"We Can't Kill Your Mother" and Other Stories of Intensive Care
by Lawrence Martin, M.D.
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NOTE: "We Can't Kill Your Mother" and Other Stories of Intensive Care can be downloaded in its entirety as an e-book from 1st Books Library ($4.95). The book can also be ordered in trade paperback format for $13.50. For purchasing the e-book or print versions, please go to 1st Books Library and enter part of the book's title or the author in their search engine. The first chapter, ROUNDS, is presented in its entirety. For each of the other chapters, only the first few paragraphs are included.
I greeted the two new interns. "Welcome to MICU. I'm Dr. Martin. I run the unit and will be rounding with you this month. How does it feel to be starting your internship?"
"Scary," said Deborah Hafly, a petite and energetic woman who came to Mt. Sinai with top recommendations. She and her partner on this rotation, Michael Highland, were both excellent students and promised to be good interns.
It was July 1, the beginning of another academic year at Mt. Sinai Hospital. As Director of Mt. Sinai's medical intensive care unit, it's my job to supervise and teach house staff and help manage patients admitted to our 8-bed ward.
"You've met the medical resident Jerry Clark, and been assigned your patients?"
"Yes," said Deborah. "He assigned us our patients this morning. We each have four."
"Good. Well, let's make rounds."
MICU occupies a large rectangular space on the second floor of the hospital. The 'unit,' as it is often referred to, consists of eight single-bed rooms arranged in a broad-based 'U' shape, in the center of which is the nursing station. On either side of the nursing station double doors lead to the hallway and family waiting area.
All the patient rooms are fronted by sliding glass doors that can be 'broken' open for quick access; drapes across the doors provide privacy when necessary. Each patient can be 'wired' so that his or her cardiac rhythm is continuously displayed on monitors at the nursing station.
The nurse to patient ratio in MICU is as high as one-to-one when every patient is critically ill. Despite the appellation 'intensive' not all MICU patients are critical. On average, when the unit is full, five nurses per shift can provide excellent care. On the regular hospital wards, which occupy floors three through 10 at Mt. Sinai, the average ratio is one registered nurse per eight patients.
MICU rounds are open to anyone on the staff who may have something to contribute. Besides myself (or another staff physician) rounds include two interns, the supervising resident, one or more nurses, and a respiratory therapist. Also participating, on occasion, are medical and nursing students, various consultants and private attending physicians, and a social worker.
If Mt. Sinai was not a teaching hospital my job would be much more difficult, perhaps impossible. Most MICU patients require constant management, something not easily done over the phone, or even during brief hospital visits. Physicians must always be available to order medications, adjust ventilator settings, put in catheters, talk to families, examine and treat new admissions, and transfer patients to the regular wards. Private, office-based physicians who send their patients to MICU are thankful for the housestaff and round-the-clock physician coverage. Without interns and residents it would be difficult to provide the excellent care Mt. Sinai's MICU is known for.
Housestaff, although licensed MDs, are in training and not certified in any specialty. They must be supervised throughout their three or more years of hospital internship and residency. Interns, fresh out of medical school, are supervised by the junior resident, he or she by the senior resident, and all the housestaff by the chief resident, full-time staff and visiting physicians.
Physician training is a dynamic, patient-centered process. Lectures occupy no more than an hour a day of house staff training. Most of the learning comes from supervised, hands-on patient care, supplemented by reading journals and textbooks.
I took the new interns over to room 1 where we met Dr. Clark and the MICU head nurse.
"Let me introduce you to Marsha Ligner, MICU's head nurse," I said. "Marsha, this is Deborah Hafly and Michael Highland, our two new interns."
"Welcome to MICU," she said. "Glad to have you aboard." Turning toward me, Marsha continued, "Dr. Martin, who can we transfer out this morning?"
"I don't know. Do we need a bed right away?"
"Yes. The ER just called. They have an overdose that needs to come up."
I turned to Dr. Clark. "Who can go out?"
"I just put Mr. Jones up for transfer. As soon as a bed's ready upstairs he can go."
"OK. Marsha, find us a bed for Mr. Jones. And please ask Patient Placement not to drag their feet. I know there are empty beds on the wards." Marsha nodded. She would make one or two phone calls and Mr. Jones would soon be transferred.
"Is the ER patient intubated?" I asked.
"Not as far as I know," said Dr. Clark.
"OK. Well, let's start rounds. We'll see the new patient as soon as he arrives. Or is it she?"
"A twenty-year-old woman. She OD'd on tricyclics."
I stood with my back to the sliding glass doors of Room 1, chart rack and housestaff before me. We were also joined by two of the MICU nurses and a respiratory therapist.
"Has everyone met Dr. Hafly and Dr. Highland?" Everyone had. I addressed the two interns, the only new people on the team. "We round at ten each morning. You should be up to date on your patients by the time rounds begin. Today is an exception of course. Also, we require that you write a chart note on each of your patients every day. You need to list all their medical problems, all drugs they are receiving, and all the tubes entering or exiting their body. Dr. Clark already went over this requirement with you, didn't he?" They nodded yes.
"Good. Jerry, why don't you briefly present each patient as we go around." Jerry Clark, 28, had been the MICU resident in June and was staying another day to orient the new interns. He knew all the patients.
"OK. In room one we have Mr. Hewlett Jones. He's a sixty-seven-year-old man admitted June twenty seventh, with a CVA."
"What's a CVA?" I asked Deborah.
"Cerebrovascular accident," she answered matter-of-factly.
"Jerry, did Mr. Jones have an accident?" I wanted to send a signal early in the month: avoid jargon if possible.
Dr. Clark showed a knowing smile. He had been through this routine with me before. In the spirit of the new year he played it straight almost.
"No, Dr. Martin," he said, with a trace of sarcasm. "He had a stroke. There was no accident."
"I see. Then why do you call it a `cerebrovascular accident?' Why didn't you why don't we just say Mr. Jones had a stroke and be done with it?"
The interns stared in mild disbelief. What kind of rounds were these? English 101? Every new doctor has heard the term 'CVA' a hundred times, always indicating a stroke of some sort. Drs. Hafly and Highland had never before heard anyone question the term.
"I don't know," admitted Dr. Clark. "That's just what everyone calls it. I know it makes no sense."
"I agree. It's just one of those terms that gets introduced into medicine, and no one ever questions. OK, go on."
"Well, he had a stroke, a spontaneously-occurring blood clot that blocked his left middle cerebral artery. The clot paralyzed his right side and left him aphasic, but I think he's getting better. Neurology's following him and he's ready for transfer."
We went in to Mr. Jones's room to say good by. Reflecting the crossover of nerve pathways, the right side of his body was limp from a blockage in the left side of his brain. Since the speech center is on the left Mr. Jones couldn't talk, but he recognized us and understood conversation. I explained that he was being transferred out of MICU, that he was improving and with continued physical therapy had an excellent prognosis for recovery. He understood. We left Mr. Jones and rolled the chart rack over to Room 2, stopping in front of the closed glass doors.
"This is Mr. Boykin," said Dr. Clark. "He's a thirty-four-year-old man admitted June twenty ninth with a severe asthma attack. He has improved but we want to continue IV steroids and inhaled bronchodilators another day. His peak flow is up to one forty."
Through the glass we saw a young man in mild respiratory distress, a state made apparent by a fast breathing rate.
"Who's got Mr. Boykin?"
"OK. Deborah, did you learn about peak flow at your medical school?"
"I didn't have that much experience managing asthma patients. I think I only had one asthmatic on my medicine clerkship."
"Well, you'll become an expert here. Peak flow is the best single breathing test to follow the progress of an asthmatic. It takes only a few seconds and if done properly the test is fairly reproducible."
I asked Greg, our respiratory therapist, to get the peak flow meter so I could demonstrate the test. He went into Mr. Boykin's room and brought back a round, metal instrument the size of a small kitchen clock. A handle on the side of the peak flow meter allows the patient to hold the instrument horizontal while blowing into a mouthpiece situated above the handle. A long needle on the face of the meter deflects when air is blown into the mouthpiece; the harder the blow the greater the deflection. A slight `puff' into the mouthpiece by a normal adult will register at least 150 liters/minute peak flow. A maximal effort will register at least 400 liters/minute.
I inserted a cardboard mouthpiece into the meter and handed it to Deborah. "Deborah, just put your lips around the mouth-piece and give a little puff." She did as instructed and the needle deflected to 180.
"Now reset the needle and take a deep breath, then blow out with all your strength." The needle went to 495.
"OK. Now let's go see Mr. Boykin." He sat in bed, a strong, virile patient humbled by his asthma.
"How do you feel? Are you any better since you've come in?"
"Oh, much better," he said, with conviction. But how much better? You can be fooled by patients. A 30% improvement from a severe asthma attack can make the patient feel like a million bucks, at least at rest. He was still breathing faster than normal and I heard wheezing on exam.
I inserted a fresh mouthpiece and asked Mr. Boykin to do the peak flow maneuver. He took in a deep breath and blew as hard as he could: 170. I asked him to repeat the effort. The needle went to 168.
"Well, you still have a way to go. Your peak flow is still reduced. We're going to keep you here today and continue the intravenous medication. You might be able to go upstairs tomorrow." I thanked him and we stepped outside.
"What do you think?" I asked the interns.
"I'm surprised," said Dr. Highland. He doesn't look that short of breath."
"I agree. I think he may have chronic asthma. The only way to gauge severity of asthma is with the peak flow or some similar measurement. Despite maximal effort he couldn't get above 170 on the peak flow." I looked at Deborah. "You did better than that with almost no effort. He looks strong but if he ran a race with you right now it would be no contest."
"What's going to happen to him?" asked Deborah.
"Too soon to tell," I said. He's much better than yesterday, that's for sure. If he can't reach a higher peak flow despite several more days of IV therapy, then his impairment is chronic. He used to smoke heavily so that may be contributing. Anyway, it's too early to say. We'll watch him in MICU one more day, then send him upstairs if he remains stable."
We moved to room 3. "This is Mr. Denton Smith," said Dr. Clark. "He came in last night with a gastrointestinal hemorrhage. He's a heavy alcoholic. GI's already 'scoped him."
"What'd they find?" The gastroenterology service is good at putting `scopes,' long flexible tubes with a light on the end and a channel through the middle, into the stomach of bleeding patients.
"A large duodenal ulcer. Here's a picture."
Dr. Clark opened up the chart. Taped in the middle of a progress note was an amazingly sharp, digitized photo of an intestinal ulcer. In the middle of a normal stomach lining sat a white dime-sized patch, and in the middle of that a tiny dab of red. I read the handwritten legend under the photo. "Eroding gastric ulcer with bleeding vessel as shown. Vessel cauterized."
"Has his bleeding stopped?"
"Yes, but GI wants us to observe him for another day. We've given him a total of three units of blood."
"OK. I see in the note that he has continued to drink. Was he drunk when he came in?"
"No, he says he hasn't had anything to drink in three days. So we're also going to watch for DT's [delirium tremens]."
"Didn't anyone ever tell him to quit drinking?" I asked. It was a rhetorical question. "What's his hematocrit?"
"It was 23% on admission. After the three units it's up to 30."
Suddenly two nurses from the station began running toward room 7. The first to arrive punched open the door and the other one hauled in the red crash cart. We arrived seconds later. The patient was Mrs. Waldstein, a 76-year-old woman with end-stage kidney and heart disease. The day before she had received a shunt in her right arm for kidney dialysis. We had spent considerable time with her and her family discussing such issues as quality of life, what she could expect with dialysis, possible therapy without it, and so on. In the end she said she wasn't ready to die or become a vegetable, and accepted dialysis.
Even so, her kidney doctor was concerned about whether her heart was strong enough to withstand three times a week dialysis. She had suffered two heart attacks in the past year. Two days earlier she was admitted to MICU with pulmonary edema excess fluid in the lungs from kidney and heart failure. Now her heart had suddenly stopped beating altogether. If we did nothing in the next two minutes she would be dead.
"Get the EKG. Let's get a rhythm strip."
Dr. Clark positioned himself at the head of the bed and began ventilating her with an Ambu bag while I took up chest compressions. One of the nurses began infusing epinephrine into an arm vein while another stuck Mrs. Waldstein's femoral artery for a blood gas sample.
"Any heart beat?"
"Stop pumping for a second." My pumping was creating an artificial heart beat which could mask the patient's own.
"I'll give you three seconds," I said. "Anything more and she's lost."
"Still flat line."
"Give an amp of calcium." The nurse handling drugs infused the calcium.
"Give an amp of bicarbonate. She's acidotic from her renal failure. Somebody please listen to her chest." Deborah complied.
"Good breath sounds when you're bagging," Dr. Martin, we've got a rhythm. Looks idioventricular."
"Only when you pump. Can you stop for a minute?"
"Impossible. A minute is eternity." I stopped for four seconds.
"I feel something. Let me check her blood pressure."
The anesthesiologist arrived. Good, I thought, it's Josh; he's one of the best. Anesthesiologists are expert at intubating patients, so we always call them for a cardiopulmonary arrest. By now there were at least seven people in the room.
Josh went to the head of her bed.
"Hold off intubating for a second, Josh," I said. "Let me see what her rhythm is."
"If she's got a pressure you still want her intubated?" he asked.
"Yes. I want to make sure she's adequately oxygenated and ventilated. This can happen again. What's her blood pressure?"
"I'm getting 90 by palpation," said one of the nurses. Do you still want epi to run in?"
"Yes. Now, let's get her intubated."
Josh expertly slipped the foot-long tube into Mrs. Waldstein's throat while I held my pumping. Seconds later I resumed chest compressions. Dr. Clark continued bagging her, only now he was pumping fresh air through the endotracheal tube, a direct conduit into her lungs.
"Looks like a nodal rhythm, Dr. Martin."
"Good. I'll stop pumping." I felt for a pulse in her groin and felt a repetitive thump against my finger tips. "Look's like she's gonna make it. Let's get a ventilator hooked up and also another blood gas. Stop the epinephrine."
We stayed in Mrs. Waldstein's room another twenty minutes, to make sure she was stable. The nurses' initial response to the cardiac arrest was so quick I doubted she had suffered any brain damage.
On leaving Mrs. Waldstein's room I noted that Deborah and Michael were staring rather idly at the cardiac monitor, Michael with hands in his pockets. They felt insecure in the midst of this emergency and sought to reassure them.
"Don't worry. By the end of the month you'll know exactly what to do. I promise." Affecting nonchalance I added, "Let's resume rounds." We moved on to room 4.
"This is John Popola," said Dr. Clark. "He's seventy-two, with end-stage Alzheimer's. He was sent here for pneumonia and respiratory failure. His sputum culture's growing pseudomonas aeruginosa. We have him on gentamicin and piperacillin. We can't get him off the ventilator until his pneumonia clears. He's DNR." Before us was a man looking perhaps ten years older, white hair, face grizzly, eyes sunken in. He was not awake, an effect of sedation given to relieve respiratory distress.
"You two know what DNR means, I assume."
"Do not resuscitate," said Deborah.
"Right. So why's he connected to a life support ventilator?" I asked. There was no answer.
"Jerry, if he's `Do Not Resuscitate,' why the ventilator? Isn't that a form of resuscitation?"
"He wasn't DNR until after he was intubated. Then the family decided they didn't want any more heroics. They don't want him resuscitated again if his heart stops or he crashes. So we made him DNR."
"His wife is deceased. We talked to a sister and his son. They both agreed."
"Michael, how does being DNR affect the care of a ventilator patient?" This was not a fair question for the first day of internship, but I wanted the interns to think about it anyway.
"I don't know," he said.
"It just means we don't add more life support," I explained. "Otherwise it doesn't affect the care at all. We'll treat Mr. Popola's pneumonia in the usual way, and will do our best to get him safely off the ventilator. In some circumstances no treatment may be given a DNR patient, but that's not the case with Mr. Popola."
"Does the family have to sign for DNR status at Mt. Sinai?" Michael asked.
"No. You just have to write a note in the chart documenting that you talked to the patient if he's competent, or to the family if the patient is not."
We reviewed the ventilator settings and blood gases, then all of Mr. Popola's medications. There was still a way to go before he could breathe unassisted by the machine. We moved on.
"In room five we have Elsie McKnight," Dr. Clark said. "She's a tylenol overdose."
"Looks like a young woman to me," I said. At that, Dr. Clark rolled his eyes and made a here-we-go-again face. I ignored him.
"Suppose a patient pointed to you and said, `There's a stethoscope,' or 'here we have a reflex hammer.' "
"OK, OK," Dr. Clark said, in a manner of `enough, enough.' Actually he took my comments good-naturedly. They were really intended to impress the interns and, perhaps, change in some minuscule way the language of medicine. Doctors already well into their post-graduate training, like Dr. Clark, were usually beyond my message.
"Miss McKnight is a twenty-five-year-old woman who took an overdose of Tylenol tablets. When she came to the ER they measured her acetaminophen [tylenol] level; it was twenty-four."
"Michael, do you have any question about that? What would you want to know at that point?"
"Was she breathing?"
"No, I don't mean about her vital signs. Obviously you want to know if a patient is breathing, if her heart is beating, and so forth. I mean, given that she took tylenol and you have a blood level of the drug, what specific question should you ask?"
Jerry thought for a moment. "What else did she take?"
"Well, that's important too, but let's assume it's only tylenol. It is, as far as we know, isn't it Jerry?" Jerry nodded yes.
"OK, it's only tylenol. What specific question do you need to ask?"
"I'm not sure what you're getting at, Dr. Martin."
I turned to the other intern. "Deborah?"
"When did she take the pills?"
"EXACTLY. You need to know when she took the pills because treatment depends on that information and the blood level. What's the story, Jerry?"
"The blood tylenol level was drawn about six hours after she took the pills."
"OK. What would you do?" I addressed both interns. Deborah spoke up first.
"At that level I would definitely give acetylcystein."
"Right. We gave it to her," I said. "Otherwise, what can happen?"
"Severe liver toxicity."
"Right." Clearly, of the two new interns Deborah was the sharper one.
We went in to see Ms. McKnight. Not the most pleasant person, she so far had refused to talk to anyone. A tall, thin, flat-chested young woman, she sat up in bed with arms crossed and glared straight ahead. Based on a suicide note and the number of pills she took, her attempt was no gesture. She was angry because we saved her life.
"How do you feel?" I asked. She looked at me, then away, and did not answer. The cardiac monitor above her bed showed normal vital signs. By now her risk for liver toxicity was minimal because of the treatment she received from acetylcystein. This drug which prevents tylenol from forming a toxic metabolite. As soon as she could be evaluated by psychiatry she would be transferred from MICU. I saw no point in spending more time in her room. We moved on to room 6.
"Here we have the strangest case of all. Everyone meet 'Jane Doe,'" said Dr. Clark.
"That's not her real name, is it?" asked Deborah.
"No. They found her in a parking lot. Comatose, no identification. She's been here since yesterday morning. I'm told she was intubated in front of a Cadillac. Anyway she has severe aspiration pneumonia and is on the ventilator with one hundred percent oxygen. Right now, except for Mrs. Waldstein, she's our sickest patient. She's got a chance to make it. Nothing here that's irreversible."
"Jerry, did you call the police?"
"Yes, I called and asked if there is a missing persons report on someone of her description. A black woman about sixty years old. They haven't got back to me yet."
As we talked the interns took notes. They seemed over-whelmed, but in less than two days they would know everyone in detail, including any new arrivals.
We stopped in room 7 to see Mrs. Waldstein again. Her cardiac rhythm and blood pressure were holding steady. Arterial blood gases were adequate, albeit with artificial ventilation. She seemed in no immediate danger so we moved on to room 8.
"Last but not least, room eight, Marie Jackson. Very sad case," said Dr. Clark. Before us lay an 80-year-old woman completely comatose and connected to a ventilator.
Jerry opened her chart and pointed to the top of one page. "What do you see there?" he asked the interns.
"What's the date?"
"Two months. She came to Mt. Sinai on May third for a dementia workup. Her private [physician] ordered all the right tests, but nobody ever asked her or her family about what to do if she needed resuscitation. Well, she went for a CAT scan of her brain and guess what happened?"
"Right on the table. It was a mess, trying to get her intubated. To make a long story short she must have been apneic for a good five to ten minutes. After her cardiac arrest, which was on May sixth, she developed every complication. Pneumonia, kidney failure, sepsis. We've treated everything. Family won't let go. Neurology agrees she has severe hypoxic encephalopathy, with almost zero chance for meaningful recovery. Actually they said that on June 1. Here we are a month later."
Ms. Jackson tube in throat, life supported by machine had her eyes open but demonstrated no awareness of us or of her surroundings. She just stared past us. Periodically there was a twitching, writhing movement of her face and mouth, an indication of partially suppressed seizure activity.
"Why does she need a ventilator?" asked Deborah.
"Good question," I said. "Hypoxic brain damage by itself doesn't usually require artificial ventilation. Unfortunately, her pneumonia was so severe that her lungs became permanently damaged. She probably has also some emphysema, from years of smoking. Anyway we can't get her off the machine.
"What happens when you try to wean her?" Deborah asked.
"We tried once. She lasted a day and then developed respiratory distress. We gave her family the option of not connecting her back to the ventilator, but they couldn't agree. Some relatives said yes, some said no. Finally guilt prevailed. They asked us to reconnect her. So we are not even trying to wean her from the ventilator. She would probably arrest again and it would be a bad scene."
"There's also the problem that it happened in the hospital," Dr. Clark added.
"Yes," I said. "But the family's not talking lawsuit or anything. It's just that because it happened here everyone is skittish about pushing them to let her go. I'd love to get Mrs. Jackson out of MICU but the ward isn't ready for her just yet."
The interns just shook their heads. It would take time to adjust to this reality of modern medicine: with all our machines we sometimes do more harm than good.
"Well, let's go look at x-rays. Afterwards you can come back and get to know your patients in more detail." We went to the x-ray viewing room across the hall from MICU. About ten minutes later the phone rang in the viewing room. One of the house officers answered the phone and took a message from MICU, then relayed the information to the rest of us.
"The overdose is here."
In these stories dialogue is presented pretty much as it is spoken on rounds. You are right to be offended if you ever hear patients referred to as a diagnosis or organ; phrases like "this overdose," "that gallbladder," and "the heart," when referring to specific patients, are abhorrent. Unfortunately, doctors and nurses are incorrigible users of jargon and it is not an easy habit to break. I apologize for any conversation that may offend. Despite the way some doctors and nurses may occasionally communicate with one another, in my experience they invariably speak to patients and families in a manner that is most respectful.
Dr. Martin was Chief of the Division of Pulmonary and Critical Care Medicine, Mt. Sinai Medical Center, in Cleveland from 1976-2000, when the hospital closed its doors. He is now practicing pulmonary medicine with University Mednet, and is an Associate Professor of Medicine, CWRU School of Medicine. Send e-mail to email@example.com
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