Five

Hail,
I've been going through these posts, shaking my head at some of it, and wondering if I've managed to get things across. Part of what I wanted to do when I started writing was to give some idea of what it's like to do some of this, to work in the ICU, or to work in the ED. And looking back, I think some of the posts have worked, but most of them haven't got that across.

This is only to be expected. People don't pour their experiences directly out onto the page. Something happens, and people see it another way, and they go away and think about it in another way, adding and eliding, then eventually when it comes to writing stuff down they what comes out is another thing altogether*.

But anyhow. I haven't been getting the experience across because a lot of what I write is reflective, whereas the actual process of ICU or ED or Drugs and Alcohol of course is looking forward. In the blog I write "This is what happened", whereas in real life, work is "I'll do this and hope to God it works out".

Okay. I am at the ICU. Today in beds eleven through to fifteen, we have five patients. They are all extremely unwell. They are all receiving maximal or near-maximal care. Statistics say that each of them has about a one in five chance of dying. If you factor in average lengths of stay, morbidity, mortality, it's a fair bet that one in five will die within the fortnight*.

So. Five people. Identies disguised as per usual, named after the Chinese elements, but I will describe these people as it happens, looking forward, rather than looking back.

Bed Eleven is Mr Ayre. Mr Ayre is in end stage airways disease. He wheezes, he pants, he sleeps on home oxygen, almost drowning in thin air. He has a resting tremor, and his pupils are wide, and I suspect it has been years since he was not afraid. No-one visits him. He is thirty four.

He is one of those truly unfortunate people against whom nature has conspired. Smoking kills many many people, but it tends to kill those we are less concerned about saving - the elderly, the unwell, the unattractive (compare anorexia nervosa, or most injectable drugs). To be brought down as far as Mr Ayre has been brought as quickly as he has been is rare - he's one in four thousand, actually.

Mr Ayre has alpha one antitrypsin deficiency. In normal people, the molecule alpha one antitrypsin protects the lungs against protein-dissolving chemicals. Mr Ayre makes an inferior version of this molecule, and thus is dying of emphysema many many times faster than anyone else who smokes cigarettes.

On the positive side, he is down to a pack a day.

Bed Twelve, Mrs Burns. Mrs Burns may be a victim of medicine and the need for certainty. She presented to her doctor a month ago with concerns about her constipation. After some perusuading, her doctor referred her for a colonoscopy, the camera-on-a-metal-tube-up-your-bum thing. It went hideously wrong, as these things do. There was an obstruction (a benign one, it later turns out), they tried to get past, the camera-on-a-tube penetrated the wall of the intestine. There was a massive tear in the gut, although this was not immediately apparent. She went back to the ward where she lay while everything inside leaked out into her abdominal cavity. A few days later she presented to emergency, belly taut and swollen, blood pressure almost undetectable.

The surgical team have so far done four operations to fix this. Normally there is a bit of an "attitude" between surge and ICU, there is the strong sense that they see us (and emerge and psych and...) as muggles, but in this case surge are petrified. Mrs Burns is on hardcore antibiotics, she is intubated, chemicals keep her heart running, and every day or so she is having her belly opened up and "washed out". There is only so many times people can take this.

Bed Thirteen, Mr Mettle. A man of remarkable strength and health, his relatives say. Twenty six, an amateur fisherman and volunteer fireman. Brought in from Ratbite River regional hospital with pneumonia that has progressed to ARDS, acute respiratory distress syndrome. When you X-ray his lungs they are not the open, empty black of healthy lungs, they are white, clouded like mist or veined like white feathers. Still, he is tall and strong, and pictures of him amongst his family (blonde wife, blue-eyed child, him bending down to get through a doorway in their holiday shack, him and his brother kicking a football down at Fang Rock).

ARDS is bad, extremely bad. His white cell count is high - almost thirty - and even on the ventilator his blood remains dark and deoxygenated. His fundamental health and fitness and the evident love of his family weigh in his favour.

Bed Fourteen, Mr Wood. Mr Wood lives in a nursing home. All daily activities are carried out by his carers, he can neither feed nor dress himself. He is ninety one. He has had a stroke, he has had a heart attack, he has had laryngeal cancer and cannot speak. Two days ago he had a sudden attack of pneumonia, was rushed to Florey ED.

In the absence of what is called an "advance directive", doctors and nurses assume that full measures must be taken, and Mr Woods was aggressively resuscitated (I think they broke a rib doing CPR) and sent up here.

Here's the problem. Because Mr Wood is in no shape to speak, being deeply confused and all, and his son is his nest of kin. His son lives in Sydney and has not seen him for eighteen years. He has ordered that all possible measures be taken. If his heart stops beating, we crunch on his chest until it does. If his kidnes shut down, the machine. If he stops breathing, it's the tube down the throat.

Miracles, Mr Wood's son avers, do happen. This is true, but I don't know that keeping Mr Wood alive will be one. But it looks like this is what will happen, at least until someone can come up with a better plan.

Bed Fifteen, Erica Stone. Erica lives on the edge. Hep C, spleen removed following a stabbing in the eighties, steel in her skull following an assault in prison in the late nineties. A few days to a week ago she got a dirty hit - although the details are understandably sketchy. What we do know is that she has multiple organ compromise - bilateral (both sides) pneumonia, swarms of something in her blood, and a heart damaged by at least two previous episodes of the same.

Plus she's somewhat immunosuppressed (amphetamines plus Hep C plus an absent spleen) and has something wrong with her thinking - definitely present but difficult to define - some frontal lobe pathology, some memory thing. That could either be from the previous overdoses or it could be from the endocarditis - you inject heroin into your blood, skin bacteria get in, travel to your heart, start growing, clumps of vegetation break off, whirl downstream, stop the blood supply to the brain...

I should point out, this woman is not one of my drug and alcohol clients. The difference in morbidity and mortality between IV drug users on methadone and IV drug users who are not is huge. Arguing against Mrs Stone's survival is her multiple organ failure, the simultaneous presence of at least three different infectious agents in one small woman. Arguing in her favour is the demonstrated fact that death does not want her.

Anyhow. We are going to try to keep all of them alive. And we're a pretty good team. Very smart people do ICU, and we have a large number of consultants, some truly superlative nurses, an ICU that is getting money and people pumped into it at a dizzying rate. But I suspect the mathematics will apply, and at least one of them will die.

I will keep you informed. That plus the update on a few of my previous patients.

Thanks for listening,
John

*I can't remember a lot of my maths. But from what I recall, if each patient has a one in five chance of dying within the fortnight, then the chance of all five surviving the fortnight is aroundabout a third. The chance of at least one dying is approximately two thirds. The chance of things going horribly awry and all five dying is low - about one in three thousand - but it can obviously happen, and has happened before.

And all this talk of odds and percentages, all these cold equations, sound ghastly, but that's what everyone (doctors, nurses, administrators, health economists) does all the time. We've got numbers on everything.

**And that's assuming that the person concerned is even trying to write down what went on. I remember seeing our Glorious Leader on the TV the other day and trying to work out if what he was saying was what he thought actually went on, or (more likely) what he wanted us to believe went on, or (even more likely than that) what he or she wanted us to think he or she believed at the time was going on, or .... then one of my frontal lobes got caught in my amygdala and I fell over.

Seriously, watching him was like watching a professional card shark. What's the term for that mix of emotions you experience when you seen someone doing a truly terrible thing very adroitly, that melange of "What an evil rodent bastard" and "How the hell has the evil rodent bastard managed to get away with this stuff for so long" and "You know, other evil rodent bastards, trainee evil rodent bastards maybe, could learn from this... they should set up a school"?

The Germans probably have a word for it. If they do I'd like to know.