My new patient looked terrible. He was an old Hispanic man with two chest tubes on the right and one on the left, a Foley catheter, and two large-bore IVs. He looked pale and was clearly not with the program mentally, whether as a result of his trauma or from preexisting dementia I couldn't say. He had a non-rebreather face mask delivering 10 L/min oxygen and soft restraints on all four extremities.
The report I received from the trauma team was less than satisfactory. "This is a 94-year-old goner," I was told. "He wrecked his car on the interstate, got those right-sided chest tubes at an outside hospital, then got turfed here where we put in the left chest tube. Massive hemothorax on both sides. He's down about 2.5 liters of blood now. He's DNR/DNI." And before I could get my bearings to ask any more questions, the trauma team had fled the SICU and left me alone with the patient.
I've been a part of many major trauma resuscitations in the OR, but this was something different. I was used to a full-court press in the OR: pressors, blood products, the works. What was I allowed to do in a patient who was DNR/DNI? I knew I couldn't shock him or run a code on him, but could I give blood? What about low doses of pressors?
The patient was mentally in no state to answer for himself and his family hadn't arrived yet, so I did the only thing I felt I could safely do: I ordered the nurse to blast him with a full liter of Voluven. His wrists were both scored with multiple attempts at arterial line placement, so I prepped his groin and started a femoral a-line under ultrasound guidance. His pressure was very low and his heart rate was very high, but he was seeming to respond to the volume we were giving him. I ordered another 500 ml of Voluven, then started a subclavian central line to help guide our volume repletion.
While all this was going on, my intern was handling the issues with the rest of the SICU service. He occasionally poked his head in to ask a question or clear a decision with me, but the SICU pager never left him alone for more than a few minutes.
In the midst of this perfect storm, the patient's daughter arrived. The patient didn't look very good but was holding his own (barely), so I stepped out to speak with his daughter. "Mrs. Martinez," I said, "your father was in a bad car accident and it looks like he lost a lot of blood. I understand he's DNR/DNI and I want to respect that, but his advance directive is pretty vague about what I can and cannot do. I need to know if I can give him blood products."
The man's daughter was teary-eyed as she looked around the SICU, overwhelmed by the foreign surroundings and the persistent feeling of sickness and death that permeates the place. "I don't know," she answered. "I have power of attorney, but I need to talk to my brother and sister to answer that."
"I understand. I recommend calling them now, though, so we can press forward with treatment if it's OK."
His daughter took her leave to call her siblings and I checked up on my intern. Things were beginning to settle down, my intern had handled everything perfectly, and I said a quick prayer of thanks for being paired with such a capable junior.
After a few minutes, Mrs. Martinez came back. "Doctor," she said, "we all agree that you can give our dad blood products if, in your professional judgment, it will save his life. But please don't intubate him, and don't give him blood pressure medicines, and don't shock him or do CPR. I'll sign whatever paperwork you need for this."
I thanked her for her prompt response and asked a nurse to draft up the necessary forms, then I called the blood bank and asked them to expedite the blood matching process. In short order, the blood began to arrive and the nurse and I started transfusing the patient.
The rest of the night was a blur. I spent nearly all of it at the patient's bedside. The patient's nurse and I used labs, vital signs, and in/out volume measurements to guide our efforts as we replaced red blood cells and clotting factors and fluid that had been lost. We had no idea whether the patient had healthy kidneys, so we were somewhat conservative in our volume replacement -- conservative enough that my attending ripped me for "under-resuscitating" the patient the next morning on rounds. As I always do when taking crap while 29 sleepless hours into a 30 hour shift, I smiled, said "Yes, sir," and thought about going home and to bed.
Over the next 36 hours, the patient showed significant improvement. His mental status recovered and he showed himself to be sharp as a tack, with a quick wit and a great sense of humor. His family was ecstatic and humble and began to refer to me as "Dad's doctor," even though I was a relatively junior member of a large team. I spent a lot of time with that patient over the next week, getting to know him and his children and his grandchildren and his great-grandchildren, who hugged me as if I were a longtime family friend. They asked about my kids, and I told them that my son would be turning three on the last day of my SICU rotation.
The patient did remarkably well. He was out of bed and working with the physical therapists within days of his crash, and by a week out he was ready for transfer to a rehab facility. I stopped by to say good-bye on his last day in the SICU, the day before my son's birthday. As they often are, the farewell was bittersweet: a terrific patient was about to leave my life, but he was able to because my ministrations had helped make him whole. He shook my hand and thanked me for helping him get more time on Earth to spend with his family.
When I went to shake his daughter's hand, she stood and embraced me, tears in her eyes. "You've been a guardian angel to my dad, Doctor," she told me. "You've saved his life." Then, reaching down, she picked up a large gift bag. She smiled as she pushed it into my hand. "I know you can't accept gifts from family members or patients, but you can't stop the Martinez family from buying a birthday present for your little boy! You take this to him, or I'll follow you to your house and give it to him myself!" And then she hugged me again.
My son opened his birthday presents the next day. The Martinez family had given him a Buzz Lightyear toy, one that has phrases in English and Spanish. My boy fell in love with it.
And now, every time I hear "Buzz Lightyear a tu servicio!" I remember that long, sleepless SICU night, and how I helped save the life of a 94-year-old goner.
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ReplyDeleteI am so enjoying reading your blog. If you weren't a doctor, you'd have a career as a writer! Thanks for taking the time to share!
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