“We Can‟T Kill Your Mother!” and Other Stories of Intensive Care
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Part 2 (pages 112-236) “We Can‟t Kill Your Mother!” and Other Stories of Intensive Care TABLE OF CONTENTS Preface.................................................................................... 1 1........................................................................................ Rounds 3 2..................................................................................... Overdose 14 3................................................................................. Call NASA! 25 4.................................................................. A Strange Pneumonia 33 5...................................................... Asthma in the Last Trimester 37 6................................................... “We Can‟t Kill Your Mother!” 45 7......................................................................... The Yellow Man 52 8.......................................................... Adult Respiratory Distress 57 9.......................................... Too Much Sugar, Too Little History 70 10...................................................................................... Crusade 79 11........................................................ “Just give me a cigarette!” 85 12............................................................................... Pickwickian 92 13......................................................................................... Coma 106 14............................................................................ Cocaine Wins 112 15......................................................................... Crisis and Lysis 119 16 ................................................................... Extraordinary Care 129 17........................................................................... Thyroid Storm 138 18............................................................... As High as a Giraffe‟s 147 19.......................................................................... The Red Baron 155 20......................................... “Mommy, why don‟t you hug me?” 173 21........................................................................... The Wild Man 206 22....................................................... „Lou Gehrig‟ Strikes Again 207 23............................................................................ “Shock Him!” 218 GLOSSARY………. .............................................................. 232 111 14. Cocaine Wins Lester Brown was a large man, at least 6 feet 2 inches and 240 pounds. Even asleep he looked menacingly big, someone you didn‟t want to wake up before he was ready. The day he was brought to the Emergency Department you could have shook and pinched and tickled Mr. Brown and he wouldn‟t bother you. He had a ruptured blood vessel at the base of his brain. It started at home. A few minutes after snorting some cocaine his posterior communicating cerebral artery began to pulsate, causing him to complain of “the worst headache of my life.” Seconds later he fell to the floor, unconscious. En route to the emergency department the artery burst and he suffered a full blown subarachnoid hemorrhage. The loss of an ounce of blood into the surrounding brain tissue relieved the arterial pressure and the hemorrhage ceased, but by then it was too late. Irritating blood washed over the normally smooth brain surfaces where it didn‟t belong and in the process shut down his central nervous system, or at least the part responsible for consciousness. Lester Brown lapsed into a deep coma. Mr. Brown was 41 years old and had been using cocaine for six or seven years. Like all cocaine-related knockouts, Lester‟s occurred not from a steady accretion of drug but from a single, exciting snort. Within 30 minutes after inhaling the cocaine he was in our ED, comatose and intubated, his breathing fully supported by a ventilator. A CT scan of his brain confirmed the clinical diagnosis. It showed blood everywhere, both within the ventricles of the brain and covering the outside surfaces. From CT scan he was sent back to the ED, where he awaited a bed in MICU [medical intensive care unit] to be opened up. While in the ED both neurosurgery and neurology consults were called. I also went down to the ED to evaluate him. His brother, three years younger but equally large and sinister looking as Lester, gave us the history. „Buba‟ Brown made no attempt to hide his and Lester‟s illicit drug activity; indeed, he recounted the details as if we knew all along about their habit and drug trade. “We just did our thing, man, and this happened. We didn‟t try to hurt no one. We just dealt with dudes we didn‟t know too well. Shit, man, this could‟ve happened to me. Mother fuckers!” He was plainly angry in a menacing sort of way but, for the moment, his anger was directed elsewhere. I scanned the ED and thankfully noted the two security guards on duty. Although Lester‟s hemorrhage was explainable by a sudden whiff of pure coke ) a well-documented cause of stroke ) his brother believed in a more sinister cause. “I told him not to buy off those guys,” he said, as if I knew who “those 112 guys” were. “Lester, he didn‟t think he had enemies. Man, what are you going to do? I can‟t believe this happened to Lester. Mother fuckers! MOTHER fuckers!” “What do you think they sold him?” I asked, more out of curiosity about the drug trade than belief that the answer would affect Lester‟s outcome. “Never you mind,” Buba said. “I know. And they know I know. Is he gonna make it? I mean, that‟s what I need to know now, Doc, is he gonna make it?” “It's too early to tell but it doesn‟t look good. The neurosurgeon and neurologist are on their way to see him now.” * * * It is axiomatic that all patients are treated without distinction in both the emergency department and intensive care units. The physical space, the level of nursing care, indeed the entire resources of acute care hospitals are the same for all ED and ICU patients. This equal level is not always true elsewhere in the hospital, where there can be distinctions between single vs. private rooms, private duty vs. staff nursing, care by private office-based physicians only vs. care by salaried staff physicians, etc. In the ED and ICU it doesn‟t matter if you are a pauper or king, drug addict or company president (or both). Care is delivered by the same people to everyone, and is based solely on assessment of the medical problems and the available resources. Notwithstanding equality of care in these areas, most physicians consider drug addicts and dealers the lowest form of life. We accept that they will lie, cheat, steal and, if necessary, kill to get what they want. But in the ED and ICU even the lowest of the low receives the same top notch care as anyone else, even if their physical problem is 100% drug-related. Doctors and nurses often ponder the irony that the life we save today may rob (or harm) us tomorrow. So Lester‟s drug habit and reason for coming to the hospital didn‟t matter. We would have done whatever necessary to salvage his brain regardless of the cause. Unfortunately there was just very little to offer. Within an hour of arrival to the hospital both neurosurgery and neurology consultants confirmed Lester‟s dismal prognosis. Apart from the fact that the neurosurgeon operates, while the neurologist is mainly a diagnostician of nervous system disorders, a principal distinction between the two specialists is the amount of words they leave in a consultation note. The neurosurgeon always writes what is necessary in a 113 page or less. The neurologist seldom makes do with less than two pages, and sometimes writes four or five. The neurosurgeon who consulted on Lester summarized the situation thus: “Massive SAH [subarachnoid hemorrhage, a hemorrhage into the brain]. Little hope for survival. Nothing to offer surgically.” This assessment took him only about 10 minutes in the ED. The neurologist‟s summary was a bit longer, and was not completed until after Lester had been transferred to MICU. He wrote: “In the presence of deep coma from SAH the prognosis for survival is very poor. Based on data from Levy, et al, (Annals Internal Medicine, March 1981, pages 293- 301), patients like Mr. Brown have a 74% probability of dying from SAH. However, given his specific neurologic findings, particularly the absent oculocephalic response [eye movements when the head is turned] and absent corneal reflexes [blinking when the eyeball is lightly touched], Mr. Brown‟s chance for survival is only 5%, and even at that he would in all likelihood remain in a vegetative state. I simply cannot be optimistic because of the size of his bleed and level of coma. Suggest discussion with his family regarding DNR [do not resuscitate] status. Thank you. Will follow.” Eight vs. 117 words to say the same thing. Yet both consultants were helpful. The neurosurgeon told us that brain surgery was no use, and that Mr. Brown could be transported directly to MICU; a stop in the operating room was not a viable option. The neurologist told us, authoritatively, what to expect and what to tell the family. * * * Once ensconced in MICU Lester had plenty of visitors. It was not easy to know who was related by blood and who by economic considerations. On his very first hospital day I was told he had “one brother and one sister.” The next day, two brothers and two sisters came to visit. He had no wife but at least two “girlfriends.” The only relatives I felt certain about were Buba, his younger brother, and their mother, an attractive, well-dressed woman in her early 60s. To facilitate