Tag Archives: ICU

Bad Night

19 March 2018

4 Comments

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.

impella

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.

IMG_6345

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)

Concert in the ICU

24 February 2018

8 Comments

Inside ICU room 34* of our hospital, there is an ongoing musical performance. One young man is playing an instrument and another young woman is singing.

Music therapy is a burgeoning field of science. We have known since the history of man, that music has a healing property. During Biblical times, young David was summoned to play his harp whenever King Saul of Israel was stressed and troubled. Pythagoras, Plato and Aristotle all wrote about how music affects health and behavior.

Now, modern science and current medical studies back this up. In Harvard’s Health Blog, one article mentioned that music therapy can aid pain relief, reduces side effects of cancer therapy, restores lost speech in people who suffered stroke, and improves quality of life for dementia patients among other benefits.

One study from Austria conducted in General Hospital of Salzburg, has found that patients who are recovering from back surgery had increased rates of healing and reported to have less pain when music was incorporated into their rehabilitation process. I consider Austria a leading authority in music science, after all that’s the country where great classical composers like Mozart, Strauss, Schubert, Czerny and Haydn all came from.

Several years ago, when I was doing my Critical Care Medicine training in New York City, we had a music therapy team that plays to our patients in the ICU. The team, composed of a flutist, a violinist and a cellist, would go from room to room in the ICU and would play for about 5 to 10 minutes in each room. Even if the patient was medically sedated or comatose, they would do it anyway. It was soothing for us medical staff as well, when they come, as we got to listen to their music.

Music-Therapy-1

ICU music therapy (image from wakingtimes.com)

Since music therapy is the in-thing right now, I even told my daughter to look into a career in this field, that is if she would be interested, since she is pursuing a music degree. Perhaps I can have my own therapy someday.

Back to our ICU 34, the mini-concert though is not done by our hospital’s music therapy team, for we don’t have an official team like that as of yet. The music is being performed by the patient’s son and daughter who are both college-age and are both enrolled in music degree.

The son is playing his French horn, and the daughter is singing. The daughter even composed a special song for her mother, our patient, and would sing it for this special occasion.

However, their mother, who is only 44 years of age, is not going to wake up again. Not even with the beautiful music rendition from her children or any music therapy session on earth for that matter. She suffered a devastating head bleed which caused her to be in perpetual comatose with no hope of meaningful recovery. She is just being kept alive by life-sustaining machines.

The whole family agreed, that their mother would not choose to live a life in a vegetative condition like this. So they decided that they will take her off all life support. But only after they perform their mini-concert in her presence. They would like to dedicate their music as a send off, as she passed on beyond this world.

Sometimes music can be a therapy too for the broken-hearted and for those who are left behind.

(*ICU Room number was purposely changed)

 

Last Walk of a Fallen Jedi

5 December 2017

3 Comments

(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.

Of Hawks and Turkeys

21 November 2017

Leave a comment

Last Saturday was gray, damp and cold. It was windy too with strong wind gusts all day. It was a dreary day. I hope Thanksgiving would be a better day as it may be hard to be in a thankful spirit when you’re freezing, fighting fierce winds and just trying to hold on to your hat.

As we were going out, I noticed a large bird hovering high above a field. It could be an eagle as we have eagles in Iowa, though rare. But I believe it was a hawk, as they are so many here in our area. Hawks and strong gusts of wind are what we have in abundance here in Iowa, so no wonder our two big State Universities’ sport teams are called Hawkeyes and Cyclones.

I know hawks or even eagles may not be the right bird to talk about during this occasion. We should be discussing turkeys, right? By the way, wild turkeys abound in our area as well. You can spot them just hanging out in the empty corn fields. Perhaps we can skip the grocery and just capture one of them and make it our dinner for the Thanksgiving.

Enough of the turkey, and back to the flying hawk that I saw. Maybe flying was not the right term, for it was barely flapping its wings. It had its wings open, and like a big kite, it was effortlessly gliding in the sky. It did not seem to mind the strong gusts of wind, and may even be thankful for it. For the stronger the wind, the higher it soared.

Sometimes the strong winds in our lives, those gusts that we think will shred our plans, and those storms that can blast our dreams away, may just be helping us soar to higher heights.

Last week, the lady in the gym’s reception desk, the one who greets me cheerily every time I come in, gave me a book. The book was entitled “Praise God for Tattered Dreams.”

I have observed this lady as always upbeat and has a sunny disposition in life, day in and day out. I am impressed on how she remembers all the names of the gym goers, as she greets everyone by name. And I mean everyone.

Few months ago this lady, after greeting me for years since I have been coming to this particular gym, learned that I am an ICU doctor. She then told me that she was a patient many years ago, in the hospital where I work, and even stayed in the ICU. But that was a couple of years before I came to Iowa.

Since then whenever she sees me, she would always try to convince me to write a journal about my experiences as an ICU physician. She said that it may be interesting to share those stories, and I may even make some money from it.

Last week, after coaxing me to write a journal every time we meet, I finally told her, that I was indeed already writing a journal. Well, sort of. I told her about ‘this’ blog. I rarely tell people I know, that I blog. Why? So I could write about them!

After learning that I write, she went to the back, retrieved a book from a drawer and handed it to me. She told me that she wrote and published this book, and it’s about her trying experience. She added that I can borrow and read it, but if I spill coffee on it, then I have to buy it.

She narrated in the book that she was a vibrant mother with two young boys, and with a promising career, when out of the blue, she suffered a near-fatal stroke. It was a large bleed in the head. She was only 33 years old at that time.

She was close to death when she was brought to the hospital. The doctors, including the neurosurgeon, gave her only 10% chance to live.

But she lived!

She was comatose for several days and spent 3 weeks in the ICU, and a total of 3 long months in the hospital. This does not include several more months of rehabilitation after being discharged from the hospital.

She described that half of her body was paralyzed and was unable to speak for a while. In that dark moment of her life, she found God and discovered a new purpose in life. When she felt that her dreams have ended, God showed her that she was only beginning to live a more meaningful life, for which she was very thankful for.

Now she is speaking and walking with almost unnoticeable residual of her stroke. She is happily working in the gym and encouraging people to be healthy and happy. She definitely has a story to tell. From tattered dreams to an inspirational life.

As we gather around our dinner table this Thanksgiving, with our roasted holiday bird, (the turkey, not the hawk), let’s thank God for everything. Including our trials and disappointments. For storms and strong winds can make us soar higher.

Happy Thanksgiving!

IMG_5638(*photo taken with an iPhone)

 

Death by Chocolate

30 October 2017

5 Comments

All she wanted was to taste the chocolate.

All these years she was strongly warned against having chocolates. It’s not that she’ll have pimples or she’ll get fat when she eats them. It is more morbid than that. Her parents said that she is allergic to it. Deathly allergic to it. The last time she tasted chocolate was when she was 5 years old. And that was more than 30 years ago.

But chocolate is irresistible.

Everybody likes chocolates. In fact it is the most popular dessert in the world. Perhaps many will consider it as God’s gift to men. Some pundits would even say that the food Eve fell for was chocolate that was in the Tree of the Knowledge of Good and Evil.

As you probably know, chocolates are made from cacao. Interestingly the Latin name for cacao tree is Theobroma cacao which means “food of the gods.” Theo is god, and broma is food.

Why does eating chocolate so irresistible?

According to scientific facts, chocolates contains several chemicals that can affect our mood. Especially dark chocolates. Caffeine and theobromine are among those substances, which can make us more alert and gives us energy. I’m sure you’re familiar with the “pick-me-up” effect from the caffeine in your morning brew.

Chocolates also contains Anandamide that helps stimulate and open synapses in our brain that allow “feel good” waves to transmit more easily. A similar chemical, tetrahydrocannabinol or THC can have the same effect. THC is from marijuana. And you wonder why you can’t resist your craving for chocolates?

Furthermore, both serotonin and endorphins, neurotransmitters or chemicals in our brains, are released when we eat chocolates, and in turn, this brings on a sense of well-being. Just so you know, exercise also can release those endorphins, that can give you a euphoric mood after a work-out. Many call it as the “runner’s high.”

Lastly, Phenylethylamine is a chemical that our brain releases when we fall in love. It also acts as an anti-depressant by combining with dopamine that is naturally present in our brain. And guess what? Chocolates contains Phenylethylamine.

So go ahead, give chocolates to your loved one. Send chocolates to the one you want to date. Give chocolates on Valentine’s. I know flowers are nice, but can they release Phenylethylamine? Eating the flowers is not suggested.

Chocolate production is a multi-million dollar business. Ghirardelli, Godiva, Lindt, Cadbury and Hershey, to name a few, are big-name companies that are successful in this trade. Though I am still biased to the Filipino Choc-nut.

Besides chocolate bars and candies, there are also several chocolate-flavored desserts. Like cakes, ice cream, mousse, cookies, shakes, drinks, and whatever you can think of. There’s even chocolate-flavored cigarettes! That’s evil.

Then there’s different confectionaries that are called “Death by Chocolate.” I’m not talking about the chocolate-flavored cigarettes, though that is an apt name for that. “Death by Chocolate” is an idiomatic term they use to describe various desserts that feature chocolate.

Death by chocolate IIIBack to our patient, as I stated in the beginning, all she really wanted was to taste chocolate again. So she took a bite of a chocolate cookie. And she liked it! She took another bite, and another. The chocolate tasted so good, she finished the whole cookie.

Not too long after, she felt that her body was getting numb. She got alarmed, she took Benadryl. Four of them. But the symptoms did not get any better. She then started having some shortness of breath. Soon her tongue and lips swelled up. Then she cannot swallow or breathe anymore.

Finally she was brought to the Emergency Room. She was immediately intubated to establish an airway and then was hooked up to a mechanical ventilator. That’s how she ended up in our ICU.

All because of chocolate.

For two days she was on life support. Her blood pressure also dropped to dangerously low levels. These were all due to severe allergic reaction.

But she improved. With intense supportive care and mechanical ventilation, plus IV fluids, steroids and anti-histamines, and some tincture of time, she got better.

On the third day, she was weaned off the ventilator, and was discharged out of the ICU. I then warned her, that in no instance ever, that she should taste chocolates again.

Death by Chocolate? Almost.

(*photo from here)

Barriers

29 September 2017

4 Comments

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.

IMG_5491

(*photo taken with an iPhone)

Death Snatchers

2 June 2017

Leave a comment

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

2 May 2017

Leave a comment

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

17 December 2016

Leave a comment

(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

23 October 2016

1 Comment

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.”