Bardos

Buddhism has this concept of transitions, or bardos, transitions between one state and the next. When a practitioner is prepared, they can be opportunities for enlightenment; for the unprepared, they can be terrifying. Buddhism captures the same fears and opportunities many religions do about death, just in a different framework. The picture is the 'big buddha' on Lantau island off of Hong Kong, which I saw in college--although my favorite was the tiny stone buddha in an alleyway in Kathmandu.

When I saw those buddhas and read about bardos I had never seen people die. From my perspective they really do withdraw; wikipedia above describes all these stages of the bardo of death--final breath, lucidity after the final breath, then the space until the next life. I feel as though my whole service right now is in that state--some stage on their way out. Three brain-dead patients between yesterday and today, two donating organs, preserved for now. I joked I was the angel of death. Now, I think not so much. That's too stereotyped, co-opted by the halloween crowd. Bardos are more my style. They're more real, too. Death can be terrifying, but maybe, if we prepare ourselves, it might be a transition to something else? I hope?

Old School

When my hands ache from four central lines and an arterial line, and I laugh inappropriately at the MRSA swab on the brain dead 20-year old overdose admission because I'm too tired to care about hiding my derision...

When my boss tells me to go upstairs and talk to the overdose girl's family and it's just me and two parents who have lost a daughter and the nurse...

When it gets to be one in the morning and I haven't even started my documentation for the three afternoon transfers...

When these shifts come along, they make us doctors.

For The Love of God, Wear a HELMET

Natasha Richardson's death is tragic and sad. No one is prepared for such an event, and the mysteries surrouding her case have prompted a rash of articles on traumatic brain injury on CNN and in the New York Times.

With the exception, finally, of this article on CNN, which actually advises people to wear helmets, gasp, everyone has been discussing imaging and neurosurgery. It was noted that the initial hospital didn't have an MRI scanner, as if that would've been used. It was noted that she could've had a carotid or vertebral artery dissection that would've required special imaging, and then 'months' in the NICU, as if the best imaging and the best critical care was what she was missing. Perhaps she needed a craniotomy, or better yet, a hemicraniectomy where half her skull was removed. Then, in a one-liner at the bottom of the article, we get, 'it might've helped to wear a helmet'. Maybe.

The autopsy report showed an epidural hematoma according to the AP. The ONLY WAY to get an epidural hematoma is by TRAUMA. Not some rare neck artery dissection, not some wierd syndrome, or Moya Moya, or an aneurysm.

I have some bad news for the public. If you get this injury, we can do virtually nothing to reverse the damage to your actual grey matter if it has already occured. Yes, you can get a CT scan and then a hole in your skull or your skull removed and we can reverse any coagulopathy and we can monitor you in a beautiful ICU and control your blood pressure to within strict parameters and monitor your blood sugar and correct your electrolytes and prevent clots and use new, fancy drugs, and protect your airway and eat for you and pee for you and poop for you and then give you the best in long, slow, painful rehabilitation...

Or you can WEAR A HELMET!!!

This post does not in any way disrespect the tragedy that befell Ms. Richardson. But, why, by all that is holy, in that aftermath, wouldn't you advise people to wear helmets strongly? Another ABC article starts with a debate over whether acute care would've made a difference, and on page 3 says, well, she should wear a helmet but 'there's little evidence' that a helmet would've helped. Well, shoot, let me go out and conduct a randomized controlled trial on helmet use. We'll put half our people in helmets, half not, and then ram them all into a snowbank and see what happens. Heaven forbid we advise safety precautions before we have 'good evidence'.

Everyone should wear helmets. They're warm, they're stylish, they have ports for headphones, and, contrary to some asinine contentions on CNN and other major media outlets, they don't restrict your peripheral vision or encourage reckless skiing. Please. Please. Wear one.

End of Life Care

I morbidly joke, usually on my ICU months, that when my time has come, I'm taking my morphine and going on a long hike.

The way we treat end of life care in this country bespeaks a discomfort with death that is bad for the dying. My jokes aside, ICU patients are often there for unexpected catastrophes: muggings, subarachnoid hemorrhages like time bombs in people's skulls, car accidents. That these people are alive is a medical achievement of high order.

However, as Buckeye Surgeon notes, the return on our investment is somewhat less than miraculous. After these catastrophes, despite our ability to image the smallest blood vessels in the brain, and measure a gazillion-and-one physiologic parameters, we rarely are able to restore full or even almost full function. As a pediatrician I was shadowing once said to a patient, 'we can fix some things, but if you fall on your head or neck, we can't always fix it'.

For families, this presents a problem. Some don't care; they bring the social security benefits form in for their comatose relative to 'sign' with an X so they can collect a check. Others are in the ICU room for days and days, monitoring tiny changes in progress. My wife blinked. My mom moved her toe when the doctor yelled in her ear.

I think we need a frank discussion in our society that makes it OK to transition to comfort cares. Hospice docs have long held that allowing a failing body to expire on its own is more comfortable than prolonging life. Gradually failing lungs raise CO2 levels and essentially sedate the dying patient. Procedures to monitor ICU patients, on the other hand, are often painful--bladder catheters, arterial catheters, needles, ventilators.

Don't get me wrong--these are life-saving advances. But when it becomes clear that the prognosis is poor, it should be easier to say, 'enough'. We need to face death and accept it, not hide it behind sliding glass doors and curtains.

Damn it all

Just had to intubate the Marlboro man, in room 3. Stubborn bastard wouldn't keep his sats up. Second time in a week.

This tube didn't feel like saving a life, it felt like ending it. He'll never come off the vent.

Scary

Room 1 is an 84-year old stroke, clotted off her whole left carotid. We had to place a central line. Her BP is supposed to be like, 220.

Room 2 is a forty-something with c-spine surgery that lead to fulminant meningitis on the ventilator.

Room 3 is a COPD-er who is breathing 30-40 and dropping his saturations to the low nineties on BiPAP who we are giving one last shot at breathing because if we tube him he will never breathe without help again.

Room 4 is an intubated subarachnoid hemorrhage who moves her feet, sometimes, and blinks.

Room 5 got tPA today and was bleeding from her IV, her ET tube, her NG tube, and her eyeballs when she arrived. Her blood pressure is supposed to be low. Pray I don't mix room 1 and 5 up.

Room 7 is a poor guy who got mugged for three dollars after his car skidded into a ditch and the person who offered to help him beat him up. He only moves half his body.

Room 8 is bleeding from her tracheostomy, has renal failure, and can't move because she's been here so long. She's having trouble breathing.

I'm the only white coat here.

Only six more hours until the others return.

Only five hours, fifty-nine minutes until the others return.

And so on.