Monday, December 31, 2007

weirdness abounds

Happy New Year!
I don't really get why we celebrate the new year, maybe because we made it through the last one alive?
The holidays always remind me of bad things. Historically I have always had to work new years and I have to say the ICU is damn depressing this time of year. Because most hospitals close the OR for the holidays and most patients get discharged out before the holidays the patients that are left are always the living dead.
The living dead are patients almost always in their late seventies early eighties who were competent enough to say yes to an incredibly complicated, damn dangerous operation. These people always come in to hospital with diabetes that has never been well controlled so they have terrible circulation and usually an open sore or two that hasn't healed for months but they forgot to tell anyone. They have terrible kidney function because their uncontrolled diabetes has ruined the arteries that supply the blood to them.They all smoked for fifty years and have the crappy lungs to prove it.
So, here they are, New Years, stuck on a ventilator with their brand new trach. Dialysis running continuously beside their bed. On the end of the bed is the machine that provides suction to the wound dressings all over their body. Behind the bed are the ten or twenty IV pumps. One is running in a continuous supply of liquid nutrition right into the brand new G-tube. The other nineteen are for the antibiotics the open wounds need, the fluids that the dialysis machine needs to function, the pain medication and the sedation that makes it possible for the patient to tolerate the agony of all those central lines , chest tubes and open wounds and finally the inotropes that are the ONLY thing keeping this patient alive.
Epi, Levo and Vaso the magic triangle of septic survival. A little renal dopamine because no one can agree if it works or not.
The only side effect is they divert all blood supply to the main organs. That means the feet, toes, fingers and hands slowly turn black dying from lack of oxygen and nutrition. Th open wounds can never heal.
Without the inotropes the heart stops, no blood pressure, no life, sure death.
With the inotropes a long, ugly, painful trip that ends the very same way, sure death.
So, they are the living dead.
Their families drift around the bedside worried about ludicrous things. "He likes to sleep on his side" "She needs her hair washed"..all things we know if attempted would probably kill the patient. We know that any small interruption, any wrong move could push this train wreck into the deep abyss. No matter how many meetings, the families refuse to believe, refuse to understand. Blank faced they tell us of miracles, of a caring, attentive God focused only on their loved one. They tell us of stories on CNN and the internet of incredible survival. We tell them Granny isn't a twenty year old professional athlete in perfect health. They don't care.
Then a new patient. Dying but resolute, no machines for me thank you. We all stop, stunned and helpless.
Is this a patient we can help? Finally. We buff and fluff. We send for music and her own comforter and pillows. We send for her minister. We bring chairs, chairs and more chairs. We help her grandchildren up onto her bed so they can all cuddle and cry and say good-bye.
We create a private room where none exists.
We find the right pain medicine that keeps them comfortable but awake and engaged. We agree with all their choices. No more oxygen? That's fine. Hungry? Food is on it's way.
They don't eat but just enjoy the smell of fresh seafood, the scent of the ocean far away.
Then with family all around smoothing the way they pass quietly, painlessly.

After it is over, this amazing strangely joyous passing, we return to the living dead.

Do me one thing for the New Year.... get a living will. If you are over the age of seventy five and have three or more serious medical problems that include heart disease, diabetes, kidney failure and lung disease don't have major high risk surgery. You don't get to live forever okay? No one does. Try for a little dignity instead.
Choose the DNR.
Watching you die piece by bloody rotted piece for months is a crime against me and I don't think you have the right to torment me, my colleagues and your family just because the technology exists to do it.
If you just can't resist that TAA? Make a plan for when we can stop flogging you please and tell every one about it.
The half a million dollars it costs to keep one living dead can be spent on knee and hip replacements for fifty still living.
Thank you.


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