysis as he or she would receive a long-awaited kidney. Another person will be given a new breath of life as he or she would receive a new set of lungs. And another person out there will be given a new lease of life, as he or she would receive a new heart.

All because of the gift of a tortured soul.

Spinning Plates

When I was much younger, I had a fascination for juggling. I learned how to juggle on my own. I could juggle 3 tennis balls, or toy blocks, or even plastic bowling pins. Though I did not and would not try juggling chainsaws.

Juggling is an art. The more dangerous and challenging the feat, the more captivating it is.

Have you seen an act of spinning plates, where the juggler spins several plates on sticks? He goes from plate to plate to keep them spinning or else the plates drop to the floor and break.

plates

Three weeks ago I had one crazy weekend duty. I think it would fall as one of my busiest calls in the ICU in my recent memory. It was so busy that my Friday to Sunday, kind of blended to one very long day with only a few hours of sleep in between.

In one particular stretch of that call, hell broke loose.

I worked on a very sick young man in his 30’s, who was admitted to ICU room 3. I intubated him, placed him on ventilator, placed a large neck catheter for IV access, and started several medication drips on him, all in one rapid succession. I was in the midst of trying to stabilize him when another patient, a lady in room 18, went into cardiac arrest. “Code Blue”* was called.

I have to drop what I was doing on the first patient and ran to room 18. When I got there, the ICU resident was already running the code. After 10 or 15 minutes of CPR and fast paced intervention, we were able to resucitate her back. With her heart rhythm semi-stable, I ran back to room 5, and continued what I was doing.

Not too long after, the patient in room 18 went into cardiac arrest again. I ran back to that room once more. This time I beat my resident to the room and took charge of the Code Blue. My resident who eventually arrived told me that she got hung up in ICU room 16 who was also crashing. I saw another resident who responded to the the Code Blue, but I sent him to room 5, to continue on what I was working there.

After more than 10 minutes of CPR we got our patient in bed 18 going again. It was heartbreaking to see that while the CPR efforts were in progress, the family was just outside the room crying and wailing as we work furiously on their loved one.

After we got the patient’s heart beating again, I gathered her family to a nearby consultation room and discussed with them the dire situation. I told them that there was no guarantee that her heart would not stop again. But given of how sick she was, especially after successive cardiac arrest already, I knew her chances of walking out of the hospital was close to nil, and continuing to do the CPR would be an exercise of futility.

I was talking to the family, when I was called emergently to see room 16 who they were about to call Code Blue. This was the one my resident told me about earlier. We got the patient intubated and hooked to ventilator, started several IV medications and got him stabilized, at least for the time being.

After getting out of room 16, the family of room 18 approached me and told me that they have decided that if her heart stop again, to let her go peacefully.

Less than 30 minutes later, she died.

The patient in room 16 that we attended to also continued to circle down the drain. And despite our efforts, he also succumbed several hours later.

I finally was able to concentrate on room 5 when there was a lull in the chaos we were in. I decided to place him on extracorporeal life support, also known as ECLS** (see previous post about ECLS here), as he would not survive without it. The ECLS team was mobilized, and around 2 o’clock in the morning, the patient was off and running on ECLS.

I have not even mentioned the other 17 ICU patients under my care, but were not actively crashing during that time, nor the other 3 new ICU admissions that came during that span of 4 hours of absolute craziness. I even accepted another patient from an outlying hospital during that period, for whom I ordered our flight crew to fetch. Though the patient did not make it to our hospital, as he was so unstable and our helicopter crew was reluctant to fly him unless they stabilize him more for the flight. I heard he died shortly then.

Spinning plates? Seems like it, right? Sometimes I wonder if I could  keep up with this pace or would I like to continue doing this. Don’t get me wrong I do like my job. But I don’t like the awful stress and the awful reality that comes with it. For it is not just plates that are falling and breaking.

About the patient in room 5? He improved after we placed him on ECLS. He eventually was weaned off ECLS and ventilator after almost 2 weeks in the ICU. He went home from the hospital the other day, walking unassisted and off oxygen.

Success stories like him, though few and far between, keeps us going. After all, I believe it is still worth doing this.

********

*Code Blue: an emergency situation announced in a hospital or institution in which a patient is in cardiopulmonary arrest, requiring a team of providers (sometimes called a ‘code team’) to rush to the specific location and begin immediate resuscitative efforts.

**ECLS: extracorporeal life support (ECLS) is an extracorporeal technique of providing both cardiac and respiratory support to persons whose heart and lungs are unable to provide an adequate amount of gas exchange to sustain life. It is done by siphoning blood out of the body and artificially removing the carbon dioxide and giving oxygen to the blood by running it through a special machine.

Broken

I take care of “broken” people. Both broken, physically and emotionally.

Due to the nature of my specialty, I deal regularly with people who overdosed and those who attempted to commit suicide.

This past week, we have a lot of them. Every single night we have at least 2 admissions to our ICU of attempted suicide by drug overdose. There’s one that even slashed her wrist besides taking medications. It was full moon after all.

I am not superstitious, but I believe there is a real science behind the connection of the cyclical phases of the moon and human’s crazy behavior. Just like the gravitational pull of the moon affects the ocean tide, maybe it can influence our mind too. The human’s brain is 75% water anyway.

Most of the times our drug overdose admissions are “trivial” overdoses. They took a handful of pain or sleep medications as a cry for help, with the so familiar line of “I just want to escape from my problems” or “I just want to take a long sleep.” Though many will also claim, “I just want to end it all.”

Most of these overdoses just needed to be closely monitored for several hours in the ICU as they sleep off the effects of the drugs they took. When they sober up, we call the psychiatrist to evaluate them whether they are clear for discharge or transfer to the Psych unit.

However there are some who are “serious” with their attempts, that they overdosed with an awful amount of drugs or took highly toxic substances that they present to our ICU half dead. They have multi-organ failures, and would require infusion of medical antidotes if there’s any, be placed on life support, including mechanical ventilator, cardiac and circulatory support, and even dialysis, if the medication or poison they took can be dialysed out. Few of these gravely ill patients would slip through our fingers and die despite of our best efforts.

SONY DSC

Taking care of overdoses and attempted suicide patients is my least favorite in the line of my job. Why?

First of all, as I mentioned above, most of them don’t really need ICU care, as they just require time to sleep it off. But I guess they needed to be in a highly monitored bed in case something goes wrong. So many times it just add to the burden of the ICU staff who are already overloaded in caring other critically ill patients.

Secondly, for those who are “serious” in their suicide attempt and comes to us almost dead, after we work our tails off saving them, they are not even grateful to us when they recover. They are even bitter. Why? For the obvious reason that we prevented them from getting to their ultimate goal, which is to die. It is a thankless job.

Over the years that I have been an ICU physician, I have observed that our admission of drug overdoses and suicide attempts seems to be increasing. Has our society gone so cold and uncaring that many among us feel so lost and so unloved, that they are willing to do foolish things just to get the care and attention they hunger for? Maybe it is the world that is broken. Maybe it is all of us.

As a health care professional, it is my duty and my obligation to care for these people when they come to our ICU, irregardless of how “stupid” their acts seems to be. I’ll listen to their stories. I’ll reassure them. And if care and attention is what they want, deserving or not, I’ll give it to them.

Even though these “broken” people think that the world is so indifferent and no one seems to care, but when they leave our ICU, I can honestly say to them, I cared for you.

 

(*image from emaze.com)

 

Steak and Rye

It was late afternoon of New Year’s Eve, and I was rounding on our patients in the ICU. I came to one room and the patient was sitting upright in his bed. On his bedside table was a tray with a large piece of steak on a plate, a drinking glass, and a bottle of rye whisky. What? Is this a restaurant or hotel? Is this the new hospital food?

Most of our patients in the ICU are not awake enough to eat food, let alone have a solid meal like that. We provide nutrition through a tube in their nose that goes to their stomach and they feast on liquid feedings. Or if their gut is not working, we give them “gourmet” nutrition through their veins. In fact once patients can eat solid food, most of the time they graduate out of the ICU.

But what about this patient? A slab of steak? And is alcohol sanctioned by the hospital now? Here’s the story.

He presented to the hospital with worsening shortness of breath. After some imaging work-up, he was found to have a large tumor in his chest. I saw him several days ago when he was admitted in a regular room, not in the ICU. We were consulted for the lung mass and I scheduled him to have a bronchoscopy (a procedure putting a flexible scope to the lungs) and biopsy.

However before the scheduled procedure could be done, he suffered a cardiorespiratory arrest, got intubated, was hooked to a ventilator and was moved into the ICU.

Good thing was despite the circumstances, he improved enough that we got him off the ventilator. Yet we don’t have a tissue diagnosis to confirm that what he has is cancer, even though the signs indicated that it was malignant. But we needed to be sure.

So I proceeded with a bronchoscopy and got a biopsy, and finally established a diagnosis. It was lung cancer alright.

Unfortunately his condition got worse again. He again required ventilator support, though a non-invasive type, which is like a CPAP machine. I told him that the final pathology proved that it was cancer. And based on its extent, plus with his grave condition, he was an unlikely candidate for any surgery, or chemotherapy, or radiation to treat his cancer.

That’s when he decided that he wanted to go on his own terms. His own way. Like Frank Sinatra’s song, “I did it my way.”

He requested that we discontinue the non-invasive ventilator, even though he was struggling without it. He asked to have a New York steak and a bottle of rye whiskey for his last meal. So in between labored breath and heavy heaving, he chomped on his steak and sipped on his rye.

When I came to his room that afternoon, despite his terrible situation, he was even smiling while having his last supper.

After he had his meal, we transitioned him to full comfort care per his request. No more ventilators, nor machines, nor any more interventions. Only comfort medications. And while he was watching TV in his ICU bed, waiting for the ball to drop in New York’s Time Square, he quietly slipped into a blissful sleep.

Just before the old year ended, our patient went out peacefully into the eternal night. He exactly did it his way.

For us who made it through another year, may we find new aspirations, new hope, and renewed zeal for life, as we face this new year.

IMG_5243

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. 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.

IMG_0726_2

(*name intentionally changed for privacy)

********

Update 12/22/15: after posting this story here, I learned that our patient was featured in the local news. See link here.