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.

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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.

 

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

 

 

Constipated Teaching

Since I am practicing in a teaching hospital, besides treating patients, part of my duty is educating and training residents (doctors-in-training) and medical students. In fact the state university even gave me an academic title. My official title is: Adjunct Clinical Associate Professor. Adjunct, means extra or accessory. In other words, not that major. Maybe “A Junk” Professor is more appropriate. In my native language, saling-pusa.

Anyway, most of the time when I am seeing patients in the hospital, I am accompanied by medical residents or medical students. In the ICU though, my entourage could be quite large, composing of 2 to 3 residents, a medical student, a pharmacist, 1 to 2 pharmacy students, a respiratory therapist, and respiratory therapy students. Then when we round on a specific ICU patient, the nurse taking care of that patient will join our discussion too.

Having a group shadow me on my rounds has its perks, as many of the scut work the team could already accomplish in my behalf. Plus the bigger the entourage, the bigger the likelihood that people think you are important (not mere “a junk”), just don’t let that get into your head. But it has its disadvantages too. For one, I have to ask permission to break rounds, every time I needed to go to the restroom.

In our rounds, besides talking about the patients’ cases and our plan of treatment for each one of them, we also discuss about snippets of medical teachings, current trends of practice, new drugs and even latest research that support our plan of management. Thus I really needed to be updated on the most recent guidelines and studies.

Few weeks ago, as I was conducting my ICU rounds, we have been dealing with some very difficult cases as well as some unfortunate patients in our ICU whose chances of surviving were slim. As we went through consecutive depressing cases, I could sense the sadness and stress rubbing in into my team. I could feel the morale of the team was low, for taking care of these sad cases of patients.

As the captain of the team, besides making sure that the right management is given to each of our patient and assuring proper education and adequate training for my residents and students, I feel that it is my duty as well to keep a high spirit in my team.

One particular patient that we have was having a bad case of constipation that was made worse by his requirement for pain medications, on top of all his other life threatening conditions. We then discussed causes of constipation and its management in general. One complication of using opioid pain medication is constipation, as it can slow down the intestinal movement. So we decided to give our patient the relatively new injectable medicine for constipation that blocks the opioid receptors in the gastrointestinal tract without decreasing the pain relieving ability of the opioids.

Then I asked the team, “Have you heard of the long-awaited big study on constipation?”

They all looked at me shaking their heads as they have not heard of it, and anticipating more words of wisdom from me.

To this I said: “It has not come out yet.”

Realizing that I made a joke, and not to be outdone, our knowledgeable pharmacist chimed in, “But I heard of the recent study that said that diarrhea is hereditary.”

The team was smiling now, and seems to be in a better mood , waiting for the punchline.

The witty pharmacist concluded, “Because it runs in jeans (genes).” Eeeww!

With that we moved on into our next ICU patient.

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Pahabol na hugot: Constipation ka ba? Kasi I cannot get moving since you dumped me.

 

Intern Blues

The other day, I let our medical intern in the ICU place a dialysis catheter on one of our very sick patients. It is a minor surgical procedure of placing a thick catheter in the patient’s jugular vein using ultrasound for guidance. Of course she had lots of supervision, as one of our senior resident was assisting her, and I was around as well for support.

The intern was not able to place the catheter that quick being inexperienced, so it took a little longer doing the procedure. Though that is nothing out of the ordinary. This is normal for a teaching hospital, as interns and doctors-in-training has to start somewhere.

While we were doing the procedure, the patient became unstable, and then went into cardiac arrest. We called a Code Blue (a call for help on a patient having cardiac arrest). Moments later the whole room was teeming with hospital personnel responding to the code.

The patient survived and was stabilized after several minutes of furious cardiopulmonary resuscitation.

The intern was visibly shaken to what just happened. I saw her later in the workroom crying. One of the senior resident told me that the intern felt that it was her fault that led to the cardiac arrest.

However after extensive work-up, we found that patient has a weak heart to start with, and in fact was in congestive heart failure and kidney failure, and that was why he was in the ICU. Then he suffered a heart attack, that caused the cardiac arrest. It was just coincidental that it happened while we were placing the catheter. It was not a direct complication of the procedure.

I reassured the intern that it was not her fault, and gave her some words of encouragement, that this is all part of our work. Besides, this intern is good, intelligent, comes prepared on rounds, and has initiative to learn. I see a great potential in this young doctor. Her only fault is that she is new and inexperienced. But we all have been there.

I have been an attending physician in a teaching institution for a long time now. In fact five of my partners in our practice, who are now full pledged Pulmonary and Critical Care doctors are once my medical interns in the hospital. So at some point in time, I showed them the ropes. And now they are probably better than me, and once in a while I asked for their opinion in difficult cases.

I remember when I started my medical internship in a Columbia University-affiliated-hospital, I was not a “good” intern. At that time, I was a new arrival to the US from the Philippines, was new to the American system of medicine, and definitely not the sharpest among our batch. Compared to our star intern, a graduate of Johns Hopkins University, I was like a kindergarten. I was really lost and I struggled in the beginning. But I am thankful for my seniors and attending physicians who saw the rough potential in me. Though I would be lying if I tell you I was not lectured on at times, or even chewed and spewed.

At the graduation ceremony of my Internal Medicine Training, they gave me the “Tabula Rasa” award. It took me a while to figure out what it meant. But I guess I was really like a “blank slate” when I started, which what the Latin “Tabula Rasa” means. I must also had that blank stare like a deer in the headlights, that goes with my blank mind.

But as I said, we all have to start somewhere.

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hospital teaching rounds, circa 1940’s

In some academic centers they have a very defined hierarchy. Even one year of seniority feel like a world of difference. The attending physicians act like demigods as they would climb up their high horses when they do their rounds. The attendings treat the medical residents as dirt. In turn, the senior residents treat the junior residents as dirt. The junior residents treat the interns as dirt. The interns treat the medical students as dirt.

It may be hard to admit, but I witnessed this hierarchical state of thinking when I was in my medical school in the Philippines. And being the medical student, I was at the bottom of the totem pole.

But I don’t buy into this old-school hierarchical philosophy and system that treats our inferiors like dirt. I adopted a philosophy of providing a more collegial environment which I believe is more conducive to learning even for the least of us. A resident, or an intern or even a medical student can approach me freely without fearing of being chewed on.

Back to my intern, I hope she’ll learn something from that difficult day. I know someday she will become a good, experienced and a well-rounded doctor too. And if someday she becomes the chief of the medical staff in this hospital, as she has a great potential, or becomes the head of a big-shot medical corporation, or even becomes the US Surgeon General, I hope she remembers me and the words of encouragement I gave her during one difficult day.

(*photo taken from reddit.com)

 

The Dead Speaks

Part of the benefits of a physician practicing in a teaching hospital is that there are regularly scheduled academic conferences and meetings where you can attend and learn something.

This morning I attended the Medicine Grand Rounds which was a clinical and pathological presentation of an interesting case.

A senior medical resident talked about a woman admitted in our Intensive Care Unit several weeks ago, who came in very ill. Her condition deteriorated quite rapidly that she died in less than 24 hours after admission despite of all the efforts to save her. An autopsy was requested from the family, to know what caused the patient’s demise, and in addition it was felt that the information from it would help us care for future patients.

After the history and the hospital course was presented, the Pathologist revealed his findings. He showed pictures of the gross and microscopic features of the autopsy. He then gave the verdict on the cause of death. And it was something unexpected. At least for me.

For all the medical specialists, it is the pathologist that always have the correct and final diagnosis. When I was still in medical school, which was more than 20 years ago, I have heard this saying:

“Internists know everything but they don’t do anything.” (Meaning internist like me have all the knowledge but don’t open up and explore the patient to intervene.)

“Surgeons don’t know anything, but do everything.” (Meaning, even though they don’t know yet, they open up and explore the patient to find out.)

“Pathologists know everything, and they do everything, but it is too late.”

Though in fairness to the surgeons, nowadays, with the advent of all the high-tech imaging modalities, like CT scan and MRI, they almost always have all the information they need before they cut open the patient.

I would say that part of a doctor’s learning is from the morgue. In fact, when we have a patient that died and we were granted permission for an autopsy, I make it a point to have my medical residents rotating with me, to come down to the morgue during autopsy and learn what the findings of the pathologist were. I think this is essential for a good training.

I am not trying to gross you out, but that’s the reality of our line of work. Though with all the TV shows, like CSI and NCIS, anybody can witness an autopsy, whether it is real or imagined.

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scene from an episode of NCIS

My first exposure to a real autopsy was when I was a 4th year medical student in University of Santo Tomas, in the Philippines. I was rotating in Forensic Medicine at Fort Bonifacio. There was a victim with multiple gunshots, and two pathologists were performing the autopsy. It takes a lot to gore me out, so it was no big deal to me. Plus we have been exposed and even dissected cadavers in our Anatomy class. By the time we got used to it, we can even eat our lunch in the Anatomy Hall.

While the autopsy was underway, an army sergeant walked in into the morgue with several new army recruits in tow. The sergeant told the recruits to stand in the corner and watch the autopsy so they know what would happen to them if they were killed.

As the pathologists extricate the internal organs one by one to examine them, I have noticed that the new army recruits who were standing in attention started to sway. Their stoic faces started to grimace. Well, who wouldn’t? I guess it was a sort of cruel initiation for them.

Since then I have witnessed several more autopsies over the years, not including what I watched in NCIS. It is not that I enjoy them, but I have to admit, I learn from them.

However I have maintained my utmost respect for the deceased. These bodies that were cut open for us to study were once living individuals. They were persons. They have a name. A purpose. A life. But now gone. Yet in these hallowed halls, they still speak.

Inscribed over many entrances of morgue, medical examiner’s office and anatomy hall is the Latin maxim, “mortui vivos docent,” meaning “the dead teaches the living.” Yes, indeed.