Depressing?

I was talking to a friend yesterday and mentioned I was on MICU. She asked if I had seen anything depressing, and I have. The thing is, I don't really get depressed by the MICU. The patients there are VERY sick, and many are not going to get better. But I'm learning and doing so much that it doesn't really sink in. One thing I had never really had a good grasp of was when it's appropriate to keep trying new interventions, and when it's best to just step back and hope the family will make the patient DNR (do not resuscitate). It's a little clearer now -- mostly because I look at a patient, realize they aren't going to get better, and declare to myself that I never want to be in that state, so therefore, they would be better off passing on. (Obviously, my opinion of what constitutes a fulfilling life is not the be-all and end-all of end-of-life decision making, but you get the point.)

I used to get really upset when a patient's condition was due to their own stupid actions, and it still does bother me a little bit (pregnant women who use drugs, people with alcoholic liver disease, etc), but I realized that it only bothers me the most when the patients are awake and defiant and (sometimes) mean, despite what we are trying to do to help them. When the patients are so sick they're in the ICU, they're usually intubated and sedated and they don't piss me off because they can't talk or complain. So I distance myself emotionally from the reason they're in liver failure and instead am just interested in treating it.

What DOES bother me, though, is when people get bad treatment from other services. Now, I know there is a long tradition of surgery mocking medicine and medicine mocking surgery, but the truth is, surgeons do not know how to handle infections very well at all. Everyone gets put on prophylactic antibiotics even when there is no reason for it; people with positive cultures get put on the wrong antibiotics; people with mounting signs of infection don't get worked up for them adequately. I'm really happy I rotated on infectious diseases last month and wish all surgeons had to.

Case in point: we have an elderly gentleman who just got transferred to us from the trauma service. He was in a car accident a few weeks ago and fractured his hand. They operated on the hand and fixed it, and he's been recuperating. Then he started spiking fevers, so they checked some cultures and found he had MRSA in his blood. So they treated it with what they thought was an appropriate antibiotic. But the thing about bloodstream infections is that they don't just appear out of nowhere -- they always have a source. The surgeons didn't change his central lines or get an echocardiogram to find or treat the source. After 10 days of MRSA treatment and persistently positive blood cultures, they called the MICU service. We got an echo. He has a huge-ass abscess on his mitral valve, and more vegetations (a nidus of bacterial growth) on his aortic valve. In other words, he has endocarditis. Now he needs surgery. The surgeons are apprehensive because he's a poor candidate for surgery (ah, the irony). Hopefully both the family and surgeons will agree with proceeding with surgery and there may be some chance of infection resolution, but the prognosis is poor, because with every beat of his heart, he is showering bacteria into his bloodstream and every corner of his body. If the family doesn't ask for surgery, then they should make him DNR, because he is not going to get any better (there are other issues going on as well that contribute to his poor prognosis).

But anyway, here's what I actually intended to blog about. We're in the process of declaring another one of our patients brain dead, which is a very serious, but also very interesting thing. This patient was found down initially and spent some time in the ICU with various infections and an altered mental status. He finally got better enough to be transferred to the regular floor while they were looking for long-term placement options. He was originally a British citizen, but has lived in the U.S. for over 30 years illegally. As such, he has no U.S. citizenship or claim to government healthcare, and the UK won't take him back either since he has been gone so long. He has a daughter who wants nothing to do with him and apparently doesn't care that he's this sick. He just has a friend from California who is legally not allowed to do anything because he's just a friend. Actually, this friend is his music partner -- the two of them are folk guitarist/singers and they have a few songs on YouTube that I've watched. I'd share, but I'd be violating HIPAA, sorry.

Anyway, while he was on the floor and they were trying to find a nursing home or rehab facility that would take him without any form of payment (haha, yeah right), he went into cardiopulmonary arrest. They were able to restart his heart, but the anoxic brain injury didn't do him any favors. He was put back on the ventilator and transferred back to the ICU, where he eventually developed ventilator-associated pneumonia. Eventually we realized that his mental status was very depressed despite being on no sedating medicines, so the process of evaluating brain function was initiated.

First, you check for deep pain reflexes, like the sternal rub (rub really hard on the sternum -- it hurts! -- to see if the patient withdraws from your hand) or supraorbital pressure (press really hard on the eyebrows to elicit a withdrawal reflex). You check to see if the pupils react to light (they should constrict when you shine a light in the eyes). You check for corneal reflexes (touch the tip of a q-tip to the eyeball, which should make you blink reflexively). You check for a gag reflex. You do the doll's eye maneuver. You do caloric stimulation, in which you squirt cold water in the ear, which should elicit eye movement called nystagmus. Finally, you turn off the ventilator and see if the patient has any spontaneous respiratory drive. Respiratory drive is the last of the brain stem reflexes to disappear.

On Saturday, this patient had abnormal versions of all of those tests (that is, no withdrawal to deep pain, fixed pupils, no corneal reflex, no gag reflex, no doll's eye movement, and no nystagmus with caloric stimulation) except he still would breathe spontaneously. So we put him back on the ventilator (even though he was breathing on his own, he wasn't taking good enough breaths to get good oxygenation) and checked again the next day. Yesterday was my day off, but I know he had an EEG (actually not necessary or useful in determining brain death), and sometime over the course of the day he failed his spontaneous breathing trial. So the final piece of declaring brain death is to do an apnea test.

I'm not going to describe all the little details of apnea testing, but here are the basics. You breathe in oxygen and you breathe out carbon dioxide (I know you know that, but I have to establish the basics, you know?). If you hold your breath, you will eventually succumb to the urge to take a breath again -- try it if you don't know what I'm talking about. This urge is not because your body senses that it doesn't have enough oxygen; it's because your body senses you have too much carbon dioxide building up in your blood and you need to get rid of it. Your body is very acutely tuned to carbon dioxide levels, and will regulate your breathing automatically to keep them at a normal level (normal for most people is a partial pressure, or paCO2, of 40 mm Hg).

*Side note: if you are submerged underwater, one of the reasons you actually drown is because your CO2 levels get so high that your brain kicks in and forces you to take a breath -- of water. Oops.

OK, so back to apnea testing. A non-brain dead person, even one who is unconscious, will respond to CO2 buildup by initiating a breath. So to determine brain death by apnea testing, you are looking for the patient to NOT take a breath. Of course, there are rules: the patient can't be hypothermic, or have any toxins in the body, or have any sedating medicines on board. First you get an ABG while the patient is on the ventilator and make sure the pH is normal (so there is neither excess acid nor base in the body) and the CO2 is normal (40). Then you turn off the ventilator, and give the patient 100% oxygen flow through the breathing tube (normal air is 21% oxygen) for 8 minutes. The cells in the body are still alive, so their mitochondria will use that oxygen and create CO2 as the byproduct, which is released back in the bloodstream. Because there is so much oxygen being given, there will be a lot of CO2 produced, which should trigger the breathing reflex in the brainstem. After 8 minutes (this isn't an arbitrary number, but the details are not necessary here), if the patient hasn't breathed, then you draw another ABG, and if the CO2 level is 60 or higher (meaning 20 mm Hg more CO2 in the blood than previously), then you have a positive apnea test and the patient is brain dead. There are also rules about who can determine brain death (obviously, not me!). In our hospital, you need two different services to do it, so in this case it's MICU and neurology. After brain death is determined, you keep the ventilator turned off, and the combination of hypoxia and hypercapnea will cause physiological death.

Anyway, the apnea testing is happening today. When I left, they were still trying to get the patient's blood pH normalized as the first step. I don't think he's going to be there tomorrow.

Don't worry, there are some patients who get better. Not everyone is this depressing. But what you, yourself, should do ASAP -- tonight! -- is write up your advance directives. A lot of these situations arise because the patient has never clearly expressed any wishes regarding end-of-life treatment, and family members are unavailable or unable to agree on decisions. So check out this website, which has lots of great information, and then click on the link on the right from the National Hospice and Palliative Care Organization to find an advance directive form for your state. Fill it out, make some copies, and give them to the appropriate people.

Another note: brain death is actually pretty clear-cut. If you're brain dead, there's no point in keeping you on a ventilator. The murkier issues are where you are still breathing on your own but your higher mental capacities are damaged, so it is a quality-of-life issue. So the things you need to discuss with your health-care proxy are what you think constitutes a good quality of life. If a good life is dependent on you being able to read a book and discuss it with someone, that is very different than if you think you would be happy lying in bed all day staring blankly and not knowing what is going on around you. I'm not saying either is better than the other, just that they are very different states of being.