Still My Beating Heart

She laid there motionless in the ICU bed. The only movement was the regular rise and fall of her chest as the ventilator blows air into her lungs. The only activity in the room was the continued bleep and tracings of the bedside monitors attached to her, indicating that she still has a blood pressure, and a heart beat, for otherwise she really appeared lifeless.

As I entered the dimly lit room, I noticed a photo on top of the counter near her bed. It was a photo of a happy family. In it was the patient and her husband, surrounded by their eight children. Yes, eight. That was kind of large family to an American standard, or perhaps anywhere else nowadays.

I appreciate families placing photos beside their loved one’s bed. Especially in our patients in the ICU as most of the time we never knew them before they got sick and deteriorated to their current condition now. Somehow the photos gave us an insight to the life, a snapshot if you will, of whom we are taking care of. It humanizes them, at least to us. That they were someone’s mother, or wife, or friend. Or they were once a decorated soldier (as their uniform indicate), or a coach, or a teacher. That they are not mere blob of a body hooked to life-sustaining machines.

My patient was in her early fifties. I learned that all the eight children that she have, were all adopted. They ranged from sixteen to eight years of age. That tells me what kind of person I am caring for. A woman with such an enormous heart, with overflowing love to adopt eight kids, and call them her own.

Unfortunately, it was also her heart, I am talking now of her anatomic organ, that caused her illness.

Few years ago, she needed an open heart surgery to replace one of her heart’s valve, the aortic valve, which was diseased. The aortic valve is the one that opens and closes as the heart pumps out blood from the left ventricle (the main pump chamber) into the aorta (the big artery that distributes blood to the head and the rest of the body). Her aortic valve was replaced with an artificial mechanical valve.

A replacement mechanical valve can last for many years, in fact, a lifetime, unlike a tissue valve (usually a pig’s or a bovine’s valve) which only last an average of ten years. However, a mechanical valve increases the risk for forming blood clots, and thus the recipient of those valves requires to be on blood thinners (anti-coagulants) permanently.

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mechanical heart valve

A few months ago, our patient underwent a necessary outpatient simple surgical procedure that required her anticoagulation to be interrupted briefly. Sadly to say, this caused a catastrophic event. She developed blood clots that led to a very extensive stroke. Our patient really never recovered completely after that. In spite of all the efforts and rehabilitation, she never walked again, she never spoke again, nor she did much of anything anymore.

I can just imagine the heartache to her husband and their kids to see her in that state of helplessness. But their family tried to move on.

And now this happened. She developed a severe bacterial infection that spread into her blood system. She went into septic shock. This infection caused a bacterial nidus to settle in her mechanical heart valve, a condition called septic endocarditis. The problem with a prosthetic metal valve affected with an infection is, it cannot be treated with antibiotics alone, it needed to be removed or replaced surgically. A surgery that she perhaps cannot survive through, nor can she survive without.

As I met with her husband and discussed her grave situation, he softly told me, with tears rolling down his cheeks, that the most loving and humane way of caring for her, was to let her go. I cannot agree with him more. And as we end our talk, he was not the only grown up man with tears in his eyes, for I did too.

The children came one by one to her room and they said their final goodbye. It was so painful to watch. After that, the life support was taken off. All the medication drips, except for medication to keep her comfortable, were shut off.

After several quiet moments of waiting that seemed like an eternity, her beating heart……the heart that was large enough to adopt such a large family, and the heart with such infectious love to share, and the heart that beat for others…..became still. Very still.

A Father Till the End

It was 2 o’clock in the morning. I was on-call that night. I had to come back emergently to the hospital, and my medical resident and I had been working on this patient for the past 3 hours, trying to stabilize him. However, in spite of all the efforts, it seems like we were just spinning our wheels, without gaining traction.

In the past couple of hours we had (re)placed on him 2 central venous catheter, one in the neck (jugular vein) and one the groin (femoral vein) for  intravenous access and for dialysis access. We also inserted a tube in the side of his chest as his left lung did collapse (pneumothorax). We tried to restart his continuous dialysis after we replaced the catheter (the previous one malfunctioned), but we were met with hemodynamic problems. I added several intravenous drips to his already multiple ongoing medications (his bedside looks like an intricate web of  inverted bottles, tubings, poles, and catheters) to increase his blood pressure and regularize his heart rate, but it remained erratic. I played with different modes on the mechanical ventilator to keep his oxygenation half decent, but failed. In other words, he remained very unstable.

I really thought he would go, on my watch……

*****

He is a 41-year-old man. A father of 2 boys, and a good father at that, according to his wife. He had no previous medical history, in fact, he had never been to a doctor since his childhood days. However, he started not feeling well for more than a month, but he thought he just had a bad case of flu. And when he finally went to see a doctor, he was deemed very sick and got admitted to the hospital the same day. After a flurry of work-ups, he was diagnosed with acute lymphoma — a cancer involving cells of the immune system .

He was promptly started on chemotherapy. After a few days in the Oncology floor, he was moved to the ICU as his conditioned worsened. In his fourth day in the ICU, he deteriorated further as he developed pneumonia and went into respiratory failure, requiring intubation and mechanical ventilation. He then also went into septic shock (a grave condition from overwhelming infection causing life threatening low blood pressure). His condition became so serious, that I had a somber discussion with his wife, and told her that he may not survive this.

But that discussion was more than three weeks ago.

Since then, he continued to battle for his life. Different life-support machines had been added to his ICU room (mechanical ventilator, dialysis machine, stand-by external pacemaker and defibrillator). In his almost month-long stay in the ICU, one after another, his organs failed: lungs, heart, kidneys, liver, bone marrow, and gastrointestinal tract. He was poorly responsive, deeply jaundiced, swollen all over, and overall plainly looked awful. All of the different specialists involved on his case knew it was improbable that he would pull through this.

But he hanged on. Even with almost every organ system failing, the only thing that keeps on going was his will to survive. Somehow it tells us that he was still fighting. Still fighting for something. Yet, the spirit is willing, but the flesh is weak. Or in his case, the flesh is almost dead.

*****

That brings us to the night I was on-call.

After working on him furiously that night, I called his wife at 2 in the morning, and updated her of the situation. She knew it was time. She had seen him suffer enough. She was ready to let him go.

However, for some reason he still survived that night.

The following morning, the wife brought their 2 sons into the ICU to say their final goodbye. She had made up her mind to withdraw the life support, a decision that she was dreading to make for days, but had to eventually.

Their sons were 9 and 4 years old. The older one was obviously distressed and loudly crying. The younger one appeared lost, not fully understanding the gravity of the situation. The wife was as expected looked distraught, but trying to be strong for the sake of their 2 boys.

With his parents in the room, she leaned over to him and said: “I will take care of our boys, you can let go now.”

Not long after that, his blood pressure dropped further. His heart rate slowed down gradually and finally stopped. We did not even have to turn off any of his life support. He went, on his own.

I wanted to believe that those boys were always on his mind. Yes, even in his cloudy mind (made by his illness and medications). He was just waiting for the reassurance that they will be alright. And then he let go.

He was a father till the end.

I can’t let you go.

(picture from here)