Done with MICU!

It was a long and intense two weeks, but I made it, and I finished by taking call last night and finishing post-call today, which has its own special feeling. Here's what's happened the last couple of days:

The musician guy who we were declaring brain dead, was declared brain dead. The intern taking care of him made a CD of some of his songs and played them in his room all day. That afternoon, the ventilator was turned off and, according to the intern, his heart just kept plugging along for a few minutes at about 90 bpm and then, all of a sudden, just stopped.

The car accident guy that surgery made a mess of died last night while I was on call. Since my last update, we discovered that he had a dead bowel, and things were not looking good. The family was insisting that he was still a full code, however, but I think they understood the gravity of the situation because they summoned his sister from Alabama yesterday afternoon. Yesterday evening, the intern I was on call with talked again with the family and they decided to make him DNR. In these situations, you really want to think about the life your loved one led: Were they fiercely independent, vowed to drive until the couldn't see, and hated asking for help? Or were they content being a little less active, a little more dependent on others, and wouldn't have minded needing someone else to take care of them fully? In any case, he was made DNR yesterday evening, and our goal was to keep him alive until his sister got here today. No care was withdrawn; he kept getting all the antibiotics and medicines he was getting anyway. He ended up dying at about 10 pm, so his sister didn't get to see him, which is unfortunate. But in hindsight, he was going to die no matter what at 10 pm, so by making him DNR, his family spared him getting useless CPR for 30 minutes, which is nice.

Last Wednesday, on my first call night, we admitted a woman who had been in status epilepticus for an unknown amount of time. She also had end-stage renal disease and had required dialysis for the last three years or so. We continued dialysis, neurology kept monitoring her EEG and was finally able to break her seizures, but she never woke up from her sedated state after we stopped her sedation medications. She was only requiring a little bit of supplementary oxygen and was breathing on her own, and didn't have any infections, so she was in better shape than most -- except for the fact that she was in a coma. The neurologists examined her and her EEG again, and finally concluded that she had a poor prognosis, with little chance of any mental status improvement. Unlike the musician, she was not brain dead, but her brain had been fried by the continuous seizure. She still had most of her brain stem functions, like corneal reflexes, although she did not withdraw to deep pain. Yesterday morning the neurologists told her daughters about her poor prognosis, and they took it very well, considering. There were lots of tears, but I think they themselves had already realized that their mother wasn't in very good shape. They told the doctor, "Thank you for being honest with us."

So what was keeping my patient alive at this point was dialysis, tube feeds, and a little bit of supplementary breathing support with CPAP. The dialysis was the biggest thing. After talking to the nephrologist, though, the daughters decided to stop dialysis. I overheard one of them say, "There are other people who could benefit more from that dialysis machine than my mother can." While that's not really necessarily how resource allocation works, it was still touching. Because it's true: If you are otherwise mobile and have something to live for, be it grandchildren or a job, dialysis is great. But if you are in a coma with very little chance of recovery, it doesn't really make sense to keep someone alive with it. She had actually just finished dialysis yesterday morning and wasn't due to get it again until tomorrow, so that wasn't going to imminently kill her; in fact, if you are otherwise OK, death by renal failure can take up to a week or so, and is actually pretty peaceful and not painful at all, which is a blessing.

So the daughters withdrew dialysis, and after talking with the palliative care team, decided to withdraw the feeding tube and extra breathing help (CPAP) as well, and provide comfort care only. I thought she would make it a few more days, but she was requiring more and more supplemental oxygen and was getting tired breathing. I checked in on her at 7 am today and she was not great, but OK. But by 8, she had passed. Heart heart rate had been pretty fast, in the 120s, then it slowed to the 80s, the 60s, the 40s, the 20s, and eventually just stopped. It was kind of bittersweet, in the sense that she was my first MICU patient, and she died on my last day. Not that all, or even any more, of my patients should follow me in and out of the hospital that way. But still.

In other news, we are in the middle of a big (by Louisville standards) snowstorm. It started snowing around 7 am today and there was about an inch on the ground by the time I left the hospital at 10. They were calling for anywhere from 2-8" by the time it's over. We definitely have at least 2 right now, but I don't think we'll get to 8. They closed the public schools preemptively this morning, and the university was closed at 1 pm today, and has already been closed for tomorrow as well. Not that it would affect me, since the hospitals never close. Plus, I'm off for the weekend!

One of the worst feelings in the world is having to go to sleep in a call room, followed by waking up in a call room. But one of the best feelings in the morning is getting home post-call, absolutely weary, taking a very hot shower, putting on a comfy robe, eating some breakfast (or lunch, depending on what time you get home), and crawling into bed for post-call sleep. You feel absolutely peaceful and rested when you wake up.