As luck had it, Block 2 bunched my patients by type as much as they were in Block 1. The Powers That Be saw fit that this month, my patients had a tendency to get sent to the ICU more than anywhere else, including back home.
Ms. D - 61 years old, admitted for gram-negative bacteremia, transferred to ICU for a neck mass causing a narrow airway.
When someone drops a chart into your hand (literally) and it almost pulls your shoulder out of the socket, you know the binder has a story to be read. You read that correctly.
"Binder."
Despite all orders and test results (in addition to physiotherapy, occupational therapy, nutrition, speech and language therapy, and nursing notes) being entered on a computer, doctor's notes are still written by hand. In a binder. Despite advances such as the moon landing, antibiotics, and Go-Gurt, I am still writing notes by hand. What, and I can't stress this enough, the fuck? Ms. D's binder was full, the kind where the front and back cover sit perfectly parallel.
She came in for a blood infection, or "bacteremia," but she had a previous diagnosis of cryoglobulinemic vasculitis. Essentially, she had antibodies in her blood that attacked her blood vessel walls (vasculitis), and when this blood is cooled in a test tube below 37.0 degrees Celsius, the antibodies clump (cryoglobulinemic). Cool. Weird. Shitty for the patient. But really, this diagnosis wasn't her biggest problem. The antibiotics for her new, fun infection caused an acute interstitial nephritis (AIN), a situation where the tissue that holds all your kidney's millions of tubes together becomes inflamed. And THAT wasn't even the reason she went to the ICU.
I got paged while in the team room one morning, where I was sitting with our attending and the overnight resident, getting handover about what happened in the last 16 hours. "Excuse me doctor, Ms. D. is a little short of breath." Shortness of breath is one of those symptoms that makes every doctor groan internally. Everything, including anxiety, causes shortness of breath, but that also includes things that cause dying. Dying is not something I was planning on letting my patients do today, for fuck's sake.
As I walked into the room, I heard the distinct sound of what I thought was a fry pan being scraped against another fry pan. Except that's ridiculous, because no self-respecting chef rubs two fry pans together.
What the nurse called "shortness of breath" was actually inspiratory stridor, a high pitched whistle which only happens when you inhale against an airway that is far narrower than it is supposed to be. One look at Ms. D was all I needed to start making phone calls. Her neck muscles were straining to lift her rib cage, which is what your brain automatically starts doing when the diaphragm isn't up to that whole breathing thing. One call went to the Respiratory Therapy team, and another to the Ear Nose and Throat surgeons. A text to my attending read "inspiratory stridor, called ACCESS and ENT, patient sat'ing 90%."
"Sat'ing" is short for "saturating", which is a measure of what percentage of your red blood cells are carrying oxygen. Healthy people without COPD "sat" over 94%. 90% isn't necessarily an emergency, but this woman's breathing pattern and sudden decrease from 96% to 90% indicated it was Go Time.
A few invasive tests later, we determined a mass in her neck was rapidly pushing her larynx closed. We hit her with the big guns: IV steroids in case it was inflammatory or lymphoma; IV antibiotics in case it was infectious; a trip to ICU in case she needed intubation.
She never needed intubation; and fortunately, the mass started to shrink very quickly.
Unfortunately, we didn't know if it was the steroids or the antibiotics helping her.
Unfortunately, she refused a biopsy to make a definite diagnosis.
Unfortunately, her kidneys (see above) were too fragile to withstand a CT scan that used IV injections to highlight the tissue.
I have since rotated off of that team, and Ms. D is still in hospital dealing with this neck mass and a few other esoteric infections she has racked up along the way. Her kidneys are puffing along, and her vasculitis continues to lie in wait, probably for the next inconvenient moment to flare up. I wouldn't be surprised if she is still in hospital by the time New Year's rolls around.
Mr. E - 84 year old, admitted directly to ICU for a retroperitoneal hemorrhage causing an anoxic brain injury.
Anoxic brain injuries can be caused by anything that reduces oxygen to the brain. In Mr. E's case, he bled so profusely into the space behind his internal organs that his blood vessels didn't have enough to deliver to his brain. It is similar to a stroke, but often damages a wider, less distinct area of the brain (whereas strokes will block a particular blood vessel damaging a finite area of tissue).
Mr. E was a professor with at least one Ph.D., and when I saw him on his first day back, he could barely hold his head up straight. Brain injuries like this always carry some degree of permanent damage, and permanent change in functional status. The worst thing you can do as a patient is be old, as that significantly reduces your chance of recovering function. Mr. E was no longer really awake, and would spend most of his day tossing and turning in bed, half asleep, not able to communicate anything to those around him.
I barely sniffed Mr. E's chart the first day he was transferred back to our ward before he was again sent to the ICU for aspirating fluid into his lungs. This led to the need for high-flow oxygen, pneumonia, sepsis, and big-gun antibiotics. Five days later he made his second appearance on our ward, where I finally got to do something to care for him.
Mr. E was never going to recover, and his daughter, a physician, knew it. But his wife of 62 years believed in miracles, and told me as much. She spoke to him constantly, brushed his hair, played him music, and asked if she could personally fund a 24-hour-care nurse to make sure he was always receiving attention that might help him recover.
It might not be the hardest part of the job, but bursting someone's bubble, or "managing expectations," is certainly in the top 3. We truly did not know what potential he may have had for recovery, but I know the deck was stacked against him. I know repeated visits to the ICU worsen one's prognosis. I know that old brains recover far worse than young brains. I know that feeding this man with a tube through his nose, into his stomach, will only last him a few weeks, at which point a surgically implanted tube in his abdomen will be the only realistic avenue for feeding him. I also know his wife will never give up hope, and that unless he dies first, she will go the rest of her days thinking there is a chance he will one day be the man she has known her whole life.
Mr. F - 19 year old, admitted to the ICU for cardiac arrest after swallowing an unknown substance.
I met Mr. F and his family while in the ICU. I was on call the night he was ready to be transferred back to our ward. I was to handle the transfer. I'll summarize a portion of his admission note: "Mr. F was at the police station on [---] Street when he swallowed a bag of an unknown substance before being searched. He collapsed and required extended CPR for v-fib arrest before he was resuscitated. Total down-time: 29 minutes. He was intubated by EMS and given IV fluids on route to [---] Hospital. He was admitted to ICU where he required pressor support. Pupils were equal and reactive on admission, and he maintained gag reflex."
Mr. F's heart stopped in a very dangerous way because the substance he ingested was likely an illicit drug. He received CPR and multiple shocks and was in this state for 29 minutes. We would later confirm that, much like Mr. E, he had suffered an anoxic brain injury due to having his heart stop for so long. A fully functional, young man was now in need of a breathing tube, feeding tube, urinary catheter, and close monitoring just to stay alive.
His transfer to our ward came because many of his medical issues were resolving; his kidneys, which also suffered a type of anoxic injury, were starting to recover; he no longer needed assistance breathing; his electrolytes, which were a mess due to his kidneys being so injured, were finally stabilizing. He was also clearly awake.
On Day 1 after his transfer, he could fix his gaze on me only when I stood to his left. On Day 3, he could track people to both sides of his bed, and answer commands with blinking. On Day 7, he could take a deep breath if asked. On Day 9, he could squeeze a ball with his right hand. On Day 11, our Speech and Language Therapy team assessed him and deemed him to have good swallowing function. His feeding tube was removed.
I had the same conversation with Mr. F's family as I did with Mr. E's wife: his confirmed anoxic brain injury meant it was likely he would lose function; we just didn't know how much. The greatest asset on his side was his age. Young men like him have been known to walk out of hospitals after admissions like this, and despite hundreds of years of combined medical experience working on that ward, each and every one of us held out hope he was one of those cases.