Apparently I am merciless...

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Bostonredsox

Bostonredsox

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Case: 65 year old end stage biventricular failure with AICD and Biven pacer dependent and chronic loculated Pleural effusions with indwelling PleurX x 8 months. Right lung is complete white out. Sx says no way in hell will he survive VATS or decortication. Add in hes Jehovahs witness so no blood in terms of any surgical procedure. Fails bipap after 2-3 days of worsening Left sided pleural effusion, again the right is totally F'd at baseline with essentially no ventilable lung. Oh yes, also Severe sepsis from multifocal PNA, loculated in some parts of the effusions. Tubed him 2 nights ago as hes still full code. Worsens despite FiO2 steadily rising to 100%. No effect with diuresis as his MAP is in 50s on .5mcg of Levo. Full anasarca. We find out last night the reasonable brother is POA not the CRAZY F'ING 90 year old mom who wants to sue the hospital over everything wrong with her son...long discussions by myself, another senior, attending and CTsurg attending. He is denied transfer to 3 university tertiary cares as they say nothing left to offer at this point. AICD starts firing all day today as hes in sustained VT from hypoxia and the fact that HES TRYING TO DIE. no response to any meds. Start jacking fentanyl to quell pain. Again, long talk with family. Pt can answer questions on vent alertly. Agress enough is enough. CMO orders, terminally extubated. As I place magnet on Defib the mother, again 90 y/o 4'11 in a wheelchair, literally makes as if shes gonna hit me and calls me the devil and says im soul-less and have no mercy. Pt expires after about 45 min on NC with comfort measure drips.

Do not think I have ever worked so hard to try and do what is morally and ethically right for a patient and then get spat in the face by a family member. Was depressing.

FYI rest of family was totally on board and I think were holding out on this decision 2 days ago for fear of upsetting mom/grama.

Moral......we need physican decision making capacity for medical futility and unethical care. badly.
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30yo male with unexplained heart failure (E.F. went from normal to about 30% or less in a matter of weeks). No one knew what hit him although some advocated for alcoholic cardiomyopathy. He was in horrendous shape. Can barely walk. Got a hernia no one wants to repair because he probably won't survive the operation. Long story short he was basically dying. For some reason it was up to my friend (the medical student) to explain to him that. I was on a different service but saw her being yelled at by the guy about us not doing enough etc.

Tough to watch.

Oh and yeah you are a terrible person. Just like the rest of us.
 
Don't let the crazies bring you down. Of course we have to be professional and give due dilligence to explain. But you can't win an argument with crazy or stupid. You always lose.

They say never wrestle a pig - because you both get dirty and they enjoy it.
 
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Its just tiring. I walked in tonight to two sickies...a massive PE that got improperly lysed with TNK in ed and is in hemorrhagic shock and a BB OD/KyperK in complete HB with temp pacer....and I feel like the CMO talk was far more exhausting then these 2 combined. It shouldnt be this arduous to de-escalate care and allow a dying pt to die.
 
Tranexamic acid and priest for first one.

i had a double calcium channel blocker OD 2 yrs ago: diltiazem + nifedipine. given to a psych pt for "migraines." She ended up infarcting gut and later blowing a cerebral aneurysm. zero you can do.
 
jdh71 said:
high dose insulin
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We did that. glucagon, insulin, levo, DA, epi, dobuta, and vasopressin. Dialysis wont help. It was a nightmare. She was in her 20's. She made it through but then got ards, needed paralysis, roids for adrenal dysfunction, got myopathic, AKI, dialysis, DIC, Fungemia,trach, gtube, open belly left to heal by secondary intention, etc etc. after 4weeks of hell, POP, herniated....
 
VentdependenT said:
We did that. glucagon, insulin, levo, DA, epi, dobuta, and vasopressin. Dialysis wont help. It was a nightmare. She was in her 20's. She made it through but then got ards, needed paralysis, roids for adrenal dysfunction, got myopathic, AKI, dialysis, DIC, Fungemia,trach, gtube, open belly left to heal by secondary intention, etc etc. after 4weeks of hell, POP, herniated....
Click to expand...

Ugh.

Though I wonder . . . Were all the other pressors necessary on top of the high dose insulin drip. All the high dose pressors infarcting the gut.

It's cases like this that often bias my opinion that the MICU takes care of the sickest patients on the aggregate. It's not like I'm saying other critical care services don't get sock patients just not patients that train wreck so spectacularly as often. They get their sick patients way more "T'd" up than we do - I mean how often do we get patients simply because surgery or cards won't do anything or touch them with a 10 foot poll? Hell, half the places I rotate through I'm also taking care of cards patients too but that's a story for another day.

And it's a unit full of cases like this, that I think really get to ya. I mean you do some community MICU work and most of the time the patient comes in they usually live but spending a month in a university MICU which is often the literal last house on the block in any give state in the country and its a farking nightmare. I'm always fried by the time I'm done with a month at the U MICU.

We all know really sick patients die. But some days you just want to win one when everyone is dropping like flies.

Sounds like God/the universe was merciful to this patient with that brain bleed. Still makes you mad sometimes.
 
Unfortunately all the pressors/inotropes were needed. Each one added on as the previous was maxed. I've only been nervous a few times in my career, and this was one of those times. she'd brady down, vtach, bounce back, over and over. even the cards fellow couldnt figure out ekg/strips. .her age is what made me nervous. Hate to see a young person go on my watch.

other times:
1)tubing a 6yr old at childrens memorial ED with congenital airway defect while team doing chest compressions. awful but i got it after several tubes wouldnt go past glottis. froth from pulm edema flooding airway. aim for the bubbles...
2)community hospital, only doc at 3am=me, cant ventilate cant intubate morbidly obese...threw in LMA, taped the **** out of it, put him on vent pressure control 20cm...SUCKED!
 
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VentdependenT said:
Unfortunately all the pressors/inotropes were needed. Each one added on as the previous was maxed. I've only been nervous a few times in my career, and this was one of those times. she'd brady down, vtach, bounce back, over and over. even the cards fellow couldnt figure out ekg/strips. .her age is what made me nervous. Hate to see a young person go on my watch.

other times:
1)tubing a 6yr old at childrens memorial ED with congenital airway defect while team doing chest compressions. awful but i got it after several tubes wouldnt go past glottis. froth from pulm edema flooding airway. aim for the bubbles...
2)community hospital, only doc at 3am=me, cant ventilate cant intubate morbidly obese...threw in LMA, taped the **** out of it, put him on vent pressure control 20cm...SUCKED!
Click to expand...

To this point in my training, I've always had cavalry back-up for airways, and have yet to have that omfgairway moment where it's just me. I've seen these occur to the cavalry - I always try to pay attention. The airways seem to have, in many ways, been taken away from pulmonary/crit in many places, giving too many of us some experiencial holes in the training. Though, it's not like I don't ever intubate, but if I was the designated first crack at every airway that needed an ETT, I'd have quite a bit of nice experience at this point. Oh well, such is life and training.

"maxing pressors" is another topic that always makes me smirk, especially when dealing with nursing, how much extra "extra" alpha or beta action really occurs when you have multiple agents like levo, dopamine, dobutamine, and epi. I've always wondered in situations like this, why not just start the epi and crank it up? I mean there are plenty of papers showing equivalence between epi vs dobutamine + levophed, at least in septic shock.

We NEED a cases thread. I wonder if we should ask for it to be private?
 
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agree with cases thread.

I am fortunate to have had anesthesia training in terms of airway management and I try and teach as much as possible. However almost every pt I tube is in less than ideal circumstances to allow for trial and error by my peers.

That being said I couldnt even find the friggen cords in the bronch suite the other day! fellow nailed it first try. I have to learn how to do them without a jawthrust/tongue pull manuver (as I have had in the OR) WHILE passing it over a cramped oropharynx from damn bite block.

We have 2 new interventional pulmonologists here so there should be plenty of learning opportunities!
 
KLPM said:
30yo male with unexplained heart failure (E.F. went from normal to about 30% or less in a matter of weeks). No one knew what hit him although some advocated for alcoholic cardiomyopathy. He was in horrendous shape. Can barely walk. Got a hernia no one wants to repair because he probably won't survive the operation. Long story short he was basically dying. For some reason it was up to my friend (the medical student) to explain to him that. I was on a different service but saw her being yelled at by the guy about us not doing enough etc.

Tough to watch.

Oh and yeah you are a terrible person. Just like the rest of us.
Click to expand...

30 y/o with EF 30% is far from a lost case. Joking aside, either the numbers are wrong, or it's altered for dramatic effect.
 
VentdependenT said:
We did that. glucagon, insulin, levo, DA, epi, dobuta, and vasopressin. Dialysis wont help. It was a nightmare. She was in her 20's. She made it through but then got ards, needed paralysis, roids for adrenal dysfunction, got myopathic, AKI, dialysis, DIC, Fungemia,trach, gtube, open belly left to heal by secondary intention, etc etc. after 4weeks of hell, POP, herniated....
Click to expand...

Clear that you did all you could here. But FWIW there's some stories (I avoid the use of the word 'evidence' in the specialty of anecdotalology) that methylene blue might help in Ca channel block overdose refractory to the rest:

Ann Emerg Med. 2011 Dec;58(6):565-7. doi: 10.1016/j.annemergmed.2011.02.025. Epub 2011 May 5.
Methylene blue in the treatment of refractory shock from an amlodipine overdose.
Jang DH, Nelson LS, Hoffman RS.
Source
New York University School of Medicine, Bellevue Hospital Center, NY, USA. [email protected]
 
jdh71 said:
To this point in my training, I've always had cavalry back-up for airways, and have yet to have that omfgairway moment where it's just me. I've seen these occur to the cavalry - I always try to pay attention. The airways seem to have, in many ways, been taken away from pulmonary/crit in many places, giving too many of us some experiencial holes in the training. Though, it's not like I don't ever intubate, but if I was the designated first crack at every airway that needed an ETT, I'd have quite a bit of nice experience at this point. Oh well, such is life and training.

"maxing pressors" is another topic that always makes me smirk, especially when dealing with nursing, how much extra "extra" alpha or beta action really occurs when you have multiple agents like levo, dopamine, dobutamine, and epi. I've always wondered in situations like this, why not just start the epi and crank it up? I mean there are plenty of papers showing equivalence between epi vs dobutamine + levophed, at least in septic shock.

We NEED a cases thread. I wonder if we should ask for it to be private?
Click to expand...


Your point about just sticking with one and ratcheting it up is well taken. I've been a fellow/locum doc/attending at a few places now and there is so much variability - some centers like multiple pressors, other like to stick with one until it is determined to have no more effect if titrated upward.

In other words, there is no "maximum" dose -- at least in terms of an arbitrary number -- despite what nursing wants you to think. The "maximum dose" should be considered to be when either a) further titration upward results in no discernible benefit - "bang for the buck" if you will or,

b) complications of said pressor become evident (usually tachy arrhythmia or distal perfusion problems).

I think the truth is somewhere in the middle. As an axiom, I think less is more and I try to avoid adding extra pressors if I haven't reached my "max" (see above) on another. However, I think it is pretty clear that in any given patient, sometimes synergy occurs, i.e. with vasopressin as a pressor sparing agent.

Also, while I think the theoretical debate about which pressor is the "right one" to start for a given clinical scenario is worthwhile as it pertains to pressor #1, I think once you start adding 2nd and 3rd agents, all bets as to which is the "correct" pressor(s) are off. No one has ever (could ever!) do a study looking at what happens physiologically when several different pressors are whacked into the blood stream simultaneously. And it is evident to me after a decade at the bedside that sometimes people's individual complement of receptor genotypes and phenotypes make them react to a given pressor in a different way than the population-based studies say they should.
 
It's funny you mention that because I could intubated just about anyone with a bronchoscope.

Like anything else, you get used to finding the epiglottis and chords. It's probably muscle memory.
 
emergiQ said:
Clear that you did all you could here. But FWIW there's some stories (I avoid the use of the word 'evidence' in the specialty of anecdotalology) that methylene blue might help in Ca channel block overdose refractory to the rest:

Ann Emerg Med. 2011 Dec;58(6):565-7. doi: 10.1016/j.annemergmed.2011.02.025. Epub 2011 May 5.
Methylene blue in the treatment of refractory shock from an amlodipine overdose.
Jang DH, Nelson LS, Hoffman RS.
Source
New York University School of Medicine, Bellevue Hospital Center, NY, USA. [email protected]
Click to expand...


We had ZERO to lose. So I appreciate the info! This pt would probably ended up on an impella or ecmo if we had those at UL. We only have em at the huge private hospital we had.
 
jdh71 said:
It's funny you mention that because I could intubated just about anyone with a bronchoscope.

Like anything else, you get used to finding the epiglottis and chords. It's probably muscle memory.
Click to expand...

lol, thats exactly what one of our IP's told me! I can intubate just about anybody with a MAC3!
 
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Just wait JDH, the lady I damn near cric'd I couldn't even get the bronch past all the soft tissue/epiglottis. I even shoved a miller blade down to try and help, and nada.
 
I am going to find an airway course sometime this next year. I know they'll give me the time off for it, and might even pay for it.

Though, I think if I've got someone that I can't get a bronchoscope into, then I'm in trouble, because I'm not going to be better with a laryngoscope. Though perhaps in some situations a glide with a bougie might save my ass. Hell, I'd try retrograde intubation, seems straight forward enough. Though, I'd hope by that time I'd have someone who can do a surgical airway at the bedside setting up and getting ready.
 
If you go to the ACCP airway course, let me know how it is, I thought "the difficult airway course" was pretty good, but may consider doing another.
 
jdh71 said:
I am going to find an airway course sometime this next year. I know they'll give me the time off for it, and might even pay for it.

Though, I think if I've got someone that I can't get a bronchoscope into, then I'm in trouble, because I'm not going to be better with a laryngoscope. Though perhaps in some situations a glide with a bougie might save my ass. Hell, I'd try retrograde intubation, seems straight forward enough. Though, I'd hope by that time I'd have someone who can do a surgical airway at the bedside setting up and getting ready.
Click to expand...


By the time your done dickin around to find a guidewire, a needle driver, and a non safety 14g angiocath and pray that wire comes out nose (then may need 6.5 tube) or mouth quite some time will have passed.
 
jdh71 said:
I am going to find an airway course sometime this next year. I know they'll give me the time off for it, and might even pay for it.

Though, I think if I've got someone that I can't get a bronchoscope into, then I'm in trouble, because I'm not going to be better with a laryngoscope. Though perhaps in some situations a glide with a bougie might save my ass. Hell, I'd try retrograde intubation, seems straight forward enough. Though, I'd hope by that time I'd have someone who can do a surgical airway at the bedside setting up and getting ready.
Click to expand...

I am going to the ACEP difficult airway course in baltimore this september. 27th to 29th I think it is. 3 day course, about $1000, covered by my CME here. not sure where you are around the country but they have several from may-nov in like boston, b-more, vegas and N'awlins. They cover cric/retrogrades and all that good stuff.
 
jdh71 said:
To this point in my training, I've always had cavalry back-up for airways, and have yet to have that omfgairway moment where it's just me. I've seen these occur to the cavalry - I always try to pay attention. The airways seem to have, in many ways, been taken away from pulmonary/crit in many places, giving too many of us some experiencial holes in the training. Though, it's not like I don't ever intubate, but if I was the designated first crack at every airway that needed an ETT, I'd have quite a bit of nice experience at this point. Oh well, such is life and training.

"maxing pressors" is another topic that always makes me smirk, especially when dealing with nursing, how much extra "extra" alpha or beta action really occurs when you have multiple agents like levo, dopamine, dobutamine, and epi. I've always wondered in situations like this, why not just start the epi and crank it up? I mean there are plenty of papers showing equivalence between epi vs dobutamine + levophed, at least in septic shock.We NEED a cases thread. I wonder if we should ask for it to be private?
Click to expand...

I have done this a few times but the doses I have ended up needing to maintain MAP goal, and I usually have Vaso running at around 0.03-0.04 too, seem to have too much Chronotropic effects and im dealing with HRs in the 140s and impaired ventricular filling times. I seem to haveless arrythmogenic problems in the septic shocks with Levo/dobutamine then Epi. This makes sense to me as the problem in the septics is impaired SVR and thus alpha agonists are the biggest winners. the septics that maintain good ScvO2s without an ionoptrope seem to do better with Levo vs epi in terms of arrythmia and HR control.
 
IlDestriero said:
I think the prison system has put out some literature on the effects of high dose potassium. It's useful for all kinds of end stage pathology where patients are receiving prolonged and futile care. Have a look. ;)
Click to expand...

pretty sure it as the effects of cardioplegia....to a pt not having their heart operated on. But I am also pretty sure this is what you were getting at in the futile care pt ;)
 
Bostonredsox said:
I have done this a few times but the doses I have ended up needing to maintain MAP goal, and I usually have Vaso running at around 0.03-0.04 too, seem to have too much Chronotropic effects and im dealing with HRs in the 140s and impaired ventricular filling times. I seem to haveless arrythmogenic problems in the septic shocks with Levo/dobutamine then Epi. This makes sense to me as the problem in the septics is impaired SVR and thus alpha agonists are the biggest winners. the septics that maintain good ScvO2s without an ionoptrope seem to do better with Levo vs epi in terms of arrythmia and HR control.
Click to expand...

right

I don't personally see a great reason for epi, UNLESS you were also considering using levo+dobut

Though, epi probably does get more bad press than it often deserves.
 
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