Who is alive: man or machine?

Originally published on KevinMD

He had cardiomyopathy and CHF for over 20 years. At the time, doctors told him he could die at any time. That was 20 years ago. His EF was 10 percent — barely livable.

Two decades later, this admit kept him on a see-saw with respiratory distress, a bad heart, bad lungs, atrial fibrillation with RVR and heart rate in the 140s all day long. He progressed from nasal cannula to Optiflow to 100-percent BiPAP. A Cardizem drip was added to no avail. His next step would be intubation.

I pulled his wife outside of her husband’s room. And I told her that he wasn’t doing well and we may have to progress to a ventilator, and not to let him drink anymore — aspiration and aspiration pneumonia.

I could see the years of suffering on their faces. The dedication and love they had for each other.

His wife agreed. But 20-minutes later, she came to talk to me.

“We don’t want a ventilator. We’ve dealt with this for over 20 years. He doesn’t want a ventilator,” she said.

I grabbed our intensivist and gave her the heads up. She talked with the wife and the patient who both requested a DNI.

The patient stated he would go through one round of CPR … just one round. A strange request, I thought.

The MD added DNI to the patient’s chart.

An hour later, his wife came to talk to me again, “This doesn’t make any sense to not put him on a ventilator but to do CPR and crush his ribs and hurt him when we know he has a bad heart and lungs. I think it would be cruel! He’s ready to die. He told me so. We don’t want to see him suffer anymore. He just wants to be pain-free. No more pain and suffering.”

I could see the years of suffering on their faces. The dedication and love they had for each other.

Back in the day, we had a universal policy: All or nothing. Either a full code with CPR, intubation or nothing at all. Now patients and families can choose. There are different variables: no intubation but do CPR. Or give ACLS meds but no CPR. Many of these variables/ protocols make no sense to me, but the families and patients get to choose.

I agreed with Mrs. Smith and explained to her as we were surrounded by three respiratory therapists that by not intubating but doing CPR one time was like giving him a car but telling him he couldn’t have any gas.

The respiratory therapists agreed.

I introduced the thought of morphine in small amounts. A 2 mg IV push helps with breathing and anxiety and air hunger.

She agreed. And Mr. Smith was made a DNR/DNI.

The man’s family came from near and far. His sons, daughters, sisters, brothers, his buddy from elementary school, his favorite chaplain and his wife. They all sat by his side and kept vigil. They shared stories of Mr. Smith as they laughed and cried.

As Mr. Smith nodded in and out of consciousness, they held hands and hugged one another as a tear rolled down Mr. Smith’s cheeks.

We made Mr. Smith “comfort care.” And that’s what it means: providing comfort at end stage lung, kidney, heart, liver diseases, terminal cancers and multi-system organ failure.

Morphine was given as needed for comfort.

And we watched Mr. Smith drift away from our universe — the inevitable.

I cry as I write this. But I rejoice in knowing that we did not torment this man with CPR, cracked ribs, ventilator, wrist restraints, central lines and dialysis.

I remember something my husband once said to me,”Who is alive: man or machine?”

One and done: a heroin and fentanyl cocktail

Originally published on KevinMD

There was her 28-year-old daughter lifeless in an ICU bed.

Her name was Tricia, and she had dabbled with drugs since she was 15. As a child, she was artistic, adventurous, and always found excitement with other kids who tended to do risky things. She’d justify their behavior and say they were more fun and had better personalities.

Eventually, her mom and dad moved to a small town thinking it would be a safer environment. But when Tricia started middle school, she again sought friendships with those “bad kids” on the edge.

It was as if she was heading down a path of destruction her whole life.

But her unsavory friendships didn’t keep her from excelling scholastically. Tricia was quite the student: she was smart, absorbed information in a flash and had a mind like a computer that was always on. And she was especially good at biology and chemistry. In fact, she obtained a bachelor’s degree in chemistry — she was that smart.

After college, she landed a decent job. A job that paid the bills and her drug habit.

Heroin costs less than Percocet pills on the street. But there was also a new way to get high in town. The “ultimate high.”

The combo: Heroin laced with fentanyl.

ER docs and nurses call this mixture “one and done.”

But that didn’t matter to Tricia or the crowd she hung out with. Even though they heard that this combination killed, they were willing to take a chance. They knew it wouldn’t happen to them.

After all, weren’t they invincible?

Apparently, they weren’t.

A car sped up to the ER entrance, and Tricia was pushed out right before her “friends” put the pedal to the metal and took off. Workers later said it was too late to capture the license plate. All they knew was that it was a red Mustang. Other than that, the occupants of the vehicle were a mystery.

There was her body on the cold pavement. No pulse. No breathing.

“Code Blue” blared throughout the hospital.

CPR, intubation, central line, loads of normal saline, Levophed, and vasopressin — it took over 20 minutes to gain a pulse on Tricia. They found opiates in her blood.

Her “friends” had thrown her wallet out when they dumped the body. That’s how the hospital identified her.

But her mother already knew something was up. It was a week since she last heard from her daughter, and Tricia usually called every other day. After dealing with Tricia’s friends who “knew nothing,” mom called the police who heard of the dump and referred her to the hospital.

The ICU nurses understood she was dead. It was just a matter of time after so many hours of ineffective “Code Cool” protocols. We lowered her temperature to preserve her vital organs, but it was too late. She was down for too long.

Her mom rushed in, shook her beloved daughter’s arms and screamed, “Wake up, Tricia! Wake up!” The only movement was a decerebrate response.

Tricia moved her mom thought.

“She’s moving!” her excited mom yelled to the nurses. But we had to explain to her that movement from decerebrate response is one of the worse signs of neurological damage.

Tricia’s body was rigid with head and neck arched backward.

After EEGs, MRIs, cold caloric tests and failing “Code Cool,” the promising, smart, adventurous woman with a chemistry degree was pronounced brain dead.

Another one down.

One and done — the ultimate high.


Was it really worth it, Tricia?

Heroin and fentanyl. They call it “Theraflu,” “Bud Ice” or “Income Tax.” And it’s happening across the country in cities and town big and small. Some are lucky. Some get to the ER in time. Naloxone (Narcan) IV push can reverse heroin. But when it’s laced with fentanyl the chances are much slimmer like Tricia’s case.

Should you know someone or YOU are that someone, get help. Get treatment. Go to rehab. You can start over.

Do something or accept and expect that you might be six feet under.

Remember, it’s one and done.