A crazy week

So, my time in the ICU has come to an end, just in time for Thanksgiving. A symbolic end to a month where I have seen some of the sickest patients I have ever encountered. This last weekend I had to work both days in the ICU and had quite an experience.

One patient came in because of problems with a "G tube", which is a tube put in through the skin into the stomach to allow a person to be fed. In this patient's case it was put in because he had two massive strokes and could no longer swallow. When we looked at the CT scan of his brain, it looked like a significant portion of the right side of his brain had been removed. And there were changes in other parts of his brain that looked like what an old stroke would look like.

One of the effects of the stroke is that he has "expressive aphasia." He can understand what we are saying to him, but, when he tries to speak, he is unable to think of the words he wants to say. It's like constantly having something "on the tip of your tongue" but not being able to say it. So the primary way he communicates with us is through gestures. We later found out from family that he had surgery to remove part of his brain because of complications from the first stroke. The G tube works fine now but he's still in the ICU because he developed an infection, though he's been started on the right antibiotics and God willing will do well.

I guess this guy's case was so striking to me because I would never have guessed that more than half of the right side of his brain was taken out...

Another patient was a trauma patient, who was developing a pneumothorax, which is basically air in the lung. The air "leaks in" and one lung starts overinflating, pushing your windpipe to the other side and smushing the other lung down. It can happen after trauma, such as the motor vehicle crash this patient was in. So surgery was in the process of putting chest tubes in him, and I was there helping to hold his legs down while they did so. After getting the tubes in, they started suctioning through his mouth to get rid of some secretions, when he suddenly vomited blood, much of which landed right on me. There are few things more revolting than having blood vomited onto you, but I just reminded myself that I was there to help someone whose situation was much worse than mine. Since there was more than enough help around, I went out, showered and had a quick change of clothes...the patient will probably never remember me (he wasn't totally conscious) but I doubt I'll forget him anytime soon...

If all that wasn't enough, there was a patient who coded (heart stops) but was successfully resuscitated with CPR and, last I heard is actually doing well. Usually people do not fare well after resuscitation, so I was glad to hear this patient made it through...

Still another patient who has an abdominal aortic aneurysm (AAA), which is when the walls of the aorta (the largest artery in your body) get weak and the artery dilates. This guy's AAA was 6cm and he was so skinny you could easily palpate it through the skin. It's something you read about in physical exam books, but rarely get to see or feel. On top of all this, he had air leaking into his body, but in his situation we couldn't find any source or reason for it. The air was tracking all the way from his brain, in his chest (but not in the lungs, so he was breathing fine), and down into his abdomen. We got a bunch of CT scans in which we inject contrast, to search for the leak, but could not find one. The surgical team was going to do exploratory surgery, but since his clinical condition was stable and he had a large AAA that could rupture, they elected not to. Last I heard he was sent to hospice because his overall prognosis was poor. He is still something of a mystery, as I don't think anyone ever figured out where all that air was coming from. I hope, at the very least, that he is comfortable wherever he is. He seemed like a very nice man, a World War II vet.

Today, I had a lady who had a hypertensive, hemorrhagic stroke. Essentially her blood pressure was so high, it caused a blood vessel in her brain to rupture and bleed, causing a stroke. It was on the right side of her brain and she has left sided weakness. She could understand everything we said, and responded appropriately, but had a lot of slurred speech because of the stroke. Prior to the stroke, she was being treated for high blood pressure with more than 5 different blood pressure lowering medications, but she has a resistant form of hypertension. So the blood vessel ruptured, despite all the medicines we were giving to try and prevent that from happening.

She apparently has had many "mini-strokes" in the past (the fancy medical term is transient ischemic attacks or TIAs) but none caused any major neurological deficit. The stroke she just had, however, has caused her not only to slur her speech, but also to become weak on the entire left side of her body. She can no longer move her left arm or foot. I can only hope and pray that she makes some sort of recovery from this stroke. Apparently her mother and grandmother both died of strokes as well. The strange thing is she never smoked but she is diabetic (although she controls it well through diet alone, which is pretty impressive). In addition, her kidneys are barely working and she was likely going to start dialysis in the near future, prior to the stroke. Poor kidney function could also be at the heart of her resistant high blood pressure (renovascular hypertension) or maybe something more exotic like an arteriovenous shunt...another mystery, waiting to be solved...

I did also interview in Milwaukee on Monday for a prelim spot. Great program up there, really resident focused. I've started noticing that smaller cities in the Midwest really do a better job in terms of taking care of their residents. Plus traffic in Milwaukee is way, way less than Chicago. From where I live to get to the Chicago Medical District is a 2 hour drive in rush hour, just ridiculous. In Milwaukee, one of the attendings told me he leaves his house at 7:15am in order to start his 7:30am rounds...I really don't think you can put a price on that...

Well, enough blabbering...happy Turkey Day everyone...