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.