This thing I refer to as My Life

I’m doing something I rarely do. I am, voluntarily, watching a football game on TV. Who would have thought? I’m watching Michigan actually winning against Notre Dame! I went to the game last week and it was terrible to watch the Oregon Ducks just kill us. But, in the first half of the game we’re actually up 31 to 0. Amazing!

Let’s go into one more story from the ICU before starting in on the Peds experience. Part of the day to day experience includes picking up patients that have already been admitted to the ICU by other people. Let’s say that one of my fellow interns was following 4 patients going into their call night. During call, that person may admit up to another 5 patients. The senior may admit additional patients beyond that, too. The next day, the patients are distributed among the interns to spread out the load.

I picked up this young patient where there had been some debate is to if he would come to the medical ICU or the pediatric ICU. The patient was still a teenager. The case sounded sufficiently straightforward: a teenager with on significant past medical history that had a couple weeks of cough and increasing shortness of breath and fever who was having sufficient difficulty in the ER that the patient was intubated. This was a story that screamed of pneumonia and the chest X-ray was in agreement with that diagnosis. However, the X-ray was limited because the patient weighted about 400 lbs and fat is very difficult to penetrate. The standard of care is pretty straightforward and includes cultures of the blood and sputum and antibiotics that are to be adjusted once a bacteria is identified. (The chest X-ray was consistent with a bacterial infection, not a viral.)

Days went by without any real improvement in the X-ray or the clinical picture. The fever never broke and ventilator requirements were increasing, not decreasing. Every time we tried to lighten the sedation, the patient would really stress out.

The cultures kept coming back negative and we finally had a CT acquired. The CT table of the first attempt actually broke due to the patient weight, but the data was acquired on the second try. We found out that there was fluid collected between the outside of the lungs and the inside of the chest wall (pleural effusion) which had been there so long that membranes had started to form making little pockets (loculations). Surgery was on-board with us and they had placed a chest tube into the side that had the larger collection of fluid, but it had not really done a very good job of draining the fluid—the chest tube is attached to a continuous vacuum. After a significant amount of negotiation (and I do mean significant) we got surgery onboard to perform a VATS procedure: this is a procedure where they take the patient into the OR and anesthesia oxygenates one lung and deflates the other and surgery uses a camera to assist them in suctioning out the space where the pockets of fluid had developed. Not 15 minutes after the successful negotiation, the patient got worse to the point where the surgical procedure could not be performed.

As part of my preparation for Surgery-Attending rounds, which happened every Tuesday. (That is a special kind of hell I am trying to put behind me.) I studied the alternatives to the VATS procedure. One of them is instillation with the same clot-busting material they use for some strokes and heart attacks. So, we instilled 6g of TPA dissolved in 200ml of saline (as I recall), into the chest tube and allowed it to sit in there for three hours with the chest tube clamped. Unfortunately, when the tube was unclamped, nothing came back. That meant that the openings on the chest tube were all being blocked by lung tissue.

Another couple of days past with cycling of improvement and then worsening of the ventilator requirements. By this time, the infectious disease doctors had been considering TB pneumonia and had started the appropriate TB antibiotics and precautions for over a week, but without any significant improvement. All of the cultures were still negative and the only way to correctly determine TB pneumonia if it is in the pleural space is to perform a biopsy of the tissue, which was not going to happen because the patient was never sufficiently stable since the day we thought about performing the VATS.

During our morning rounds, all of “us” ICU doctors decided that we were against a brick wall and nothing that we were doing was helping. And, the patient was getting worse and was a good candidate for a heart-lung by-pass (ECMO) since his body really needed time to fight the infection, but more time than we could give with our equipment. (We do not yet have ECMO at our hospital.) We decided to transfer the patient to U of M for possible ECMO and the started the process. There was discussion about transporting the patient by helicopter, but I made the correct observation that the patient was not going to fit. Having been in the helicopter helped me form that educated guess. The patient was transported by ambulance with hand-bagging the entire trip. Hand-bagging tends to deliver higher pressures than a ventilator simply by the nature of apparatus.

I went to the U the following day after work to check up on our patient and found out that things were going better. After hand bagging for an hour and performing many lung recruitment maneuvers, which is also something that we don’t do because the literature is still controversial, the patient stabilized sufficiently not to need ECMO. The lung recruitment maneuvers entails applying a constant high pressure into the lungs and maintaining it for several tens of seconds. In theory, this will blow open areas of the lung that had been closed off. The trick, however, is to not move the patient after the recruitment has been preformed because movement seems to cause the lung tissue to re-collapse.

I visited a few more times (as my schedule would allow) and the patient continued to improve and was eventually extubated. After that, I became too busy on my Pediatrics rotation to visit. I assume the patient continued to improve and was eventually discharged. At least that is what I really hope happened.

Subject: the answer is easy

Who would have thought that I would miss the MICU?! (And, there's a lot to that story.) Especially considering the following: as one might imagine, the MICU is an emotional place for all those involved. I thought I had been doing pretty well managing the intensity until about my second week.

As part of my usual routine, I was awake in the wee early hours of the morning and driving in as the sun rose. It was firey red, rising above the horizon with a thin layer of cloud cover just above it all against an ocean-like blue background. I enjoyed its beauty each morning I witnessed it. One of those mornings, as I pulled off of the expressway with music gently playing in the background and the morning sun in the foreground, something happened that I cannot quite explain: something that I have not really done as part of this career. It was nothing conscious and it was not as though I was thinking about anything in particular. Without any real warning, tears started flowing from my eyes. It was not as though I my eyes just swelled a little with wetness which is the way it usually happens now that I'm an adult. These were flowing down my cheeks. I clamored for some tissue to dry my face.

I have introspected on the event and puzzled over its possible meanings, but I was never able to really identify what was going on between my ears. I understand there are several reasons for such an event, both positive and negative, but I was never able to place my finger on what brought it on that day. And, why that day and no other day? It did not happen again during the rest of the month or the month that followed, for that matter, which I also find puzzling.