No, I Won't Do It.

There's this article, by some dude from Detroit called Rivers, perhaps you've heard of it--some weirdness about "Early Goal Directed Therapy" and some "Surviving Sepsis" type thing. Anyway, the upshot is that anyone who is septic--that is, has signs of a severe, overwhelming infection--should be aggressively resuscitated with tons of fluids, invasive monitoring, antibiotics, pressors, transfusion if needed, preferably (according to the original article) with expensive, slick-looking catheters. The kinds of catheters BMW would make if they were in the medical supply business. The kinds of catheters the resident gets yelled at for breaking.

This idea has saved a lot of lives, with interventions, and also with increased screening. However, the catheters have downsides; even the Toyota versions rather than the BMW versions are invasive. There's a big needle, and a wire, and it's stuck in a big vein, usually next to an artery, just above the lung. So, bad stuff can happen, and it's not like a Swedish Massage, either.

This seventy-eight, looks ninety-eight lady is brought in from the nursing home in her bathrobe because she's 'not acting right'. Of course, she's non-verbal at baseline, and lays on her side until someone turns her. Her legs are atrophied and contractured up so they no longer straighten. Her skin is taught like parchment. She looks at nothing, just generally up; one could imagine she looks to her eventual home. She doesn't moan or wail or complain--there's not enough left, I don't think. And yet, she's a so-called 'full code'--that is, we, as the medical establishment, should do everything to save her life, including push on her chest and break her ribs to force blood up to her damaged brain, put a tube in her throat, and stick her with needles.

Well, I'm sorry, family that can't accept the loss of your loved one that happened years ago with the first stroke, I'm not doing it.

I'm not going to lay her in a position where her head slopes down to make the vein bigger, clean her neck, and stick a long hollow needle in her neck. Do you know why? Because she's going to cry out, and try to move her atrophied, useless limbs towards me under the drape. Or worse yet, not even move. And I can't explain to her what we're doing. I can't tell her that there are risks to this but we should do it to bring her back to her baseline, because she can't respond at her baseline.

Those of us on the front lines are learning when to say no. No, this poor lady in the twilight doesn't need to be harpooned. She's going away gently already. The central line doesn't beat back time, or raise the veil.


In The Scanner...

They have to bring the CT bed all the way out from the scanner to reveal a foot-long rubberized platform; I consider standing on it for a second, then straddle it. The oximeter beeps. This chubby nine-year old breathes shallowly, eyes closed. The tool box is open beside us.

One of the RTs starts bagging for me; I've seen him multiple times, a large, happy presence at the head of the bed with great confidence that's infectious. Then we push drugs and thank you dear lord the clean, pink, kid-beautiful cords pop into view for the tube, and I've just tubed in the CT scanner. I breathe at the same time he does.

It's a maxim in Emergency Medicine that you never send anyone to the scanner that's unstable, because they die. The worst words you can year overhead aren't 'code 4', but 'MD to the CT scanner', because that means you've inadvertently caused someone to crash (or, at least, that's how it feels). This kid was hit in the head by the side window of a car driving by his school, and had been asking for his mom in spanish for about twenty minutes; he was sleepy enough for me to follow him down the hall, through three sets of double doors, and to sit in the CT control room, so I was there when his pulse ox was suddenly 86%. I'm pretty sure my staff walked into the control room just as I was passing the tube, and he looked a little pale when I updated him. Everything's under control. No problems. Just a bit of reversible hypoxemia. For both of us, since I didn't breathe the whole time.

He ended up not having much of anything; probably a bad concussion. Lucky, for all of us. Beware that scanner down the hall.