Tuesday, January 26, 2016

They Said He Was Going to Die, So I Stopped Everything. To Save Him

It is [probably] another example of Accidental Survival From Beneficient Neglect.

A middle aged man with alcoholic liver disease with respiratory and other complications had failed extubation for secretion clearance once already, and because of this scenario and suspected but unconfirmed underlying [and incurable] cancer it was planned to terminally extubate him and let him die in peace.

He was on three antibiotics and had acquired C. difficile colitis.  He had friable esophageal varices, so it was said he cannot have a feeding tube, he must be on TPN and he was fluid overloaded as a result of this and MIVF.  He had delirium and deconditioning from his index diseases but also from being in the ICU intubated and sedated with propofol and benzodiazepines for presumed ongoing/prolonged ethanol withdrawal.  (Delirium tremens happens in the minority of abstinent alcoholics.)

One conception of reality is that on day 7 this man was succumbing to his underlying diseases.  Another is that all those have passed and he is burdened by medical interventions that are either misguided, or no longer needed.  There are many other possible realities.

But, antibiotics except flagyl for C. difficile were stopped.  Sedation except minimal propofol was stopped.  Massive diuresis was initiated.  The arm of the gastroenterologist was twisted, and an endoscopic feeding tube was placed.  TPN was stopped and enteral feedings were initiated.  Aggressive attempts to awaken the patient and reduce ventilatory support were undertaken.  Alas, he was extubated.  And so far, so good.

We are not out of the woods.  But the question is now obvious:  when did (if it did) the original disease abate and status iatrogenicus begin to reign supreme (if it did)?

In another all too familiar case, an octogenerian with a UTI was sent to the ICU for vasopressor support for flagging blood pressure.  She refuses it all.  She gets out of bed and eats a stack of pancakes the next morning.  Her lactate may still be elevated, but who would know?  It has not been checked, nor have any routine daily labs - why bother if she is "comfort measures only"?

Evolution has created powerful survival mechanisms.  To think that my TPN or my chasing lactates can outdo them is presumptuous at best, and folly and arrogance at worst.  The perspicacious but humble physician proceeds with caution, always alert that his necessarily naive suppositions and even his good intentions may have crossed that fine line from lending a helping hand, to pulling the patient into the grave.

To learn this lesson is difficult for the faint of heart (or other organs), and for the closed-minded and overconfident.  But those with the fortitude, the humility, and the interest can learn it, when pursuit of the truth for patients' sakes is guided by empiricism.

Updated 1/28/2015:  The patient is on room air, passed swallow eval, is eating and drinking and has normal labs, vital signs, and mental status examination.  He still cannot walk very far, but we're making progress.  It is anyone's guess how much of his residual weakness could have been mitigated with a more "kid gloves" approach to "caring" for him.  He will likely go home this weekend or early next week.

4 comments:

  1. The elephant in the room is the terminal addiction to alcohol and smoking. This patient was admitted with no previous thought to discontinue either. If able, he has a high probability of returning to his former addictions and finding himself in a similar situation in the future. He will find his new normal whether that be living in a more medically fragile state or choosing to invest in prolonging his life and quality of that life. Unfortunately, this situation results in frequent and pro-longed hospital stays. We often can and do pull people through such circumstances. With that said, it appears that more effort is put in by the medical staff than the patient who is unchanged with respect to their health and addictions after dodging death.

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  2. Why is a pt on comfort care admitted to the ICU?

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  3. He was "full court press" until it was decided that he could not be extubated successfully, then he was transitioned to comfort care, which I reversed upon seeing no irreversible immediately terminal disease.

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