I’ve been bad about following my fellow medbloggers lately, for which I am sorry. I have just checked in with Second Shift, and wonder of wonders, he is accepted to med school!

Go over and say Congratulations. It’s hard to get into med school.

It’s always a little scary to see a patient that is your age. It’s a lot scary when they match your demographics. It’s scarier when they share your birth month. It reminds you inevitably of your own mortality, of how fleeting our grasp on this strange and magnificent little life is.

Today in our ICU, I had to do brain-death criteria on a patient who was, demographically speaking, almost my twin. Mid-twenties, married, middle-class. He had been doing some work around the house when an object fell from a shelf and struck him with a great deal of force in the back of the skull. His brain bled massively.

I was called into the room by the attending ICU physician. The patient lay in repose on the bed, surrounded by family, his young wife sobbing uncontrollably at the foot of the bed. He was eerily still and quiet; there is something about a living body absent a functional brain that is quietly disturbing.

He had failed Dolls Eyes. He had failed caloric testing. He didn’t bat an eyelash to incredibly painful stimuli. It was time for the apnea challenge.

I drew back blood from the arterial line and handed it to my cohort to analyze. Minutes later the results were in: 7.40, 36, 515, 24. Perfect numbers. The physician nodded at me and I disconnected the ventilator, threading a small oxygen catheter down the ET tube.

The room was silent. All eyes were on the patient. He was still. No chest rise, no shaking, no neck motions, no jaw twitches…just a perfect stillness.

The young wife continued her grieving. Five minutes passed and I drew another ABG from the a-line. Results came back: 7.20, 68, 480, 24. A complete failure.

The young man was brain-dead. I put him back on the ventilator and watched the realization sink in on the family’s faces. The doctor signed the declaration. An hour later we repeated the test with a different doctor and a different RT, just to make sure, and the patient remained brain-dead.

An hour after that, we discontinued all support. Shortly later the young man died. 25 years old. Barely beginning to strike out on his own, another 50 years or so before him, and due to a freak accident he was dead.

It makes you think. It makes you prioritize. It makes you re-evaluate your decisions. If I died tomorrow, would I have spent my life doing good things? Would I have enjoyed it? Would I have many regrets, or many happy memories? These questions plague me. They raise the questions of virtue, questions of the afterlife, questions of what we are supposed to do with our frightfully short and impermanent lives.

I think about these things a lot. Sometimes when I wake up, I realize that one of these mornings will be my last. I realize that I have not really enjoyed much of the prime of my life. I realize that I have made decisions that have affected my entire life and led me to where I am today, somewhat bewildered and uncertain and definitely not in a place I want to be.

That of course leads me to think: what do I do with this knowledge? How can I improve my life, make decisions that are likely to move me back in the direction of the life I want instead of the life I have been living? Should I even do that? Would that make me less appreciative of the days I have until I achieve my goal? And what of the irony that I have these realizations and do nothing with them, thus furthering the urgency of the questions?

It’s a scary place to be sometimes, in my mind. Time to retire and think on things. I hope not to be struck on the head in a freak accident anytime soon. I don’t have any of the answers I need.

It has been eerily quiet lately at the hospital.

The corridors echo when you walk them. The ER is less full of people than usual, the hallway stretchers neatly made up and awaiting patients to hold.

The ICUs are quieter than usual. Fewer alarms ring with fewer patients.

The storeroom is full of disused ventilators, CVVH machines, thermal/cooling blankets, and balloon pumps.

The ambulance bay is empty.

A cricket chirps. Somewhere, a news anchor ponders a package of ham and wonders why the dreaded swine flu has not caused a pandelerious explosion at the hospital.

This is very, very strange for mid-November. I thought for sure I would have an entertaining story to tell…but I guess I don’t. Send some patients this way, if you have any.

For Respiratory Care Week this year, our department head got us a poster that says “Happy RT week. Now get back to work, you ingrateful bastards.”

No! I jest. Our department may be badly run, but the management is at least making an honest and heavy effort to recognize us for RT week. There is a CEU blitz, a few free lunches, a few fun and festive moments, and generally a good time. RT week is the one time of the year where everyone in the hospital is made aware of our department and the work we do, and I’m glad we get the recognition and credit at least once.

New (but not “new” any more) Nurse Jane has written a lovely tribute to RTs everywhere. Thank you, Jane, for the kind words and the affection!

And, to all RT and non-RT readers, happy respiratory care week!

A commenter who is a veterinarian has made some intriguing and well-thought out comments lately, and it reminded me of a story from the vet that happened to me not too long ago.

We took our cat to the veterinarian recently because he has been scooting his ass across the floor and we were worried he might have worms, or possibly some sort of anal gland blockage. We corralled him into the kitty carrier, sprinted to the car before he shredded the carrier from the inside, and then drove to the vet, accompanied by the melodic and high-volume protest singings of our feline friend.

We got to the office, got into the exam room, and produced the cat. Our vet, a kindly older man who walks with a cane, ambled into the room, glanced at the chart and then looked at our cat.

“Well, there’s the problem, right there. Your cat’s a fatty. He’s too fat to lick his butt, so he scoots on the floor. He needs to lose some weight…that’s diabetes waiting to happen. Is he lazy? Looks like a couch potato…most fat cats are. You need to put him on a diet and get him some exercise.”

I was stunned, then awed by our veterinarian’s honesty. Instead of hemming and hawing, he was direct and to the point. I half expected him to get a megaphone and say “YO! GIVE THE DAMN CAT LESS FOOD!”

He took the time to explain to us that not only was our cat way too fat at 18 pounds, but that being fat can cause the full range of illnesses in cats that it can in humans, from vascular problems to diabetes. He told us that since we can’t really let him be an outside cat, we should play with him more, feed him less, and look into some sort of diet food.

The whole time we were at the vet I was struck by how direct and honest this man was. It got me to thinking: why aren’t human doctors like this?

I mean, I can’t tell you how many times I’ve seen doctors let people slide on things. Instead of telling people that they will die if they don’t stop smoking and drinking heavily, they chicken out and avoid discussions about that lifestyle. Instead of telling people that living an inactive life will clog their arteries and lead to stroke and heart failure, they ignore these facts and simply avoid the unpleasant confrontation about defective lifestyles. Where is the candor? Where is the honesty? If my veterinarian can have an honest and frank discussion about the way we care for our animal, why can’t the pediatricians at work tell parents that their kids are fatties and they should avoid Burger King? Instead of “Oh, he’s a husky boy!” we need to hear “Sweet Jesus that kid is fat! What are you feeding him? How about you put down the fucking fork, madam, and get involved in your childs health instead of blaming everybody else for your failed parenting? Society didn’t buy him that cheeseburger…”

It seems to me that the medical establishment is unwilling to be honest with people about the way that their choices affect their health. Maybe if human physicians could take a cue from their veterinary cousins, modern medicine would work a little better. I know if I could find a human doctor who was as honest and frank as our vet, I’d see him until he retired.

The death of a loved one can be hard to accept. Watching a family try to deal with an unexpected death is not one of my favorite things in this job.

The patient in room 12 had been here for weeks. After an unfortunate cardiac event on the medical floor, he went from being a “walkie-talkie*” to being totally sedated, on the ventilator, on continuous dialysis, with a host of a dozen IV pumps whiling away at his side.

His poor wife was unprepared for this. What she had assumed would be a routine hospital stay had turned into a nightmare of epic proportions; machines, tubes, hoses, swelling, bleeding, oozing discomfort in the 24-hour maelstrom of our busy ICU.

Today, after a long and difficult discussion with one of our ICU specialists, she decided to let her husband go. She had given him a fair chance but it was the end of the road for him, and she knew it. We waited until she and her friend were ready, and then extubated him and D/Ced his pressors, dialysis, and all IV meds but Morphine for comfort. We swept the equipment from the room and rushed the family back inside so they could be with their dying loved one. Watching from the monitor, it took about two minutes for his heart to stop beating; I never did see any independent breaths. I took a deep breath and walked away to clean the ventilator from his room, and didn’t give it too much thought.

An hour and a half later, I happened to walk past the room and an odd sight was before me. The wife and her friend were seated next to the bed, wife holding the dead mans hand, coffee cups out on a small bedside table between the two ladies. They were chatting and laughing and reminiscing, and they were speaking to the dead man as if he were present. The nurse saw me staring and we watched these old ladies from a distance for a moment.

“Oh my god!” the nurse said. “Look at the monitor!” On the bottom of the heart monitor was a rhythm strip, beating away. She had forgotten to unset the remote monitoring for her other patients, and the family–seeing the heart beating on the screen–believed that the dead man was not, in fact, dead.

The nurse went in, pushed some buttons, and removed the strip. She explained to the family that the patient was in actual fact deceased, and had been for some time. The wife continued holding her dead man’s hand, sipping coffee all the while, and told the nurse

“I know he’s gone. But I need to talk to him some more…I just need to talk to him.”

Out of some weird compassion we let them stay and chat. They were in there with him for two more hours, reminiscing and talking, before they left and we took him to the morgue. They’d have stayed longer, but all the coffee they had been drinking had made one of the old ladies crap in her pants.

Elderly women drinking coffee with a dead man and then leaving his side only when forced to by an unfortunate loss of bowel control. I hope there’s more to getting old than this.

Such is life and death in the ICU. So much for dignity, so much for pathos.

*Able to walk and talk

Holy Cow, I haven’t posted here in a long-ass time. Sorry, loyal readers; many things have been afoot here on the other side of the internet.

I have a few fun things to write about, which I’ll try to post over the next few days. It’s the usual assortment: tragicomic moments in the ICU, issues with death and dying, rants and raves about things that infuriate me.

I’ll try not to leave y’all hanging for another month. More to follow soon.

All these are things that have been said to me on the medical floors within the last week:

“Jesus fucking Christ, another breathing treatment? I don’t even take these at home. My doctor ordered it? Why would he do that? If you don’t know, why are you even giving it to me?” I have to give props, this is an excellent question.

“Why do you need MORE blood from me? The nurse just took eight vials! It’s the same blood in my veins and arteries, I know it is, there’s no difference! You can’t fool me, I went to nursing school for a semester last year…you just want to run medical experiments on me!”

“No, I don’t want a breathing treatment. Have you lost your fucking mind?”

“So, what are you, some kind of candystriper? What’s that? You went to school for this? Wow…why?”

“Man, I never even seen the dude. I don’ even know who he was. He jus’ come up to me and stab me, jus’ like that!”

“No, no, I don’t think I need any breathing exercises. I haven’t even picked up that sucking tube there. You should check with my Doctor first. …What do you mean, he ordered it? No, he didn’t. I don’t believe you. Can’t it wait until after Jeopardy?”

“Breathing treatment? Oh, that thing? Yeah, I guess I’m supposed to take them at home…I do it maybe a few times a day if I feel like it…yeah, about two packs a day, but that’s not why I’m sick! I’m sick because of that H-A-1-1 thing…yeah, the flu. Naw, smokin’s not bad for you. I guess I’ll take your dumb treatment if it’ll make you happy.”

One thing patients never say:

“Gosh, thanks for doing your best to help me feel better.”

I have to tell you, I love what this job could be. The idea of making people’s lives better by making it easier for them to breathe is awesome. But in reality, we waste a lot of time dealing with treatments that are not indicated. We waste a lot of time trying to convince noncompliant patients that they need their therapy, which they will refuse to take. Sometimes, this burns…me…out.

Tomorrow: Things Family Members In The ICU Say!

I was working in one of our ICUs last week. One of my patients was a kindly little old lady of 96 years. She was a soft-spoken, tiny, shriveled little thing, but she was sweet and alert and fully capable of interacting with the staff beyond the usual condescenscions of “Awww she’s so CUTE.” If one were to actually talk to her like a human being instead of talking down to her like so many healthcare providers do, she was just the coolest person in the ICU. A youngun’ like me can learn from a soul of 96.

At 96 years old, she was ready and prepared to pass away. “I don’t want to live forever,” she told me. “I’ve done what I needed to do.” She had a fully signed and witnessed DNR/DNI form and wanted no aggressive care.

Her family, a staunchly religious group of people, would hear nothing of it. They demanded that we do everything for their mother. They wanted ABGS, they wanted full-blown diagnostics, they wanted a dramatic full-on assault. Despite their mothers pleas that she wanted to be left alone to live out her final days in peace, they talked over her and demanded that she rescind her DNR, which she refused to do.

The attending physician agreed with them, talked with the patient, and ignored her. The nurse and I were at the bedside when he was trying to talk this awake, alert, competent, and reasonable 96-year-old woman out of her DNR. Her nurse couldn’t take it any more.

“Do you want all of this, or do you want to go home?” she asked the patient.

“I want to go home. I want to go to heaven. I don’t want any of this.”  The doctor, not one of my favorite clinicians, stared at her in disbelief.

“Get me a psyche consult, and an ABG.”  I was dumbfounded. The nurse got red in the face and raised her voice.

“A PSYCHE consult? You’re the one who needs a psyche consult! This lady is perfectly capable of making her own decisions!”

“It’s not normal to want to die! Just because she wants to go doesn’t mean we can push her off the cliff!”

At this point I interjected.

“We’re hardly pushing her off a cliff. Everybody has to die sometime. She’s 96. She’s a grown-up. She can make her own decisions.”

“Well, I don’t think it’s normal. I want a psyche consult. And an ABG. She must be hypoxic or something.” I stared at him, amazed. My fists clenched. I wanted to punch him in the face. “I’ll be sure to get right on that,” I told him, and then I walked away.

—-

I  never did get the ABG on that patient. Psyche came to see her, declared her competent to make her own decisions, and left. Last time I saw her, her family was still trying to weasel us into doing drastic measures for their mother. They called in their priest to try and guilt her into rescinding her DNR. They prayed over her bed and asked God to expel the demons from her that were possessing her. I believe in God but I don’t believe in the kind of religion that warps a mind that badly; there’s nothing holy about what those people were doing.

I hope to God we didn’t do anything drastic after I left my shift. That lady was ready to go, and if her time was up, I hope we let her go in peace instead of subjecting her to the horrors of the modern ICU that she explicitly stated she did not want.

Why is it so hard for people? Why is it so hard for Doctors of all people? Somewhere I heard the phrase “All that lives is born to die,” and there’s a lot of truth to that. I know that it’s hard to say goodbye, but the fact is that nobody on the planet will live forever. Knowing that your loved one has to die, why would you deprive them of their autonomy in the last days of their life? Why would you inflict on them sufferings that they have specifically asked to avoid? Why would you do that to someone? There’s no going back from that, no time to heal those wounds. You put your loved one through something they didn’t want, and then they die, there’s no time for them to forgive you.

Sometimes, what we do in the ICU makes a world of difference and can recover someone, lead them along the first steps to the road of recovery. I’ve seen patients in the ICU do exceptionally well and come walking back in, months and months later, to say thank you. But there’s a dark side. I’ve seen us do a lot of painful, pointless things to people who will never recover. And thinking ahead to my own eventual demise, I can only hope that when the time comes for me, it’s a natural and peaceful end to a life well lived, not a chaotic and frantic death amid the insanity of the ICU.

While browsing Second Shift I found a link to an interesting USA Today article about 24 hours in the ER. Worth a quick read.