Day 500: Pouring rain in the Intensive Care Unit

Sometimes it seems like when it rains, it sometimes pours.... today was no exception. It was one of those days. It's been a long time since I felt the way I do now. When I was an intern their was days where I felt my entire spirit and mind drained. Drained by the stress and activities of the days. The days when you drive home crying and feeling as if you just got run over by a truck of stress and being over worked.

I'm back where it all started- the intensive care unit. This time around, I'm no longer an intern, but the senior. I'm forced now to supervise and watch over the interns very carefully. However, their was this one patient we have, who happens to be the son of one of the nurses we have in the hospital, and his son has been in the unit for 4 weeks. He has a rare genetic disorder and has been in and out of multi-organ failure. He is also on dialysis daily and CHF with ejection fraction 15%. (His heart is hardly working.) He was intubated originally for a large infiltrate and collapsed lung. He was in ARDS but got out of it. HE is on mechanical ventilation and has been having difficulty getting weaned off the ventilator. Every time we shut off the sedation so that we could extubate, he starts to get tachypnic and tachycardic and starts geting agitated. It has really been a struggle. I guess what makes this case different is that it is the son of one of the nurses we work closely with. So you kind of pay extra attention to detailed. We have even seen him sleeping in the empty unit bed next to his room.

Today was a bad day. Are plan was to try to wean him off the ventilator today, and as a last resort if he didn't tolerate weaning then immediately do a possible tracheotomy and possibly peg tube or even yet let him go entirely and let nature take its course.

We started around 3 pm. We had the trauma surgeons and the pulmonologist in the room along with 5 more people and at first we took at the tube. The anesthesiologist place another tube in his trachea just in case it would close do to a stricture. He initially seemed to be doing well. But then trouble started. He started to have a lot of secretions. he seemed very "wet" he was getting tachycardic and tachypnic. hr 140 and np 160/110. His respiration was around 37. His saturation was 92%. We left him like this for 5 minutes while we waited for his father to come.

WE were surrounding the bed when his father walked in. He immediately went to the left side of the bed. He grabbed his head and kissed him on the cheek. His eyes were all red and slightly watery. (he is a stocky man. He is very muscular not the type you would think would be this emotional, but yet again this is his son.) Seeing all this was really took a lot of us back. I stood their silently trying to figure out what to do. The intensivist was their (one of the top in the region). he turned to me and ask "you think he will make it?" I just stood there not really sure what to say. He went up to him and started listening to his lung and observing him.
you can hear the crackles across the room. IS sounded like a lot of gurgling sound. They kept on suctioning him, but he still had it. He then turn to me and said not good. I wasn't sure what that would mean. A few minutes later I came back into the room and he was close to the nurse talking to him and had his hand over his shoulder and he said "I'm sorry. we tried everything we could." I still wasn't fully sure what would happen next, till I saw the anesthesiologist saying "pass me the tubs" They were re-intubating him again and they were saying that they will put do a tracheotomy on Monday. The reason this was really big news was that the family was thinking that is might not be a good idea. He would have a trach and be stomach pegged for nutrition and maybe on full restraints so that he could not pull out the tubes. He would literally be a "prisoner" tied on a bed. And add dialysis possibly every day. It would be like slow torture. As I stood thinking about all this. I looked at the back of the room. And the nurse was in tears crying and hugging the father. He was sobbing. I turned away and gave him his privacy. I stood out side the door. I could feel all the energy in my mind and spirit leaving me, as I stood their looking at the anesthesiologist re-intubating the 20yr old kid.

The intensivist came out of the room and said "put him back on the same ventilator settings... we will see what we do on monday." I placed the orders in and I walked down the unit floor. As I walked away I met up with my friend who seemed to be upset. He turned to me and said "I can't believe the schedule they have me on this weekend. I don't know why the chief gave me the schedule she did this month." I turned to him trying to be polite. In my mind I was like "are you kidding me? your complaining about a schedule? did you just see what just happen to that 19yr kid in bed 5." I turned to him and didn't say nothing. I pointed at the schedule and told him "if its any consolation, I have an extra three days more than you, and i'm on call 2 more weekends days extra than you." He kind of stayed quiet after I said this. He got the sense I was feeling tired and drained.

I told him I was leaving earlier and I signed out the other 2 patients that I had. Along with the last hour and several other patients and situations throughout the day, I felt so tired and drained. It was tough to see this type of suffering. Its a very hard thing ti get use to. Specially when you form bond with certain patients and their parents.

I drove home in about 30 minutes . I even gave superman a call over the phone. He graduated and is working as a hospitalist in Florida. I still call him when i need help. eh gave me ideas and told me not to give up. It was nice to hear those words. he told me to try to do more dialysis before extubation monday and try to limit the fluids as much as you can. even if you have to change the in antibiotics to po and limit any fluids you can. It was nice hearing his willingness to keep going. I will try to do what he recommended.

I went up stairs and sat tied on my couch. My wife came into the room from work. I asked her how she was feeling. She said "is was a bad day, I'm so tired. (she works in a busy clinic in the city) I turned to her and simply said "I know what you mean."


God Bless

Dr.Mike