Whenever I see Dr. J I think about Benito Mussolini. I can't quite explain it, but lately it has become a reflex of almost Pavlovian proportions - See figure walking down hall -> Recognize figure as Dr. J -> Think about Mussolini with dancing bundles of wheat around him.
"Why wasn't this patient extubated?", he would typically ask me, typically very early in the morning. If you don't know what "extubated" means, it actually doesn't matter, you can put any word there instead, like "violated with sunflower seeds" or "dressed like the little mermaid". It's the thought that counts, you see.
"I don't know, I just got here".
"Don't talk to me like that! I want to know who extubated her right now".
"Ok, who should I ask?", I turn my head for a second to get the patient's chart and grab the phone, but he already moved on to the nurse on bed 15 demanding to know why the patient had his urine bag on the right side of the bed, while he specifically demanded the bag be put on the left side of it.
He is a funny little guy. 5"5 with an extra inch from the shoes, it definitely has something to do with it. A little goat beard decorates his chin, and a noticeable-despite-all-efforts east European accent comes out of his mouth, which sometimes makes his temper tantrums funnier. He is a resident in his second year, which means he is actually not that high up in the food chain, and a food chain it is, but that is a story in itself.
I sometimes wonder about this guy. He mainly looks very lonely. I imagine him dreaming at night of little bundles of wheat, not too tall, doing all sorts of tricks at his command. Man, the intoxication of power. I wish I had dancing bundles of wheat at my command. I could do wonders. What will become of him in a few days, when he will no longer be able to order me around? He was clearly born to lead people, even if it is all the way to the river Styx.
Tuesday, August 25, 2009
Wednesday, August 12, 2009
Giving up
It is harder to withdraw care from a patient than to unsuccessfully treat him. There is a sense of "giving up" when you decide that the patient, and you, have had enough. You just can't treat him or her anymore. They are simply dying, almost dead, and there is nothing you can do about it. They are not conciouss, they have a tube down their throat, they are getting multiple drugs, and every now and then somebody moves them around, or gives them food through the veins, or cleans their shit. That, obviously, can hardly be called a life. Though it is, still, kind of, maybe, who the hell knows.
And then, after the patient only keeps getting worse, and basically it's your chemicals that are keeping him alive, in some form or another, and then all these infections do their thing, and decubitus ulcers every now and then, and when you get swollen as a balloon, and your balls are the size of a tennis ball, and you hardly have any lungs left, you can almost feel that this thing is not human. It was, at some point, not long ago, just a few days, but now everything seems helpless.
This was the case with Mr. B in bed 5. He was most probably drunk and hit by a car, and it all went downhill from there. At first we thought he might actually make it. At some point we even considered getting him off the vent so he can breath on his own. But then his lungs got crappy, and red stuff came out of his feeding tube, which was obviously blood. And then he couldn't keep his blood pressure up, and he needed three kinds of prsesure meds. Usually in medicine we try to keep people's pressure down, but this guy's blood pressure was so low we actually had to bring it up again. And of course infections didn't pass on this poor alcoholic, and his liver wasn't doing too great to begin with, and the last time i saw him blood was coming out of his eyes. Now you don't need to be a rocket scientist, or a doctor, for that matter, to know that this is a very bad sign.
Quickly thereafter we tohught it might be a good idea to withdraw care from this poor soul and let nature take its course. Although we can be very persuasive, this decision is not up to us, but up to his family, which was somewhere in mexico and either too busy, too poor, or without the right papers to cross the border and see their uncle. Eventually they did come, and did agree, and saw his gasp his last breaths, and then he died.
I saw him quite often during his last days on this planet. He always seemed in such pain and agony. Always breathing from the top of whatever lungs he has left, gasping for air. But today he didn't move so much. In fact, he didn't move at all. His room was quite still. I don't think there was one molecule of air in the room that was moving. Everything stayed in place.
That's the way life is in the ICU, that is usually how they go. They just do.
Having a patient die in the ICU is different than having them die in the wards. I say "different" and not "better" or "worse" because that's what it is - different. It is both better and worse. On the one hand you don't know them personally, because from the moment you got them they were unconcious (usually. If they get better to the point which they can talk to you and then die on you, you usually feel like jumping out the window). On the other, you don't know them, and the questions keep pricking you - who were they? what was their story? What do they look like standing and walking? Probably very different than the edematous face and bleeding conjunvtivae they sometimes have in the ICU. What were they like when they were kids? What did they want to do when they grew up?
I find myself asking these questions over and over when our patients comes and go. In the wards your patients are concious and go home, so there is less of a mystery. In here, it is all guessing. Sometimes it feels like a prodcution line. They show up, you load 'em on the bed, you start pokin' 'em 'n' movin' 'em and radiate their pants off with CT and daily X rays, and the occasional MRI, and then you have other people evaluate them, like a Neurosurgeon, or a Respiratory therapist, or a dietician, and all that jazz, and once you're done they are usually not dead, and you move 'em on to the next station, which is usually rehabilitation or what we call a "regular bed", meaning just hospitalization in the wards for a bit longer.
That's what it sometimes feels like when you are overworked, and not sleeping enough. Dr. Eden was my teacher, and he was (or is?) and anestehsiologist turned ICU. And on the first year of medical school he talked to us, and introduced me to an outrageous concept: "We don't heal people", he said, "we provide them with the means to heal by themselves". Now was is that crap all about? I tohught we are the big smart docs and our patients make it just because of us. My short experience in the medical field taught me otherwise. It's amazing how much we don't know, and how, like Mr. K, some people make it and how, like Mr. M, some people simply don't.
And then, after the patient only keeps getting worse, and basically it's your chemicals that are keeping him alive, in some form or another, and then all these infections do their thing, and decubitus ulcers every now and then, and when you get swollen as a balloon, and your balls are the size of a tennis ball, and you hardly have any lungs left, you can almost feel that this thing is not human. It was, at some point, not long ago, just a few days, but now everything seems helpless.
This was the case with Mr. B in bed 5. He was most probably drunk and hit by a car, and it all went downhill from there. At first we thought he might actually make it. At some point we even considered getting him off the vent so he can breath on his own. But then his lungs got crappy, and red stuff came out of his feeding tube, which was obviously blood. And then he couldn't keep his blood pressure up, and he needed three kinds of prsesure meds. Usually in medicine we try to keep people's pressure down, but this guy's blood pressure was so low we actually had to bring it up again. And of course infections didn't pass on this poor alcoholic, and his liver wasn't doing too great to begin with, and the last time i saw him blood was coming out of his eyes. Now you don't need to be a rocket scientist, or a doctor, for that matter, to know that this is a very bad sign.
Quickly thereafter we tohught it might be a good idea to withdraw care from this poor soul and let nature take its course. Although we can be very persuasive, this decision is not up to us, but up to his family, which was somewhere in mexico and either too busy, too poor, or without the right papers to cross the border and see their uncle. Eventually they did come, and did agree, and saw his gasp his last breaths, and then he died.
I saw him quite often during his last days on this planet. He always seemed in such pain and agony. Always breathing from the top of whatever lungs he has left, gasping for air. But today he didn't move so much. In fact, he didn't move at all. His room was quite still. I don't think there was one molecule of air in the room that was moving. Everything stayed in place.
That's the way life is in the ICU, that is usually how they go. They just do.
Having a patient die in the ICU is different than having them die in the wards. I say "different" and not "better" or "worse" because that's what it is - different. It is both better and worse. On the one hand you don't know them personally, because from the moment you got them they were unconcious (usually. If they get better to the point which they can talk to you and then die on you, you usually feel like jumping out the window). On the other, you don't know them, and the questions keep pricking you - who were they? what was their story? What do they look like standing and walking? Probably very different than the edematous face and bleeding conjunvtivae they sometimes have in the ICU. What were they like when they were kids? What did they want to do when they grew up?
I find myself asking these questions over and over when our patients comes and go. In the wards your patients are concious and go home, so there is less of a mystery. In here, it is all guessing. Sometimes it feels like a prodcution line. They show up, you load 'em on the bed, you start pokin' 'em 'n' movin' 'em and radiate their pants off with CT and daily X rays, and the occasional MRI, and then you have other people evaluate them, like a Neurosurgeon, or a Respiratory therapist, or a dietician, and all that jazz, and once you're done they are usually not dead, and you move 'em on to the next station, which is usually rehabilitation or what we call a "regular bed", meaning just hospitalization in the wards for a bit longer.
That's what it sometimes feels like when you are overworked, and not sleeping enough. Dr. Eden was my teacher, and he was (or is?) and anestehsiologist turned ICU. And on the first year of medical school he talked to us, and introduced me to an outrageous concept: "We don't heal people", he said, "we provide them with the means to heal by themselves". Now was is that crap all about? I tohught we are the big smart docs and our patients make it just because of us. My short experience in the medical field taught me otherwise. It's amazing how much we don't know, and how, like Mr. K, some people make it and how, like Mr. M, some people simply don't.
Monday, August 10, 2009
Basic things
Mr. S has a bleed inside of his skull, but mostly he misses his mom. His wife is standing next to his bed in the ICU, and so are his daughters. They are all extremely worried.
He has never been like this. Ever since his mother died he had not been the same. In fact, he was quite devastated. And when he started getting dizzy a couple of days ago, he knew why. And when the world was really spinning around him, until he fell right on the concrete floor, he was still thinking about his mom.
Other than a small bleed around his brain he was actually ok. He really scared us at first, because he lost his consciousness. The older you get, the less you appreciate blows to your head, or bleeds around your brain, or just a plain loss of consciousness. Your body starts taking it rather personal, and overreacts. You bleed more, and you heal less. But Mr. S was able to save himself from the statistics. He was really doing ok, except he really missed his mom.
"The Rosary is Tuesday, can I go?", he asks me, his eyes imploring. When he first told me his mom had died, I thought I didn't hear him well. To be perfectly honest, I also thought he is being delusional. We often see ICU psychosis. The name is pretty straightforward, and it means that all the pain, physical and emotional trauma, the daily needle poking, shitting in a diaper, not getting any sleep except on meds that can put down a horse, and all that jazz - can really mess you up. And drive you a little insane. And the older you get, the more at risk you are. And I thought he is being like that.
I mean, He looked like a grandfather himself. In fact, he WAS a grandfather. And we tend to assume grandfathers were just like that all the time, unaware of the lifetime they had gone through, and the fact that they, too, were someone's little child. "I promise I will do everything I can to make it happen", "but you have to help me, too". I thought to myself that this is a great bargaining opportunity. "Try to get some rest, and even sleep. You need your strength. We can't let you go if you are not in good shape". We made a gentleman's agreement that each will do his share, and waited for the next morning when the big boss will actually decide what to do.
We put a lot of effort in Mr. S's expedited management and probably took some risks, too. We got a social worker and a case manager on it, and managed to work it so he will be able to see his mom. Hell, I still don't even know what a Rosary is. I only know it was important enough for that little child that wanted to see his mom one more time.
He has never been like this. Ever since his mother died he had not been the same. In fact, he was quite devastated. And when he started getting dizzy a couple of days ago, he knew why. And when the world was really spinning around him, until he fell right on the concrete floor, he was still thinking about his mom.
Other than a small bleed around his brain he was actually ok. He really scared us at first, because he lost his consciousness. The older you get, the less you appreciate blows to your head, or bleeds around your brain, or just a plain loss of consciousness. Your body starts taking it rather personal, and overreacts. You bleed more, and you heal less. But Mr. S was able to save himself from the statistics. He was really doing ok, except he really missed his mom.
"The Rosary is Tuesday, can I go?", he asks me, his eyes imploring. When he first told me his mom had died, I thought I didn't hear him well. To be perfectly honest, I also thought he is being delusional. We often see ICU psychosis. The name is pretty straightforward, and it means that all the pain, physical and emotional trauma, the daily needle poking, shitting in a diaper, not getting any sleep except on meds that can put down a horse, and all that jazz - can really mess you up. And drive you a little insane. And the older you get, the more at risk you are. And I thought he is being like that.
I mean, He looked like a grandfather himself. In fact, he WAS a grandfather. And we tend to assume grandfathers were just like that all the time, unaware of the lifetime they had gone through, and the fact that they, too, were someone's little child. "I promise I will do everything I can to make it happen", "but you have to help me, too". I thought to myself that this is a great bargaining opportunity. "Try to get some rest, and even sleep. You need your strength. We can't let you go if you are not in good shape". We made a gentleman's agreement that each will do his share, and waited for the next morning when the big boss will actually decide what to do.
We put a lot of effort in Mr. S's expedited management and probably took some risks, too. We got a social worker and a case manager on it, and managed to work it so he will be able to see his mom. Hell, I still don't even know what a Rosary is. I only know it was important enough for that little child that wanted to see his mom one more time.
Friday, August 7, 2009
the saddest room in the ICU
Room number 9 is usually dark and a little chili. Although in the middle of a busy intensive care unit, it is surprisingly calm. A clean smell comes out its door, and the windows are half shut. Mozart's 21st concerto is playing calmly, very appropriately at the Andante chapter. It is the room of Mr. K, and it holds the questionable title of being the saddest room in the ICU.
Mr. K had a seizure disorder and a dad. The three of them lived in a small place far from anywhere. Dad was sick and K took care of him, but he didn't want to take care of his seizure disorder.
"Take your pills", dad said to his only son, but K was a big guy who didn't want to, for reasons we will never know. I am wondering what he sounded like. Did he have one of those deep voices? Did he have a Spanish accent?
One day dad came back and found K on the floor. Being disabled, it took him a while to get to a phone, but even that didn't matter much - with the nearest hospital 70 miles away, Mr. K was clearly having odds against him, and since that moment of being found unresponsive by dad he remained so. A quick imaging survey done at a hospital revealed he had a very bad stroke and also, for whatever reason that we will never know, he broke his neck.
And he has been here ever since. At first we hoped that he would get better. Every day I would check his Glasgow Coma Score, pinch him here and there, and ask him to blink his only open eye. But he would move his eyes randomly across the room and not quite follow my orders.
Maybe he IS seeing things, but just things I myself cannot see. Maybe he is alive and alert, but in a different world. Our minds are our souls are our hearts, and they are full of wonderful, magnificent worlds. Maybe he does exist on one of them, chewing on a freshly picked mango or dancing a tribal dance with a well developed mulatto.
But we are not seeing it here, on our part of the world. we just see Mr K lying there in his dark room, listening to Mozart.
Nurse R likes Mozart. She is a round, very talented ICU nurse that likes to work nights. "Too many people around during the day", she says. She is taking care of Mr. K, and figured that since he is not moving and most of the time stares at the ceiling with his one eye, he might as well listen to some good quality music. If he is not a fan, he will be by the time she is through with him. Stranger things have happened in the ICU, believe me.
In the meantime she is taking care of his ventilating machine, recording his heart rate, giving him medications, and counting exactly how much he peed. I recognize her hand writing by now, and she is the only nurse that would write the patient had peed 1500.35 milliliter during the day. She is quite thorough.
Until yesterday Mr. K was CMO, which is a clean word for a dirty meaning - Comfort Measures Only. So we only need to keep Mr. K comfortable, until he dies. For example, give him pain medicine. This was in agreement with his dad, which never comes to visit.
I really hate CMOs, and I didn't think Mr. K deserved it. First, he was moving his eyes! (ok, eye). Now that can be a meaningful thing. If you haven't seen the film "The butterfly and the diving bell", now would be a good time to do so. Second, he was on sedating medications, which might make him even worse than he really is. Third, he broke his neck! So we can't quite expect him to move his 4 limbs now can we? And fourth, he is still recovering from his injury... Maybe, perhaps, he would be better once his injuries healed a little?
As crazy as it may sound, sometimes Mr. K's quiet little room, with his Mozart and devoted nurse R feels to me like an island of sanity in our crazy ICU. I sure will miss him when he leaves, wherever that might be, and wish him lots of fun and light with his mangoes and dancing mulattoes.
Mr. K had a seizure disorder and a dad. The three of them lived in a small place far from anywhere. Dad was sick and K took care of him, but he didn't want to take care of his seizure disorder.
"Take your pills", dad said to his only son, but K was a big guy who didn't want to, for reasons we will never know. I am wondering what he sounded like. Did he have one of those deep voices? Did he have a Spanish accent?
One day dad came back and found K on the floor. Being disabled, it took him a while to get to a phone, but even that didn't matter much - with the nearest hospital 70 miles away, Mr. K was clearly having odds against him, and since that moment of being found unresponsive by dad he remained so. A quick imaging survey done at a hospital revealed he had a very bad stroke and also, for whatever reason that we will never know, he broke his neck.
And he has been here ever since. At first we hoped that he would get better. Every day I would check his Glasgow Coma Score, pinch him here and there, and ask him to blink his only open eye. But he would move his eyes randomly across the room and not quite follow my orders.
Maybe he IS seeing things, but just things I myself cannot see. Maybe he is alive and alert, but in a different world. Our minds are our souls are our hearts, and they are full of wonderful, magnificent worlds. Maybe he does exist on one of them, chewing on a freshly picked mango or dancing a tribal dance with a well developed mulatto.
But we are not seeing it here, on our part of the world. we just see Mr K lying there in his dark room, listening to Mozart.
Nurse R likes Mozart. She is a round, very talented ICU nurse that likes to work nights. "Too many people around during the day", she says. She is taking care of Mr. K, and figured that since he is not moving and most of the time stares at the ceiling with his one eye, he might as well listen to some good quality music. If he is not a fan, he will be by the time she is through with him. Stranger things have happened in the ICU, believe me.
In the meantime she is taking care of his ventilating machine, recording his heart rate, giving him medications, and counting exactly how much he peed. I recognize her hand writing by now, and she is the only nurse that would write the patient had peed 1500.35 milliliter during the day. She is quite thorough.
Until yesterday Mr. K was CMO, which is a clean word for a dirty meaning - Comfort Measures Only. So we only need to keep Mr. K comfortable, until he dies. For example, give him pain medicine. This was in agreement with his dad, which never comes to visit.
I really hate CMOs, and I didn't think Mr. K deserved it. First, he was moving his eyes! (ok, eye). Now that can be a meaningful thing. If you haven't seen the film "The butterfly and the diving bell", now would be a good time to do so. Second, he was on sedating medications, which might make him even worse than he really is. Third, he broke his neck! So we can't quite expect him to move his 4 limbs now can we? And fourth, he is still recovering from his injury... Maybe, perhaps, he would be better once his injuries healed a little?
As crazy as it may sound, sometimes Mr. K's quiet little room, with his Mozart and devoted nurse R feels to me like an island of sanity in our crazy ICU. I sure will miss him when he leaves, wherever that might be, and wish him lots of fun and light with his mangoes and dancing mulattoes.
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