Monday, February 15, 2016

Crowbarrens, chest tubes, and death on the ICU

People die on the ICU.

This is just a fact of life: we can’t save everybody. Bodies fall apart if enough bad things happen to them. Sometimes we can keep part of the body alive, but not the rest; sometimes we can support consciousness even when the body is doomed, although eventually even consciousness will fade. More often, we can keep the body running even while the brain is completely dead.

You’ll notice that, with other organ systems, we use different terms than with the brain. If your kidneys have some working tissue, but aren’t strong enough to get your blood really clean, you have renal failure. If your kidneys are so fucked up they shrivel into black raisins and you never pee again and you depend on a dialysis machine to clear out all your nitrogen waste products forever, we call it end stage renal failure, not renal death.

If your liver is a huge lumpy pile of scar tissue and blood can’t flow through it at all, you aren’t experiencing liver death (although you will soon die unless you get a new liver), you’re in end stage liver failure. If your lungs are full of gross shit and require mechanical assistance to get oxygen and carbon dioxide in and out of your blood, you are in respiratory failure; if your lungs are filled with scar tissue and nodules and all the cilia are burned out and every breath uses up more oxygen than it gains, you are in end stage respiratory failure. All of these things lead directly to death, although we’ve learned to cheat them a little better over time, but they are not death.

We also talk about heart failure, in which the heart can’t move blood well enough to maintain equilibrium without medical help. We even talk about end stage heart failure sometimes, although this mostly means this person is about to be dead. The true end stage of heart failure is cardiac death.

We call it death, because for a very long time, the lack of a pulse was death. There was no way to get it back. Once you crossed that line, you were gone.

But we’ve learned to cheat even that death, sometimes, if we’re lucky. We can, if we’re willing to break ribs and insert tubes and flood the body with toxins, restart the heart. We can even support a fatally wrecked heart for a while with ventricular assist devices. What was once death is now closer to failure.

So if we’ve blurred the line between life and death, what’s left? Is there anything that can be so damaged that we can’t compensate for it? Is there anything that truly goes beyond failure into death?

Oh yeah. Definitely yeah. The brain is still the most complicated, delicate, poorly understood, and easily destroyed organ. The body can compensate for a certain amount of damage to the brain, and it might be said that a person with varying degrees of brain damage or delirium might even be in brain failure, if you squint and don’t get too technical. But brain death is something else.

When the brain tissue dies, it swells. As it swells, trapped inside its tiny skull box, it crushes all the blood vessels that feed it. Brain death—true brain death, the kind of brain death that makes you eligible to donate organs or be removed from life support without your family’s full permission—is measured by the point when all blood flow to the brain stops entirely.

A dead brain, on a CT scan, looks like a huge white mass. There is no furrowed gray tissue, no hollow places where the cerebrospinal fluid flows, no distinct structures to manage your breathing and emotions and body temperature. There are no blood vessels. There’s only a solid wall of swollen, bloodless white.

It's beyond failure. This is death.

This is actually not the worst thing that can happen to you. By the time your brain is dead, you don’t give a shit about anything. There isn’t any pain. You don’t exist anymore. What’s left of your body is being swiftly poisoned by the imbalance of chemicals—the things your brain used to make and now doesn’t, the things your brain shit out as it died—and soon your other organs will follow your brain into death.

And yet… You would not fucking believe how many people I've heard espouse the idea that "brain death" isn't that big of a deal, they're not really dead, they're just brain dead. It's not like their heart stopped or anything.

The idea of cardiac death as the ultimate indicator of absolute death is so pervasive that an otherwise scientific study sought to debunk out of body experiences by hiding an object or a word in a place that the patient couldn't see until they "left their body" and rose up to the ceiling. The patient population they chose was the cardiac population subjected to adenosine IV push for cardioversion.

Adenosine is a predictable but pants-shittingly scary way to fix a heart that’s racing out of control—it works by stopping your heart and trusting that it will start again, hopefully in a rhythm that’s better than the old one. If you ever get to sit around and shoot the shit with a bunch of ICU staff, you will inevitably witness the old pissing contest: who’s pushed adenosine for the longest pause between heartbeats? Some people lose their pulse for a second or two; some for five. A pause of 10 seconds is pretty crazy. A pause of 30 seconds is fucking ridiculous, and at that point they probably get their heartbeat back because we code them.

Nobody is spending long enough pulseless from an adenosine push to actually die.

Seriously, we have little old ladies in afib pull pauses like that all the time. Most people don't even black out during the pause. You aren't going to even begin to approach brain death, real death, with an adenosine push.

The study would've been more reliable if they had followed cardiothoracic surgery patients with valve replacements. Those guys lose conduction all the fucking time, and unless your ICU squad is absolutely crackin, they're probably going to be pulseless for at least 30 seconds, maybe as long as a full minute. Nowhere near brain death, of course, no wall of rotten white brain flesh on their CT scan, but at least long enough for their eyes to roll back in their heads. Your heart can straight the fuck up stop for at least 10 seconds before your brain notices, and maybe longer if you're a hundred-year-old gomer whose brainpan is used to weird rhythms and saggy pressure.

You can experience cardiac death, even terminal cardiac death, and still have enough consciousness left to do a big dramatic TV chest grab and gasp out something that will make things very awkward for your family at your funeral. Hell, if somebody manages to restart your heart after cardiac death, and your brain doesn't have time without pressure enough to actually start dying, you could live to regret those last words with a fully functioning brain DESPITE HAVING EXPERIENCED CARDIAC DEATH.

As you can imagine, this instills some truly heartbreaking magical thinking in laypeople, who can look at their kid in a hospital bed and know that he blew his brains out, and the doctors say he's dead for sure, but Uncle Philip was dead once from a heart attack, and he's still around ruining Thanksgiving! Fuck your organ donation people and your grim predictions of permanent ventilators and tracheostomies and your "vegetable" negativity, if God can save Uncle Phil, God can undo that shotgun!

I personally think that TV medical drama should be held accountable for their portrayal of cardiac versus brain death, and the incredible amount of human and vegetable suffering they contribute to. Cardiac death is negotiable. Brain death is for reals.

But what if you’re kind of in, you know, not-quite-end-stage brain failure? What if part of your brain is just dead and gross and shriveled up, but your basic life processes are preserved? What if you can be supported medically in a state of brain failure indefinitely, unable to communicate or think or scratch your nose, but still technically not brain dead?

This happens regularly. Traumatic or anoxic brain injuries can render a person vegetative—that is, in a state of severe (but not end-stage) brain failure—and, if they haven’t made their wishes clear and chosen a person they can trust to make decisions for them, they can end up on a ventilator forever, trapped in a hospital bed, only aware of the world as a faint and blurry impression of pain and helplessness.

So, as you might imagine, we pay very close attention to advance directives, DNAR/Allow Natural Death orders, and which person in the family has durable power of attorney. We advise pt family with extreme gravity about likely outcomes, quality of life, and the procedures that will be necessary to maintain the body against severe, permanent brain failure. And we are very, very conservative in our advice, because we don’t want to lose credibility in such a delicate and potentially life-and-death arena.

We also have the ability, if it comes down to it, to declare an intervention medically futile, although it has to be pretty fucking futile for us to be able to withhold it. Futile here would mean “not extending life at all, by any standard of quality whatsoever,” not just “make someone hurt for no good reason.” It’s not like this everywhere; many countries allow doctors to make their pts DNR if they think the outcome of CPR would be poor for them. But, you know, ‘Murica. We depend entirely on the wishes of the pt and on the wishes of the family.

Some people just want to live forever, and leave instructions to that effect, and we will totally honor that as best we can… unless the person they trusted with their end-of-life decisions assesses the situation and tells us that the pt wouldn’t be okay with their current quality of life. (I mean, let’s be real, nobody can look at a person with all their skin rotting off and no chance of recovery, and shrug and go “eh, they’d want it like this.” Barring, you know, intense religious conviction or severe mental/emotional illness.)

On the other extreme, sometimes we get young folks in who want to make themselves DNR as soon as they hit the hospital—they’ve heard tales of vegetative states, seen family members die slowly, or just have no idea how much high-quality life is possible with chronic illness and disability. And we have people who think that, as soon as they sign the DNR form, we won’t treat them for anything at all.

It ain’t like that. If you’re young and healthy, you need somebody who can make decisions for you if something crazy unexpected happens, with whom you’ve discussed the gross and difficult issues of death and long-term disability. If you’re older and having some health issues, you need a solid advance directive or living will, and maybe a designated-power-of-attorney (DPOA) who has legal permission to make your decisions. If you have a disease that will slowly but inevitably progress toward death, or your health issues are starting to make life harder to live and you don’t think you could pull through a broken rib without months of agony, it’s time to go full DNR.

And if your disease has progressed to the point of no return and you’re ready to stop struggling through painful treatments and procedures, you can transition to Comfort Care, which is essentially a morphine drip with unlimited benzos and other medications designed to help your last hours be peaceful.

The decision to switch from a full code status—guaranteeing CPR, life support medications, ventilator, the whole works—to a DNR status (or even an altered, intubation-and-ventilation-only status) is a big one. It’s the difference between assuming you’ll be around for a while and recognizing that your time is getting pretty short.

So when Crowbarrens came in for the last time and he asked us to make him DNR, we knew it was serious this time.

I’ve told you that he had stomach cancer. It moved very, very quickly. He went from cancer in situ to some kind of splenic/lymph involvement before he was even diagnosed, and from there he ended up with multiple metastases on the quick.

The whole mess absolutely poured fluid, which is a thing that cancer does in addition to eating all your food for you like Satan's own tapeworm, and his abdomen distended until he genuinely couldn't breathe. Even his ventilator couldn't get good volumes in him. This happened in a matter of hours after his latest admission, so Dr. Pug dropped a few pigtail drains into his belly. Several days later, the weeping overtook his pleural spaces, so he ended up with two small chest tubes. An NG tube drained about 4L of weeping fluid from his stomach per day.

And he was in pain. Constant, bone-breaking pain. A week into his last stay, he wanted to be made DNR, but his wife flipped her shit at the thought of him dying and absolutely, vehemently refused.

Thing is, she’d be the one making decisions for him anyway, once he was too sick to speak, and we knew it. He could make himself DNR, and the moment he became unconscious his wife could revoke it. So as he slipped further and further into a stupor, between massive doses of pain medication and the mind-wrecking toxicity and exhaustion of terminal cancer, we entered a very ticklish standoff with his wife over what care would be appropriate and which procedures would be futile.

While we negotiated with her, the tumor spread and devoured and wept. All that fluid had to come from somewhere, so he required tons of saline to replenish his vascular volume, then several blood transfusions, then pressors. The constant struggle with fluid volumes fucked his heart over pretty well and he stopped tolerating fluid boluses greater than 250mL every four hours. He went into multiple organ system failure from hypotension and the toxins of renal failure. He dropped into profound unconsciousness on Thursday night last week and wasn't able to wake up. Dr Sunny attempted hemodialysis, but his vasculature is horrible and it took a trip to Interventional Radiology to put an HD cath in, and then he couldn't tolerate the dialysis anyway.

His wife asked us to start CVVHDF, but at this point the intensivists drew the line. His systolic blood pressures were in the sixties—his heart could barely pump hard enough to inflate his collapsed arteries, let alone to perfuse his organs. Even if we cleaned out all the toxins, he wouldn’t wake up. Finally, faced with his gray complexion and his absent slack-faced emptiness, she admitted that he might not make it out of this one.

She made him DNR. Not comfort care, DNR. It was small comfort, but we all breathed a sigh of relief, knowing we wouldn’t have to start compressions on what was left of Crowbarrens.

A few days later, they stopped the pressors, because his body had begun to rot. Even if his wife was unwilling to make him comfort care, we couldn't pretend any longer that pressors were helping. His hands and feet were pinched off from high pressor doses and had started to discolor and bloat and turn black. Turning off the pressors had almost no impact; he was already at rock bottom. He spent his last two days with a systolic BP in the 50s and passed away early in the morning having never awakened.

He was an asshole; he spent his life suffering; he was the terror of the unit. He and his wife were toxic, and their relationship was destructive, but they loved each other in their bizarre broken way. And they were terrible for each other, so I can't say they were happy, exactly. He isn't struggling to breathe anymore, and her life is now her own. So it is what it is.

We’re all kind of glad for him.

Sometimes people linger forever, barely clinging to life, while their families hold onto vanished hope. Sometimes, though, people get out easy by sheer luck, which in this case means they manage to die on us before we can stop them.

A while back, my coworker Leah cared for a pt from a nursing home, an ancient victim of family apathy and facility neglect who arrived in a state of advanced sicker-than-shit and only got worse from there. He looked like he’d been much heavier in recent months; his skin hung from his body in loose floppy curtains of evacuated adiposity. He had pneumonia from aspirating his food; pressure ulcers dug through his sagging flesh to the bones. His limbs had contracted from lack of use until his body looked like a half-melted doll whose child-owner had recently learned to hurt animals. His dementia and history of stroke had reduced huge swathes of his brain tissue to the functionality of dryer lint. He wasn’t brain dead, but he was in a persistent vegetative state—end-stage brain failure.

The pneumonia was what brought him in; I suppose the nursing home didn’t want him to die there, lest they get investigated. Of course, social work got involved, the nursing home would be investigated anyway, all the usual things that result in facility closure or lawsuits; but Leah’s job was to take care of the pt himself, who was sick as all fuck, and whose family just couldn’t believe that ol’ pop might finally die.

They wanted him full code. They wanted everything done. Ridden with guilt and denial, they wanted him back on his feet by Friday if possible, and resisted the thought of letting him go gently. So Leah, with her assigned orientee at her side, spent a harrowing twelve hours trying to keep him alive… ish… while the pulmonologist, Dr Pug again, tried to talk the family into withdrawing life support and giving him the morphine-drip farewell.

Nobody wants to do CPR on a pt like this. We know that, if any part of the brain is still capable of experiencing pain, CPR will guarantee that they feel that pain. We also know that, with swollen delicate lung tissue just waiting to rip, and with high PEEP smacking every breath into the lung with violent force, the pt will be pouring blood from their airway in a matter of minutes. In fact, this guy ripped a lung and popped a pneumothorax before we ever had a chance to compress him, and negotiations with the family took on even greater urgency.

At last, they worked out a compromise. Dr Pug would start a chest tube, cutting a hole in his chest and jamming a tube into it to suck out the extra air and reinflate the collapsing lung, and in return the family would call in its far-flung members and withdraw life support within twenty-four hours. It was a hard-won victory for the pt’s comfort and dignity, but it meant that Dr Pug had to somehow get a chest tube into that pile of slippery loose skin. Fast, because the pt remained full code, and the pt was hurtling toward that code.

(Time for another quick side note: there are multiple types of codes. Code Blue, as a standard, covers respiratory and cardiac arrests. Code Stroke/Code CVA, as I’ve discussed before, is for cerebrovascular accidents, strokes, bleeds, and the suspicion thereof. Code Gray for violence, Code Silver for armed violence, Code Orange for spills. Code MTP for a mass transfusion protocol, usually for intra-operative or uterine bleeding that can’t be easily controlled. Code Brown is an unofficial term for a buttsplosion, and you will never hear it called overhead. But when a medical professional uses the term ‘code’ alone, they mean a Code Blue, with attending compressions and respirations and crash cart and code team. It’s not the most complex one, but it’s the big one.)

So Leah and her orientee suited up, put on their bonnets and gowns, spread out a huge table of sharps and tubes and syringes and towels, and braced for impact. Leah explained each step as she went; I was next door, pushing pain medication into Lucita a little on the early side—her leg was the size of an anime-print body pillow and even more painful to look at—and I heard only the edges of the preparation and teaching.

Her orientee was still pretty green. He’s the type of nurse who keeps a good straight face and never appears to panic, but this is a little less reassuring in a new staff member than in a twenty-year ICU veteran. The ability to keep yourself from panicking is crucial in the ICU, but it makes us really jumpy if we expect someone to get excited (they’re green, they’re crazy, their pt is unexpectedly crashing) and they don’t.

That said, it’s hard to tell with some people. I spent my first year on the ICU in a constant state of terror and overwhelm, but I have a pretty solid poker face and am good at pretending I’m fine… which in many jobs means I would progress quickly and be given a lot of respect and confidence by my coworkers, but in the ICU meant everyone thought I was kind of a dipshit and possibly as dumb as two rocks taped together.

So I wasn’t judging Leah’s orientee just yet. He could just be hard to rattle; sometimes we get nurses who’ve seen active combat and don’t get really upset about spurting blood. He could be like me, a mass of blind hysteria masquerading as a human, or he could just be trying not to panic about things because he didn’t want to flip his shit like a hamster in a shoebox every time his pt coughed.

At any rate, when the chest tube procedure started, Leah and her orientee tilted the pt toward the left, exposing his right ribcage, and then she made him stand near the supply cart while she handled the assistance portion of the procedure. This is really smart, especially if you can’t predict how someone will react; they can always hand you flushes, pull up medications from the vial, and even bolus sedatives from an IV drip without ever getting between you, your pt, and the doctor with the knife.

Dr Pug is good. Really, really good. Dramatic and excitable, sure; quick to anger and quick to forgive; but most of all, the dude is hellaciously competent and has a steady hand. When he missed the first chest tube and was forced to choose another site, well, that just spoke to how difficult the pt’s anatomy was, with the loose slithery skin and the bones all taut and twisted.

Another chest tube hit air, but failed to produce the results we needed; the lung stayed deflated. The insertion site was too low, its landmarks obscured by the wreckage of the pt’s body. Leah climbed up under the drape and held traction on the pt’s arm across his body, lifting his shoulder to expose his armpit, so that Dr Pug could attempt a tube higher up on the torso. This one went as far as the rib before skating over bone and twisting sideways. Two inches down, he attempted the next one.

I came into the room to help while this was going on, twisting my hair up into the bonnet and bringing a fresh selection of tubes, since we had used up all the ones on that procedure cart. “Maybe we won’t need them,” said Dr Pug, whose hands had started to shake.

As this tube slipped in, the pt suddenly coughed up bloody froth. Leah and I locked eyes; I could see the whites of hers all the way around, and the way her mask shifted as her expression tightened. Either the tube had ripped a corner of the lung—it happens sometimes—or the pt’s pneumothorax had progressed so far that his heart was crushed to failing. We were running out of time.

That tube stayed in place, hooked up to a suction chamber, trying to pull the air out of the pt’s chest. The orientee gave extra pain medication. Leah shifted her grip and I helped her use tape to keep the pt’s arm elevated. Dr Pug opened the next tube and started looking for anterior landmarks, trying to hold the skin taut.

If it seems like we should have stopped by that point and let the poor man die, even if it meant breaking his bones, well. I can’t talk shit about pt’s families for keeping them longer than they should, sometimes. Every one of us in the room knew what a huge difference it would make if we could just get one working chest tube in—the difference between a sedate death with the whole family at the bedside, or a gasping violent death from collapsed lungs and a crushed heart. One good chest tube…

This one went in halfway between collarbone and nipple. It skated a little, skipped a rib, sank into the flesh, and coughed up a little gout of dark blood before pulling air. Plenty of air. A little more blood, but also lots of air. We hooked it up to suction and kept a paranoid eye on the pt’s vital signs: heart rate stable, blood pressure no lower than before, oxygenation poor but improving…

Then the chest tube seemed to lock up. For a moment, the air and blood both stopped, the pt’s oxygen dipped again, and Dr Pug cursed and got ready to try again. We opened the last chest tube, arranged the scalpels and sutures and chlorhexidine swabs, and shifted the drape so Leah could get a fresh grip…

Her orientee cleared his throat, a polite sound, not terribly urgent. “Hmmm,” he said, “is that normal?”

He gestured to the chest tube, which was no longer stopped up. Into its chamber poured blood.

Three hundred milliliters of blood. I said something indistinct and profane, and Dr Pug stepped back from the final cut to look down at the suction chamber. Three hundred and fifty milliliters of blood. Dark red blood. Venous blood.

The chest tube insertion had, somehow, severed his subclavian vein.

Abandoning the chest tube, Dr Pug tried to insert his fingers between the ribs, I suppose hoping he could get pressure on the venous rip. The pt’s vital signs stayed steady for another three or four minutes while we scrambled, trying to stabilize him, trying to find some survivable balance between his ripped lung and his collapsing thorax and his gushing chest.

The suction canister stood now at eight hundred and fifty mLs. “He’s exsanguinating,” said Leah.

“Call a Code MTP,” said Dr Pug.

Within two minutes, runners carried blood samples and blood products back and forth between ICU and lab. The charge nurse primed the rapid infuser, which could replace all of his blood volume within fifteen minutes, once we got it started and had the blood on hand. We all seized cards from the code basket with our assigned roles—enormously complicated procedures reduced to simple steps on laminated cards, one role for each nurse, all of us practiced and drilled and trained and still, still panicking.

It didn’t matter much. By the time the first bag of blood went up on the rapid infuser, the pt had bled 1800mL. The blood poured; the heart slowed, and jerked at last to a halt.

We laid him down, ready to start CPR, grimacing at the knowledge of how much blood would gush out of him with each compression. I pulled a pair of sterile gloves out of the cart and ripped them open—their cuffs could be unrolled to cover me almost to the elbow. Leah’s orientee, wide-eyed and clamp-mouthed, turned to the cart behind him and methodically put on a splatter mask, his hands trembling a little as he hooked it over his ears.

Yeah, I knew where he was now. Scared as shit, and blessed with a blank face. Could do well on the ICU, might need to spend a little more time on step-down until he figured everything out. Would benefit from more practice in high-intensity situations. All of these things I thought in the space of ten seconds, because they made sense and because they didn’t involve the torrent of blood I was getting ready to thrust my hands into, and before I could even get my mind back on the pt I heard Dr Pug sigh.

“Let him go,” said Dr Pug. “This is fucking futile. I’ll talk to the family.”

The room was a gory mess, sharps piled on the procedure table, blood spattered on the floor, mottling body of the freshly dead pt slumping sideways on the bed. While the doctor went to explain to the family why CPR wasn’t really a valid option at this point, and to promise them he had done literally everything in his power, Leah and her orientee and I cleaned the room—me with forceps sorting and discarding sharps, Leah rearranging the pt and covering what she could, the orientee toweling blood off the floor.

So, you know, we don’t let anyone go lightly. We don’t draw the line for futile care until the pt is really, truly fucked. But I don’t think any of us was glad to be part of that.

When you think about it, this guy got out pretty well—completely snowed on pain medication for a procedure, exsanguinated without ever knowing what happened. I’m glad his pain is over and I’m glad he didn’t have to wait a few more agonized days to die. And I’m glad Crowbarrens was able to go as gently as he did, comatose and drifting, instead of being stabbed and beaten to death as so many pts go.

You better fucking believe I went home and had a talk with my husband about my end-of-life wishes, after that.

Sorry about the prolonged absence, by the way. I had to emergently move out of my apartment while working several shifts in the space of a week, and I still don’t have the internet at home because Comcast is a turd with a sharp stick in it.

Still working on a new model for regular updates. Maybe I should just aim to update every week with a few paragraphs of light, disgusting anecdotes about poop and/or blood and/or stinky vagina holes, and once a month put out one of these huge rambling novels. I don’t think I can not write about this stuff—it eats me and makes me depressed when I’m not sharing it—but I would also like to find some way to be consistent and post regularly, because otherwise my coworker Franklin will harangue me politely until I lose my mind.

Seriously, ever since I showed that dude my blog, he’s followed me around the unit, picking on me nonstop to update. It’s both encouraging and kind of terrifying. Recently I was leaving a room, and as I went to elbow the door curtain out of the way, I realized Franklin had been standing behind it for god knows how long, just standing there waiting. “Update your blog,” he hissed cheerfully. I called him a creepy motherfucker and had the jellyfish shivers for the next ten minutes.

So there ya go, Franklin. You’re on my blog. You creepy motherfucker.


  1. I think I like Franklin. Maybe you should just do the regular poop explosion posts weekly and the books monthly. If it gets you to post regularly, please do. Your posts entertain, teach, and horrify me.

  2. Interestingly enough, Code Brown is an actual code at my hospital, we use it for "Missing Adult." Not sure why they couldn't have picked any other phrase, but there you have it.

  3. Thank you, Franklin. Thank you.
    RIP Crowbarrens. The story of your terrible illness and vile personality -- the way you treated your toxic little clan, and the way you died -- angered and saddened and inspired many people who you will never know.

  4. This comment has been removed by the author.

  5. You should coerce, I mean, gently encourage Franklin to write a guest post the next time he suggests it's been too long since you updated. :v

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