Saturday, May 31, 2008

Let me go

Mrs. Hardy is quite clearly doomed. She had a gastric bypass operation (she weighs more than 400 pounds). If anyone knows whether the hernias she developed afterwards had anything to do with the surgery, they are not saying. We have our suspicions. In any case, the hernia repairs left her with infected, perforated bowels which did not get better. When I first took care of her, all but 30 cm of her small intestines had been removed. For a couple of weeks she had been opening her eyes and looking around the room, but had been unable to respond to her name or connect with anyone. The 3’X 4’cavern where her guts once were was now filled with black vacuum sponges and covered with an airtight dressing. Two suction tubes hooked into this dressing pulled about a liter of pinkish yellow fluid off every hour and it was the nurse’s responsibility to measure this and infuse an equivalent amount of IV fluid every hour of so to prevent her from becoming dehydrated.

Any nurse knew within 5 minutes of starting to take care of Mrs. Hardy that she did not have a prayer of getting better. We see it all the time. This is going to be nothing but a long, drawn out, agonizing death. A nurse of some experience once explained to me, without any malice, that morbidly obese patients are like whales and the bed is the beach. The longer they are trapped in bed, the harder it is for them to get back up. In bed they develop sores, their muscles waste away, infections set in and they end up “circling the drain.” So when I heard in report that Mrs. Hardy had been listed for a small intestine transplant, I was disgusted. This would be nothing short of a science experiment. She was already too far gone to get better even if her intestines were intact. There is something very evil about the whole transplant industry, but I will write about that another day. I decided to make it a priority to get the palliative care team involved in managing her end of life care

Mrs. Hardy’s pain medications had been stopped more than a week ago when it was noticed that she was not responding. Still no change. I got into a difficult spot with the attending physician when, upon being asked, I mentioned the possibility of brain damage to the family. I expected that, after more than a week, I would not have been the first to do so, but Mrs. Hardy’s daughter had become alarmed. “Brain damage! No one has said anything about brain damage!” I went with some urgency to try to get the attending to speak with them and was chastised. All of her brain scans were negative for damage. Her condition was related to her blood infections and although it might well be permanent, I should not have said “brain damage.” He was annoyed at this extra task I had now forced on him. I thought about how I could have said it differently, but could not come up with anything.

The palliative care nurse, Susan, came by in the morning to see another patient (palliative care is often busy in the surgical ICU) and I caught her in the hall. I gave her a quick summary and my conclusion that Mrs. Hardy should not be used as a guinea pig. She agreed and asked me to page her so that she could be present for rounds. I did so, and when the physicians were discussing Mrs. Hardy’s case, Susan asked directly if they felt it was appropriate for her to be involved. The attending physician replied very much in the affirmative. Even if everything went perfectly, Mrs. Hardy would still have no quality of life.

Monday, May 26, 2008

Anything important to say?

Mr. Lewis had been an alcoholic and a house painter. The two had not mixed well for him when he fell off his ladder, broke his neck, and became a quad. While he could not move his arms or legs, he still had sensation. Unable to breathe or swallow on his own, he was “trached and pegged” – a ventilator tube in this throat and a feeding tube directly into his stomach. He was a “clicker.” Because of the sore on his behind or his past tendencies or maybe just his personality and a need to feel some sort of control over his fate he would constantly click his tongue to call his nurse or anyone who happened to be passing by to his aid. He wanted to be drugged as much as possible and watched the clock, keeping track of the time for his next dose of narcotics. Every two hours, about ten minutes before the dose was due, he would start to click even more. Even the most obliging nurses quickly become exasperated with this type. You cannot walk by the room without being called in, and in the end, there is not much more you can really do for them. You have another patient and other work to do. You draw the curtains so he can’t see you and avoid going in the room more than necessary. Coming up behind his nurse and clicking your tongue (it is an easy sound to imitate) elicits rolled eyes and a look that says, “he’s driving me crazy!”

On a day when he was my patient some family came. They asked to have the cuff on his trach let down so he could talk. He was being weaned from the ventilator and was breathing on his own for a couple hours at a time. If the seal around the trach was deflated, he would be able to force air though his vocal chords and speak. Not sure of his stage, I went to find the respiratory therapist. Today it was someone I had not seen before, and I would not see her again either. “Mr. Lewis would like to have his cuff down so he can speak.” I said as she sat at one of the computers at the nurse’s station. “Why?” she shot back, “Does he have anything important to say? Like ‘withdraw care?’” It is a familiar sentiment, although not often expressed so directly. A bit hard hearted for my tastes, but remember, we are all paying for the millions of dollars worth of healthcare that Mr. Lewis is receiving (this is why health insurance costs so much) and the guy screwed himself up and doesn’t even appreciate any of it.

I half played along and smiled, “Okay, I will let his family know you said that.” I made as if to head back to the room. We exchanged friendly, communicative looks and I went back to the room. “The respiratory therapist is on her way.” I said.

Wednesday, May 14, 2008

Feeding Tube

Mr. Smith had a large blood clot in his brain. He had come to the SICU to be evaluated for an experimental procedure where a catheter would be advanced through blood vessels to the brain and a clot digesting enzyme would be injected directly into the clot. It did not take a brain surgeon to know that this would be an extremely high risk procedure. The enzyme, Alteplase, is used most commonly as an emergency intervention for heart attacks. The principal danger of using it is that it can cause head bleeds. The thought of injecting it directly into an area where there was already a bleed was giving me pause. I do not know very much about brain surgery though, and I was waiting to see how things would unfold. If the procedure was going to be done, there was only a 48 hour window after the initial bleed to do it in. Less than 24 hours of that window remained when I began taking care of Mr. Smith. He would need a CAT scan with injection of IV contrast to map out the blood vessels in his brain. This would require a good IV in Mr. Smith’s arm, but we had not been able to get one so far. I asked for help from the techs and nurses who were “good sticks” and they tried again and again, but no one was able to find a vein.

As the doctors rounded on Mr. Smith my suspicions seemed to be confirmed. The surgical Attending, the senior doctor on the unit expressed disapproval. Mr. Smith had left sided paralysis, but was mentally intact. There was some chance of making him a little better, but a good chance of making him a lot worse. The resident was undeterred in his enthusiasm, however, and I sensed the involvement of another team of surgeons who were not now present. Perhaps this was why the attending stopped short of calling off the procedure outright. One has to know the limits of one’s influence and choose battles wisely. His objection now registered, the attending shrugged his shoulders and moved on to the next case.

The resident now came to Mr. Smith to get consent for the procedure. He spoke in simple terms of the clot in his brain. Mr. Smith knew about the clot in his brain. The resident made his pitch, “What if I told you that I could get that clot out and all I would have to do was make a small hole in one of your blood vessels?” My jaw began to clench, but then Mr. Smith belted out, “No invasive procedures!” as if he was burping. The resident tried again, but Mr. Smith only repeated his mantra adding that he was an old man (he was in his mid seventies) and that he did not want to take any such risks. The frustration registered on the resident’s face and it was ugly. He shifted his weight from one foot to the other. It was as if he had spent $100 on dinner and his date was now refusing to even kiss him good night. He protested, “It would just be a little hole.” He held up his pinched fingers to show how small the hole would be. “No invasive procedures!” It was clear and final. The resident gave up and left the room. We would not need to get that IV any more.

I had refrained from expressing my doubts about the procedure to Mr. Smith, but I still felt the proud parent speaking to him after the resident had left. “That was an experimental procedure he wanted to try on you Mr. Smith. I think it was right of you to turn him down.” This was maybe saying too much. I was getting caught up in the moment. I was happy to finally have a patient with some sense of the dangers of doing too much and some capacity to accept the inevitable end of his life, but we had just met and I needed to be more careful. I would soon be in an awkward position myself. Mr. Smith accepted my words happily enough. “All I need is something to eat. They haven’t given me anything since I got here. I’ll feel much better after I eat.”

I told him I would work on it, but this was going to be a big problem for Mr. Smith and he did not realize it. The few pills I had asked him to take had not gone down well. He would need to have his ability to swallow properly examined. Small amounts of food going down into the lungs with every mouthful means pneumonia and death in short order. If Mr. Smith failed his swallow evaluation, as I suspected he would, he would most likely not ever be able to eat again.

I had the doctors put in for an evaluation, but it took a long time for the speech therapist to come by to do it. Mr. Smith complained of his hunger to everyone who came by. My shift ended. I was back again the next day and I called Speech Therapy to see what the hold up was, but my heart was not in the fight. Soon I would have to stop giving him even sips of water. They came and did the swallow evaluation and Mr. Smith failed. I told the doctors and they told me to place a feeding tube. This is a minor procedure that is regularly performed by nurses, so it also fell on me to explain the situation to Mr. Smith. I gathered supplies and went into his room. I told him how he would no longer be able to eat and that the doctors had told me to put a tube through his nose down into his stomach so that we could give him some nutrition. Mr. Smith’s face quickly became flat. His previously exuberant communication was replaced with small, difficult to interpret gestures. I told him I did not have to place the feeding tube if he did not want it, but that it was the only way to give him nutrition for the time being. I looked into his eyes and asked, “Do you want the feeding tube Mr. Smith?” I badly hoped he would say “no,” but how could he? He was not ready to starve to death. He let his head come forward just slightly in a nod of consent. I prepared the feeding tube with lubricant and began to insert it in his right nostril.

Feeding tube insertion is one of the most uncomfortable things nurses do for their patients. Judging by the distress it causes it is much worse than urinary catheter insertion. As the tube hits the sinuses even the most self controlled patient will jerk his head away and grab for the nurse’s arm. For confused patients three nurses are sometimes needed; one to hold the arms, one to hold the head, and one to insert the tube. Once the tip of the tube reaches the back of the sinus it has to turn at almost a right angle to go down towards the stomach, which is accomplished simply by pushing with some force on the tube at the nostril. This is the most painful part. After this some care has to be taken so that the tube does not go into the lungs. I pull Mr. Smiths head forward, tucking his chin towards his chest and order, “Swallow Mr. Smith! Try to swallow!” He complies. Tears glide down his face, but the tube goes in without too much trouble. I tell myself that it is good that I am doing this for him, that another nurse who does not know him might be rougher on him, but I am thinking, “I hate my job today.” With this little tube, so much is being taken from him. More than he can even realize. And it is me doing it to him. I have to do it. It is my job and if I leave it for the night nurse, she will only be angry with me.

By the time the X-ray tech comes to take the X-ray which will be used to check the placement of the feeding tube, Mr. Smith has already pulled it halfway out. I push it back and the X-ray is taken. I put a wrist restraint on his good arm and tie it loosely to remind him not to pull it and talk to him about it. His expression is totally flat now. He does not even nod. I regret my previous feelings of camaraderie with him. I am his prison guard now; his oppressor. He only has one good arm left and I am tying it down. I have no right to ask for his friendship. In an hour or so the tube is out again. I put it in again and call for another X-ray. I ask him again if he wants the tube or not. If only he would give me some negative sign. Nothing. I tie his wrist restraint tightly, so that he cannot lift his arm off the mattress. There is no other option. Those who say there is have never done this work. I wish it was not so. This will be his life henceforward. Maybe next time I will leave it for the night nurse to do.

Tuesday, May 13, 2008

Talking About a Revolution

I ran in to an acquaintance over the weekend that had been pursuing a degree in nursing. He had changed course after spending some time in a hospital. He said it was not the kind of environment he wanted to work in or be in. I think I understand. I also do not like the environment. It is not because of all the blood, mucous, vomit and stool that I have to manage and clean up on a regular basis – human bodies have only a limited repertoire of grossness and you acclimate to that in the first few weeks. It is the soul crushing machine that is the modern medical system which is truly opposed to any values or sense of aesthetic I may hold. Still, I like it. I feel alive and engaged at work. I have been thinking about why, and now my friend has me thinking more. In general, I think the ICU appeals to people because of the excitement. One gets to watch holes being drilled in skulls, abdomens being sliced open, emergencies responded to. Codes (when emergency resuscitation i.e. shocks compressions etc are carried out) are always somewhat thrilling because everyone is activated and working as a team. Never mind that the outcomes of codes are usually less than inspiring. Then there is the responsibility. As you work, lives depend on you in a very real sense and while this cuts both ways, it does give a feeling of importance. Some people (not me) are also enamored with the innumerable gadgets we learn to run. And then there are those who just want to help make people better.

While all of these apply to me to some degree I find that what I most value are the frequent opportunities to engage in righteous rebellion. Now, I am not talking about a rebellion against death. Often the problem is that someone who needs to die is not being allowed to die. Neither do I have any interest in killing people off. I have no desire to take that responsibility into my own hands. Rather, what I see and fight against is simple ignorance and lack of information. The representation of healthcare in mass media is so false that people often have no clue about what is really happening around them. They watch their loved ones waste away in agony and misery waiting in vain for some TV doctor to burst in and announce that he and no one else knows the answer and can return the doomed soul from the brink. For some reason these illusions are nourished by healthcare workers. Sometimes it is because no one wants to admit failure, error, or impotence. Sometimes it is the weight of false expectations – the family plans to have the patient home by the next holiday, who will tell them that this miserable life in the hospital bed is as good as it is ever going to get now? Patients and families often respond to bad news with anger. This also discourages the flow of information. Many healthcare workers see it as beyond their duties to expose themselves to these kinds of reactions. It is much easier just to give the pills, change the bandages and say “he sure is looking better today!”

As for me, I see the suffering it all causes and derive great satisfaction from dispelling these illusions. It is best when the patient and families are open and ready to hear. When they immediately recognize and appreciate that I am being straight with them. I know that most others will not be and this enlivens me and helps me to extend myself further. It is harder when there is resistance. Often the patient wants to die, but the family will not allow care to be withdrawn or limited (this is not assisted suicide). Often the patients are beyond being able to participate in their care, and there is disagreement among family members about which course to take. In these cases there is always a risk of becoming a target of family member anger. It is natural, after all, to look for someone to blame, especially when there are often so many mistakes, and no one ever steps forward to take responsibility. Still I will crush their illusions if I can, slowly and gently if I can. I am confident that I reduce my patient’s suffering in this way and that of their families as well. Medical feathers may be ruffled from time to time, but there has been no retaliation so far. Mostly there is appreciation from coworkers. I try to be careful also. I avoid exceeding my bounds. I am cautious not to expose myself uselessly. I am older and wiser than I used to be and I do have a family to support as well. Still, there is almost daily opportunity to fight against the black darkness of ignorance that enfolds this hellish modern society. There is more opportunity here in the ICU than anywhere else I have found. I love my job for this reason.

Sunday, May 4, 2008


She could not have known she was going to end up like this. If you had been able to tell her, you would not have wanted to. A CD player in the room was turned up and music from better times filled the room. Instrumentals from songs like “Happy Days Are Here Again” in a carnival style evoked euphoria of the celebrations after World War II. Was she a young woman then? Or maybe she had just been attracted to the fresh memory of these times in her youth. The leathery, weather worn skin on her face seemed to tell of a life fully lived, but without the cruel and bitter lines that come from overindulgence and selfishness that is sometimes seen with this type. “My young days were the best in my life and I hold on to their memory in bad times,” she seems to say through this music which fills the room. But it is all so surreal. She has just returned from abdominal surgery. Her belly lies on her frame like a puddle, its open incision covered with a brown plastic vacuum dressing. Her nurse, Dan, with his 15 years of experience, dances to her music as he urgently hangs unit after unit of blood, plasma and platelets. He has asked me to bring some supplies and I have stayed for a minute in case he needs something more. I may also learn something. I am intrigued by his dancing. I do not quite understand. Is it because the shift is almost over and he is thinking about his plans for the weekend? Is he dancing to celebrate the patient’s life? Or is it that he is resisting the misery of this place and this work by outright rebellion against it? Finishing a few steps, he turns towards me, “Take it away Leo!” he orders, friendly. I hold up the pillow I have brought for him and make it bounce to the beat a few times. “You sure are a tough one, Leo. Nothing breaks you up.” He says happily.

“She will be dead by morning.” I think to myself. One gets to know the look of a person who is never going to leave the ICU. She is pale and almost yellow. Her head is tilted back slightly and her mouth opens in an O shape. All the sedation and narcotics are not taking away the look of pure agony on her face although she is beyond seeing, beyond touch. Is she beyond sound also? No way to know.

She has not died by the next day, or by the one after that. Her family comes on some days for an hour or so. I avoid eye contact, so they will not be troubled by my thoughts. “Stop doing this to her you bastards!” is what I would like to say. But then I only know this final chapter. I do not know the rest and should not judge. Perhaps if she was my patient I could talk to them. Perhaps they do not understand what they are seeing. Perhaps they are not aware that they are the only ones who are in a position to do anything about it.

That day does not come. Her music plays for three days and is then stopped, never to be restarted. She lasts for three weeks or so, the look of agony on her frozen absent face increasing day by day. Do I need to say it? She died after that.