Thursday, September 13, 2007

Not cold, not dead.

And back at the ICU, for about another month. I have already spoken to Doctor White and given him my resignation, effective end of this month. The reasons I gave were multiple - nothing to do with the amount of work or the quality of the supervision, everything to do with my own depleted stores of time and energy.

Although, having said that, I have found the entire rotation rather disturbing, on occasions dislocating. Medicine is often counter-intuitive - surgery is cutting people with knives, anaesthesia is gassing them or injecting them with poisons, protecting your child from disease may mean injecting them with dead - or even live - viruses. But ICU, existing as it does in that penumbra between life and death, has more than its share of weirdness.

Take Mrs Blaske. When I walked in this morning the staff were working tirelessly on Mrs Blaske. A nurse covered her with a blanket, another changed the bag of saline that was running into her veins. Dr White shone a light into her eyes, listened to her heart, tested her reflexes with a tendon hammer. What they were doing was fairly urgent, her family would be here within the hour.

So we had less than an hour to get her healthy enough to be dead.

The story goes like this. Mr Blaske had called an ambulance around midday the preceding day. His wife was not breathing. The ambos had instructed him in CPR while racing towards their house, sirens and lights, both sides of the road. They had resuscitated her on the bedroom floor.

When she was found she was "in asystole", a term used to describe the complete absence of heartbeat. Several shocks later, in the ED, a slow, faint heartbeat emerged. She began breathing spontaneously a short time afterwards.

However, a CT scan of the brain showed diffuse anoxic injury. An overdose of benzodiazepines, codeine and alcohol - even an accidental, recreational one like Mrs Blaske had had - causes a diffuse depression in the part of the brain that instructs the heart to beat, the chest to rise and fall. Fewer and fewer synapses fire, the electrical signal becomes weaker and weaker, it is hard to avoid the image of a flickering light dimming, or an echo dying down. Eventually, breathing and heartbeat stop altogether.

Some time after that - there is no way of knowing how long - Mr Blaske woke and started CPR.

Now, Dr White was in the difficult position of explaining the fact of Mrs Blaske's death. It is a difficult, horrible task at the best of times, the most terrible news that anyone can hear, and the most difficult news to give, and in this case it was made harder by the fact that Mrs Blaske was lying on the bed, warm (occasionally blushing), and breathing, and with a strong and vibrant pulse.

Having said that, part of this was due to the chemicals we were running through her veins, and part of it was because different parts of the body die at different rates. Previously it was believed that hair and nails continue to grow after death, we now know that it is common for hearts to beat and lungs to fill and empty. Mrs Blaskes brain was irreparably damaged, and death was coming "not in haste, but irrevocably".

So, in order to be able to say this without a shadow of a doubt, Dr White was required to fulfill the legal requirements of declaring brain death, and in order to do this, Mrs Blaske had to be warmed to thirty seven degrees (ninety eight for those who still use Imperial measurments) - there is a saying I heard in the ED "you can't be cold and dead". Previously doctors were required to ensure that the patient's electrolytes (the chemical in Mrs Blaske's blood) had normalised, and check that the levels of certain drugs had to drop to pre-determined levels.

The reason behind this is to avoid wrongly diagnosing death. Very high levels of opiates or alcohol in the blood can mimic death, as can extreme cold. " Muscle relaxants" - powerful drugs like curare - can be difficult to distinguish from death, and severe glandular problems - I don't know, but I am guessing some profound thyroid abnormalites, anyone who knows feel free to set me right here - there are a lot of things to exclude.

But Mrs Blaske did not blink when we stroke the surface of her cornea (the white of her eye) with a tissue. Her pupils remained vast and dark when Dr White shone a bright light into them. When we reached into her mouth with a smooth tongue depresser - like a popsicle stick - and touuched the base of the back of the throat she did not gag.

"Lastly," said Dr White "we assess vestibulo-ocular reflexes".

One of the nurses handed him a 20 mL syringe - without the needle - full of cold water that had been standing in a slurry of ice and water for the last five minutes. He bent over Mrs Blaske, touched her eyes with the finger and thumb of his left hand and murmured "I'm just going to open your eyes now, dear, and then a bit of cold water". Then he slid the tip of the syringe deep into Mr's Blaske's left ear and pushed the plunger.

He stared into her eyes as he squirted ice-water into her ear. "No response" he said. A nurse wrote it down.

"What's meant to happen?" I said.

"Nystagmus. COWS," he said. Nystagmus is a rapid, twitching motion of the eyeball. "Cold opposite, warm, same. You inject cold water - you get nystagmus towards the opposite side. Warm water - about forty four degrees - you get it towards the same."

"Ahah." I said.

"There's footage of one of the ambos having it done. He volunteered," said Dr White. "Water goes in, eyes start twitching, then explosive nausea and vomiting. Neurological analogue of motion sickness."

Anyhow. Much more to talk about, but I am going off to spend time with Sarah. Her arthritis is actually fairly bad at the moment, hence the shift to nine-to-five. We had an MRI done and her immunologist reacted with horror and she is being sent to an orthopaedic surgeon. I would rather not talk about this now but she may need surgery, and I feel she is too young for that.

Anyhow. On that sombre note, I shall go off and reply to comments.
Thanks for listening.


Blogger Camilla said...

Lots of *hugs* (careful ones) for Sarah. I hope she feels better soon, and that you get encouraging news from the orthopaedic surgeon (I especially hope surgery isn't necessary!).

Both of you look after yourselves!


6:55 AM  
Anonymous said...

Dear John
I've been forwarding some of your posts to my sister who has been an ICU Nurse in for many years. My wife (and I believe I too) are bipolar. I have your blog as one of My Favourites.
Humanity is worth saving.
Keep going.

11:39 PM  
Blogger Bronze John said...

Hail Cam',
I've been hugging her carefully. We have been trying to settle on a surgeon - ideally someone who specialises in this area and who got their consultancy within the last five years or so and is thus at their peak. Sarah has suggested someone who is all this and also remarkably good looking - I'm still searching.


12:03 PM  
Blogger Bronze John said...

Dead Edward - thanks for the kind comments. Get teh biploar thing checked out. And hello to your sister the sister.


12:05 PM  
Blogger Camilla said...

Hey BJ, I'm sure there's some therapeutic value in having a good-looking surgeon :P The rest sounds like good strategy - I hope you find a really good one!


ps word verification "rdmrgmrz" - sounds a bit like disgruntled mumbling induced by grudging acceptance of handsome surgeons :P

12:15 PM  

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