Inside God's Shed: Memoirs of an Intensive Care specialist

Preface

I served as an Intensive Care specialist (Intensivist) for almost 40 years at five South Australian intensive care units, initially working at the Royal Adelaide Hospital intensive care unit (ICU, then at the Flinders Medical Centre ICU and also at three of Adelaide's private hospital ICUs. I retired from full time clinical practice and apart from some teaching and research sessions, most of my time now is spent with my dear wife, our three sons, and eight grandchildren. My moniker 'Tub' was given to me as a tease during my grade four year at St. Leonard's primary school, where I was perhaps as wide as I was tall. I have always accepted it as a term of endearment.

During my professional life I published many scientific articles and wrote several books on intensive care medicine. I was the editor of the Australasian intensive care medical journal Critical Care and Resuscitation (Crit Care Resusc) from 1999 to 2005. In this journal I published numerous human-interest stories as 'occasional essays', 'point of view' articles and editorials, highlighting some of the day-to-day issues that intensive care (critical care) specialists faced. As these stories appeared to resonate with many health care workers, I have decided to republish some of the articles, in modified form, along with the remaining untold essays, to complete my portrait of a general intensive care unit.

While the memoir will be of interest to the general reader, as it breaks down many of the medical stereotypes found in novels and TV shows, the text is predominantly that which will be familiar to health care professionals (i.e. doctors, nurses and paramedics). Nevertheless, to help the general reader, I have provided an 'Abbreviations and Glossary list' (see page ix – x) and have included a key to many of the acronyms used within each story. However, to give an explanation of each medical term or to sanitize the stories in a way to make them completely understandable to all, I believe would have ruined the spirit of the tome.

The stories in this book are true encounters, although many of the names have been either changed, or are not included to protect the grace and dignity of those involved. Those who are identified are already known and their stories are on public record. In looking back I trust that I have reflected with honesty, humanity and humour, and given a useful insight into the workings of major intensive care units.

Dr. Lindsay I. G. Worthley

AM, MB BS, FRACP, FANZCA, FCICM

February 2014

Abbreviations and Glossary

A&E –– Accident and Emergency

Actrapid –– recombinant human insulin

ALT –– alanine aminotransferase (high blood levels in liver disease)

Ambu bag –– a hand operated breathing bag

ANZICS –– Australian and New Zealand Intensive Care Society

AST –– aspartate aminotransferase (high blood levels in liver disease)

BE –– base excess measures alkali and acid capacity in blood

Bradycardia –– slow pulse rate

CAM –– complementary and alternative medical therapies

CPR –– cardiopulmonary resuscitation

CRP –– C-reactive protein (high blood levels with inflammation)

Cyanosed –– bluish discolouration of skin, lips and fingernails

CV –– curriculum vitae

CVC –– central venous catheter

DDAVP –– 1-deamino-8-A-arginine vasopressin (increases a blood coagulant factor)

DT’s –– delirium tremens

EACA –– epsilon aminocaproic acid

ECG –– electrocardiograph

ECM –– external cardiac massage

Gelofusine –– an artificial plasma substitute

GTN –– glyceryl trinitrate

Hartmann’s solution –– a compound saline solution for intravenous use

HBV –– hepatitis B virus

HCV –– hepatitis C virus

HDU –– high dependency unit

HIV –– human immunodeficiency virus

Hypoalbuminaemia –– low blood albumin level

Hypoinsulinaemia –– low blood insulin level

Hypokalaemia –– low blood potassium level

Hypotension –– low blood pressure

Hypovolaemia –– low blood volume

Hypoxic –– low blood oxygen level

IABP –– intra-aortic balloon pump

ICP –– intracranial pressure

ICU –– intensive care unit

INR –– international normalised ratio (measures coagulability of blood)

Intensivist –– Intensive Care specialist

i.v. –– intravenous

Inotropic agents –– agents that enhance cardiac contractility

Kyphoscoliosis –– abnormal curvature of the spine

LD –– lactic acid dehydrogenase (high blood levels in liver disease)

Marlex –– a plastic mesh used to reinforce a body defect (e.g. to cover a hernia)

MET –– medical emergency team

NFR –– not for resuscitation

PaCO2 –– partial pressure of carbon dioxide in arterial blood

PaO2 –– partial pressure of oxygen in arterial blood

PaOP –– pulmonary artery occlusion pressure (high in heart failure e.g. > 18 mmHg)

Percutaneous –– directly through skin

Pyrexia –– elevated body temperature

RAH –– Royal Adelaide Hospital

RBC –– red blood cells

RCT –– randomised controlled trial

SNP –– sodium nitroprusside (an intravenous agent used to reduce blood pressure)

ST –– part of an ECG trace that reflects cardiac injury

Swan Ganz catheter –– right heart flotation catheter (used to measure intracardiac pressure and cardiac output)

Tachycardia –– fast pulse rate

VF –– ventricular fibrillation

VT –– ventricular tachycardia

Introduction

If I had my life to live over again, I would have made a rule to read some poetry and listen to some music at least once a week; for perhaps the parts of my brain now atrophied would have thus been kept active through use. The loss of these tastes is a loss of happiness, and may possibly be injurious to the intellect, and more probably to the moral character, by enfeebling the emotional part of our nature.

Charles Darwin

Mum he's touching me! I stopped the car. My wife got into the back seat and positioned herself between our two eldest boys.

Muuuuum . . . he's looking at me!

I looked through the rear vision mirror to see my youngest son Daniel, being nursed by my wife. He was smiling, oblivious to the bubble of mucus protruding in and out of his nostril (he's now a gastroenterologist). On my wife's right side was my eldest son Stephen (now a cardiologist), protesting that my middle son Matthew (also a cardiologist), on her left side was 'looking' at him. Matthew was staring out the window trying to look as if he was an innocent bystander.

As I was remembering these early years, approximately 35 years later, Matthew opened my office door and asked me to help him with a cardioversion for one of his patients. We both worked at the same private hospital, and the intensive care specialist on call – me on this occasion – often provided the anaesthetic for cardioversions required by the visiting cardiologist – him on this occasion.

Sure, mate I said, and wandered down the hallway chatting idly about friends who had been staying with us for the last few days. I had approximately one year left before I retired: 57 weeks to be exact. I was enjoying my clinical practice, unencumbered by teaching, research and administrative duties, as I had retired from my public intensive care practice more than two years previously.

Interestingly, as I aged I began to think more about my patients: their diagnoses, ongoing management and likely prognoses. At night I would try to get to sleep by performing a mental intensive care unit ward round, and if awoken by someone requesting me to see a critically ill patient, I needed to listen to an album by the 70's 'soft rock' group 'Bread' while driving in, to allow me to calmly consider the patient's problem. I was finding it more and more difficult to psychologically escape the unit. My retirement was probably necessary for my well-being.

Now, six years after performing the anaesthetic for Matthew's patient and five years into my retirement, I have decided to publish a number of stories about my professional life. I trust that most of these stories have held the test of time and that from this distance I can see a little clearer.

Section 1. Clinical practice

What are intensive care units?

"ICUs are areas where extraordinary accomplishments and extraordinary waste live side by side, and often where no serious attempt is made to draw a line between the two."¹

G.C. Carlon

The intensive care unit (ICU) is a dedicated hospital area designed for the management of patients with sudden, or potentially sudden, and reversible life-threatening conditions. It is the central hub of a major hospital and contains specialised monitoring devices including machines to measure cardiac rhythm, blood pressure, blood gas and blood biochemistry; as well as life support equipment that include defibrillators, mechanical ventilators, circulatory pumps and dialysers – to support a failing heart, lungs or kidneys. It is staffed by medical and nursing specialists who are trained and skilled in diagnosing and treating immediate life-threatening conditions.

It is commonly believed that intensive care medicine, as a specialty, began with the 1952 - 1953 Danish poliomyelitis epidemic, where Bjørn Ibsen and Henry Lassen at Copenhagen's Blegdam Hospital reported a reduction in mortality from 87% to 25% in more than 300 polio patients treated by prolonged mechanical positive pressure ventilation. They ventilated patients through a tracheotomy tube to maintain respiration (oxygen delivery and carbon dioxide removal) and protect the airway while the polio-induced respiratory muscle paralysis resolved.² Subsequently, an earlier paper by Albert Bower was discovered in an obscure medical journal, which reported a survival rate of 83.7% in 129 polio patients at the Los Angeles County General Hospital using long-term positive pressure ventilation.³

For the previous two decades, positive pressure ventilation tended to be restricted to operating rooms, whereas negative pressure tank ventilators were used for prolonged mechanical ventilatory support. However, as severe polio caused both respiratory muscle and pharyngeal muscle paralysis, mortality was not reduced when negative pressure tank ventilators without a tracheostomy were used, as the patient would suffocate in their oral and respiratory secretions.

Following the success of positive pressure ventilation in the management of polio victims, intensive care units were created during the 1950's and 60's throughout Europe, the UK, USA and Australia. The specialty of intensive care medicine also developed with the formation of numerous intensive and critical care societies and colleges, which provided specialised training and accreditation in acute medical care.

Fundamentally, intensive care units provide critical support for vital organs while specific therapies – for example surgery, intravenous fluids, antibiotics, etc – allow enough time for the body's natural reparative processes to resolve the acute illness. William Knaus encapsulated this by saying The best a good ICU care can accomplish is to reverse acute physiological abnormalities and buy time. If during this time, therapy works or the body mounts its own attack, the patient will live. If not, then all ICU care can achieve is delay.⁴ While amazing results can be achieved when patients are managed in these units, distraught relatives and occasionally inexperienced practitioners may have unrealistic expectations. The patient, at best, can only be returned to their prior condition; the chronic underlying illnesses are rarely, if ever, corrected by ICU treatment.

REFERENCES

1. Carlon GC. Just say no. Crit Care Med 1989;17:106-107.

2. Trubuhovich RV. In the beginning. The 1952-1953 Danish epidemic of poliomyelitis and Bjørn Ibsen. Crit Care Resusc 2003;5:227-230.

3. Trubuhovich RV. On the very first, successful, long-term, large scale use of IPPV. Albert Bower and V Ray Bennett: Los Angeles, 1948-1949. Crit Care Resusc 2007;9:91-100.

4. Knaus WA. Changing the cause of death. JAMA 1983;249:1059-1060.

The surgeon is pleased with the operation

My advice to you concerning applause is this; enjoy it but never quite believe it.

Robert Montgomery

I was on duty at the private hospital ICU and awaiting the arrival of the third cardiac surgical patient planned for the day. It was late on Friday night and the patient had already been in theatre for three hours. The first indication of any activity came when the theatre nurse entered the unit requesting an intra-aortic balloon pump (IABP) to help disconnect the patient from cardiopulmonary bypass without causing a severe reduction in blood pressure. Apparently, the surgeon had attempted to take the patient 'off' bypass in theatre twice previously but without success.

When asked about the patient's condition, she rolled her eyes and said A lot of swearing is going on.

Terrific! I thought, I knew the likely scenario. The patient would be returned to the ICU on a large dose of adrenaline, with a temporary pacemaker, blood would be welling from all chest drains and the balloon pump would be 'ticking away' on full augmentation.

I phoned my wife to tell her the news. I'll probably be home some time after midnight, sweetie.

After another 45 minutes, the doors of the ICU suddenly opened and the patient was brought in with a constant beeping of the cardiac monitor, clanking of drainage bottles and hiss of oxygen. After the bed was correctly positioned, I wandered over to the patient and watched the nursing staff go into automatic mode: shift the mechanical ventilator into place, help the anaesthetist connect the anaesthetic circuit to the ventilator, disconnect the cardiac leads from the defibrillator and replace them with the ICU monitoring leads, reconnect the chest drain suctioning system and tidy the bed.

Not a pretty sight, the anaesthetist said as he pulled his gloves off. The adrenaline is on 20 micrograms per minute with occasional boluses to keep the mean arterial pressure above 60 mmHg, and that's with full balloon augmentation. Oh, by the way, he added, the pacemaker sometimes doesn't capture, leaving an underlying nodal rate of about 30 beats a minute with bursts of VT which usually revert spontaneously – although we had to shock him twice for VF before we left theatre.

Terrific. The patient's good then? I said with a heavy dose of sarcasm.

Hmm . . . he smirked, half closing his eyes have fun! He left carrying the portable oxygen cylinder, defibrillator, and the latest 'Home & Garden' journal under his arm.

The surgeon arrived 5 minutes later. He's got diabetic coronary vessels – small, deep in fat, impossible to get at. I had to put five grafts in to try and resurrect some blood supply to a totally wrecked left ventricle he grumbled.

Uh, I said pumping in the third pint of blood, adding he seems a little 'wet', so we are also giving him platelets, fresh frozen plasma and some DDAVP. What was he like when you closed him?

He wasn't too bad. What about trying some EACA? the surgeon replied.

Sure I said, although I believed that EACA administration would just be tinkering at the edges as the chest drain loss suggested a surgical bleeding problem. We will see what we can do.

He turned and left saying that he should be home in 20 minutes, and for us to let him know if there was any change.

The ICU charge nurse hurried in and said that she had just been talking to the relatives in the waiting room and that they wished to see the patient.

Could you please usher them into my office. I will have a chat to them first before they come in and see him, I replied, now pumping in the fourth unit of blood.

Thankfully, for the next ten minutes, the patient appeared to be relatively stable, so I thought that I would take the opportunity to talk to the family.

His wife and two daughters were sitting nervously in my room around the conference table. They looked intently at me as I walked in to join them. How is he, doctor? the wife asked.

Well . . . I said, perhaps I will begin after you have filled me in with what you already know, so that I don't have to travel over old ground again. I pulled my desk chair around so that I could sit with them at the table.

Well doctor, the surgeon said that he was pleased with the operation, and that apart from a few problems, he should make a good recovery – although he did say that he was still critically ill at the moment and needed to get over the long anaesthetic. He said that the next 6 to 12 hours would be crucial.

Pleased with the operation! Make a good recovery! But why should I be surprised? I don't think that I have ever heard a surgeon talk to a patient about his or her operation and say that they weren't pleased with the operation. However, in this case, the patient was in ICU and dying, and perhaps, as far as the family could tell, if he did die, the ICU specialist (i.e. me) would be largely responsible.

As with so many conversations with relatives of patients who are critically ill and being managed in the ICU, a realistic description of the situation without telling them to lose all hope is required. Such statements as we will be doing everything possible and please be patient and he will be in no pain and at least he has not deteriorated are often used to calm frayed nerves, particularly when the ICU episode drags on for days.

Thankfully, the patient did survive, after: returning to theatre 4 hours later to treat the surgical bleeding problem (none was said to be found, yet the blood loss became a trickle immediately afterwards), 18 units of blood, 4 packs of fresh frozen plasma, 2 packs of platelets and 7 days on the IABP, to be discharged from the ICU after two weeks.

He returned to the ICU ten days later in a wheel chair pushed by his beaming wife. He had just seen the surgeon who was pleased, and probably relieved, at the final outcome. His wife wished to thank all the medical and nursing staff involved. He appeared to be slightly confused while shaking the hands of all and sundry, with porters and cleaning staff joining in. He did not remember being in the ICU at all, and certainly did not remember me, although he did remember the ICU nurse who looked after him just before he was discharged from the unit – he said she was an angel and gave her a large box of assorted sweets as a gratuity.

Such is life in the ICU. If you wish to be remembered by an eternally grateful patient, after spending hours of your mental and physical energy attempting to avert an impending death, don't become an intensivist.

So we think it's all over

"Never give in. Never give in. Never, never, never, never – in nothing, great or small, large or petty – never give in."

Winston Churchill

I was wandering through the Accident and Emergency (A&E) department one Monday evening when I came across