Making Sacrifices...

I think if I was to stop and think about the power that I have sometimes, I wouldn't be able to handle it. I haven't been writing lately as the patients haven't been that interesting; the stories maybe not so dramatic. Life for me in the MICU is simple: patients come in, patients go out, new patients come in.

Based on what I've heard, it seems that we're not as busy as some of my colleagues have been. At most, I've carried about 3 patients. Most of them have been DKA (diabetic ketoacidosis), septic infection, or a mixture of problems. I've discharged patients straight from the unit to home, and we've had one patient with a series of misadventures who died within 8 hours of being transferred from another hospital. Tomorrow I'll see if I can find out how the Guillain Barre patient is doing.

On an earlier post, I wrote about talking to families about making the decision to withdraw care and "let nature take its course." It's a powerful position to be in. In essence, we make a clinical decision that a patient's outlook is grim or continued treatment is futile - we feel that it would be in the best interest of the patient to stop medical treatment. Primum non nocere - first do no harm.

In medical school, the first time I thought about my actions leading directly to a death was in the "Dog Lab" during physiology. My medical school still had a live dog lab where we studied the cardiovascular system en vivo by giving various cardiac medications to sedated and intubated dogs. I was the one giving the medications. After a time, you stopped thinking about the dog and focused on the beating heart lying in front of you; watching the various effects the drugs had.

One of the last things we did was give a medication that would cause ventricular fibrillation "a bag of worms." We all reached into the chest and felt the irregular heart beat. We then shocked the heart and watched it slowly return to a normal rhythm. The final medication I gave was potassium chloride. This would stop the heart... for good.

I didn't think about it as I reached for the syringe and started giving the medication. We all just peered into the chestto watch the heart give several strong contractions and then suddenly stop. We were all thinking about the physiology: cardiac monocytes being flooded with potassium leading to a contraction with no release. Then I took a step back to cap my needle and realized I had just killed a dog. (We say "sacrificed" in research.)

On days like today I feel the same as I did on that day. I talk to the family who look to me to do "what I need to do for my patient." I talk to them and guide them to the decision to withdraw care. And then I write the orders: morphine bolus, morphine drip "titrate to agonal breathing," d/c (discontinue) all medications (including the ones currently keeping the heart going), d/c lab draws, d/c ventilator support. These are the "comfort measures" orders, but as I write them, I feel like I am back in medical school, pushing the syringe.

Tomorrow is Grand Rounds Wednesday, and I will be helping the medical students learn how to intubate in the evening. We'll see what the morning brings.

Last CCU Short Call

So this is my first official entry of 2008.  I didn't write on New Year's Day because after an exceptionally long morning of rounds for a non-workday, I decided to take a nap.  After waking up just long enough to have dinner, feed the cats and get things organized for another day of work, I just decided to go to bed.
One interesting thing that happened yesterday is that the patient who was brain dead died.  I spent another hour with the son the day prior and had finally gotten him to the point of thinking in terms of finding a funeral home and thinking about his parent's last wishes.  Then, he suddenly changed his mind again and said that something else could probably be done for his parent, and that as long as they were on the breathing tube, he could still come and see them.
I then told him that if his parent's heart stopped, it was no longer a matter of choice.  They would be removed from the ventilator, and he would have to tell the hospital where to send his parent for burial.  Again, I am usually very kind and understanding when it comes to talking to families about their loved ones, their conditions, and in talking to families about witholding or removing care.  But, this situation called for me to be more brusk and candid than I usually am.  I felt bad about this.  I really like to be as understanding and patient with families as I can be, but that wasn't going to be the case in this situation.
When I came in yesterday morning for rounds, the patient's temperature had dropped to the low 90's, and the nurses were having a hard time getting a blood pressure.  When the patient's heart rate dropped to the 30's, we knew we were close.  When the patient went asystole (flat-lined), we ran the code, gently, and then pronounced the patient.
I called the son to let him know his parent had died, and he would now need to make arrangements.  At that point, he finally seemed to have an acceptance of what had happened and came to the hospital to say good-bye.  The social worker promised to help him out with whatever he needed.  So that was the start of his New Year, and too, I guess, of mine.
CCU Countdown:Days until the end of the rotation:  4
Actual number of days I will be working during that time: 3
Days left until the painful attending returns: 0, actually, the painful attending never returned as there was a death in family!
Number of days until my next 24 hours off:  3 (I am taking the very last day of the rotation off, so it's going to be a while, but worth it in the end.)
Number of short call shifts remaining: 0 - I finish tonight!
Number of long call shifts remaining: 1
Number of patients: 2
Number of evil nurses in the unit: 3
Number of evil Internal Medicine residents: 2

Tags: CCU, code blue, end of life, health care proxy