I thought to give you today an overview of some of our patients in the ICU. The 4-bed unit does an amazing job taking care of quite sick patients.
A 10-year old boy, who has been in the ICU for almost 50 days now. He was diagnosed with an obstructing stomach tumor and operated on by the pediatric surgeon (a Dutchman who has been here for a very long time). Since nothing but ultrasound was available for imaging, it only became clear during the procedure that the tumor grew into the esophagus and into the thorax. A partial gastrectomy was performed, and the esophagus was partially removed. He subsequently developed mediastinitis, was reoperated on, received a tracheostomy and is now going through a very prolonged and difficult ICU stay. His main problem is feeding: he gets fed through a jejunostomy, but absorbs little and has recurrent diarrhea. As a result he is terribly emaciated with arms like sticks and a thorax that seems to consist of ribs only. He floats in and out of consciousness; during his good times he waves at us with his left arm. He is unable to move the right; we don’t know why. His mother visits him regularly, and we saw her doing perfect passive motion exercises last week. He is not really getting better, though. His ventilatory support requirements have increased over the past week, and there appears to be some fluid collection in his right lung, which might need to be drained, but no one is very keen on doing another procedure on him. Prognosis is guarded.
This bed has had a number of occupants. For a while it belonged to a sixtyish, large man, who was walking along the street when hit by a minibus – which had swerved because it had just been hit by another minibus… He sustained a moderate head injury (no imaging is available), and a number of rib fractures on the right, with possibly some component of flail chest. He was intubated, and a chest tube was placed. He gradually recovered over several days and really got better when he was mobilized. This happened once his morphine dose was reduced, since before that was done, he was (as one of the TACOs put it) “just enjoying the vent”. Once he was extubated, he rapidly got back to his normal self: a happy and jovial man. We knew he was ready to leave the unit when he proposed to marry one of the nurses, which led to an outburst of laughter through the whole ICU. It’s such a funny business we’re in. Here are people close to dying around us, everyone is laughing, and the patient sitting in bed with a big smile on his face… After he left, we admitted a young woman after surgery for a bowel obstruction. The wound could not be closed, and was covered with a temporary plastic patch. She was on epinephrine for a while (the only available pressor), but this was been gradually weaned down, and she was discharged two days ago. Today, however, we were told that she had died shortly after on the ward, because of unspecified breathing difficulties. This was quite a shock, as she was doing very well and we had no reason to expect anything but a full recovery. Meanwhile, a young man was admitted to bed 2. He had been found unconscious after a drinking spree. He arrested after admission to the hospital, had a prolonged resuscitation, and now is deeply comatose. He is tachycardic and tachypneic, possibly alcohol withdrawal. We’ll see what happens over the next few days.
This bed was occupied for a few days by the girl who had the spine deformity correction done, but she left quickly. Now there is an unfortunate gentleman, in his sixties, who was to be operated for bowel obstruction. He was very sick when he came to the OR, and arrested prior to anesthetic induction. He was resuscitated, ischemic bowel was resected, and he was transferred to the ICU, where he arrested again (and got his CPR from Christina). He required large doses of epinephrine, a central line and an arterial line was placed, and then he arrested again the next day – and was again resuscitated. Now his bowels, amazingly, seem to be working somewhat again. The main concern is whether he has suffered brain injury from three cardiac arrests. Ventilating him has continued to be difficult, and several ventilators have been used on him (since not all work completely). The vents are run off oxygen tanks, and these sometimes are not available. One night, the ACO on call removed the oxygen tank and replaced it with an oxygen concentrator (which supplies much less oxygen), as the tank was needed for the woman admitted to bed 2. But he survived the night despite the low oxygen, and once new tanks came in the morning, he was put back on appropriate oxygen. Still, despite the fact that he has miraculously survived three cardiac arrests, his outlook is bleak.
In the final bed is the 9-month old baby who was transferred from the pediatric floor. The child had been admitted to pediatrics for severe diarrhea, possibly typhoid, and had become lethargic and requiring some assistance with ventilation. The ICU was consulted, and Kai (the anesthesiologist in charge of the ICU) saw the patient and approved transfer. As we described earlier, when the child arrived at the ICU, later, it was without oxygen or ventilator support, and it essentially arrested in transfer. CPR was done, Christina intubated, and we regained circulation. But then the child did not wake up. Epileptic status was considered (we can’t get an EEG), so he was empirically started on phenobarbital and phenytoin. His infection seems improved (although we don’t have a definitive diagnosis yet), and it is now a neuro problem. Yesterday, he became a little more awake, and was extubated. He seemed to do well on oxygen by face mask. But this morning, during rounds, his heart rate suddenly dropped from 140 or so to 70. Presumed airway obstruction from secretions. His SaO2 dropped. Mask ventilation did not make it better, so he received atropine, and then was reintubated. Again, we can’t really predict the long-term outcome.
Bed 4, prior to the almost-arrest of this morning
ICU is difficult in this setting, patients are sick, and mortality is high. Of 90 surgical patients admitted here who were followed as part of a study, 1/3 died.
And in the evening, preparing lectures by candlelight, as the power is once again out…