Pearls of ICU – At
the verge of life and death
In the name of Allah, Most Gracious
Most Merciful
It has been a
spectacular, interesting and rich four weeks of ICU rotation so far.
Each case has been an eye opener, more and more so when time is spent
next to patients and their family after heavily informative ward
round. Very interesting, in normal medical or surgical wards, we do
encounter cases that touch our hearts, but patients are normally
stable and do not need intensive care and monitoring. In ICU, the
environment is really different. As trainee intern, you are
surprisingly valued by all, from consultants to highly trained
nurses. Intensive care also means intensive learning, close
monitoring of system physiology and understanding how they interact
with each other. It is also an understanding of pathophysiology and
how drugs intervene in the physiological process to keep patients
basic homeostasis at satisfactory level. Having what defines human
being at the back of the mind, the focus will initially be about
sustaining life before starting to link life to complicated human
demands. It is also unique from medical perspective since it ties
three big fields of medicine nicely, namely medicine, surgery and
anaesthesia.
What is the core to
medicine? Some may argue it is medical sciences. Some may say it is
doctors. Others may say patients. We have seen in the history of
medical practice, medicine shifts from paternalistic model of doctors
telling patients what to do to a more patient-centred medical model
now. Tell us what you think is wrong with your body and we can share
the idea and goals of how to get you better. I came across a medical
article discussing about this issue and apparently, medicine revolves
around suffering so to speak. It is quite an interesting perspective
and I suppose it holds some truth in it especially when doing ICU
currently. Suffering teaches us a lot. Learning from suffering and
from seeing others suffer give us a push on how we can better the
situation next time. No wonder people involve in research, to find
answers to questions that may shine lights to others in their lives.
Hence, at the very least, learning and researching to ease the
sufferings would be the energy that drives the expansion of medical
dimensions including sciences, ethics, cultures, principles and
values as human being.
“Ask me any question
you feel like asking, but please don't ask the question why this
happens to your family”, said one of the ICU consultants in a
family meeting. Truly it is probably one of the biggest challenges by
doctors and medical professionals dealing with hugely emotional
situations and predicaments faced by the family. It is easy enough to
explain how secondary brain injury can be reduced and controlled. It
is probably easy enough to inform what can be done to treat what is
possible but to face patients or family members with possible answers
of why this has to happen to them will be something that no man will
have an answer. The answer will very much depend on reconciliation
between our own heart and our own faith. While people will suffer due
to physical debility, and all following consequences that shall
affect activities of daily life and quality of life, the main
suffering shall come from failure to reconcile oneself with one's
perception about why this has to happen to he/she.
I wish to share and
reflect over a few of the cases that I involved directly as a
clinical student.
A case of traumatic
brain injury and multiple injuries
Miss A is a 28 years old
lady who involved in a severe motor vehicle accident when her car was
hit by a carrier van drove at a speed of 100 km/hour. She was the
right back passenger wrapped by the car steel as the crash happened.
She sustained serious multiple injuries including fronto-temporal
hematoma, bilateral pneumothoraces, L forearm fracture, unstable
pelvic fractures, bilateral comminuted subtrochanteric femoral
fracture, left tibio-femoral butterfly fracture, right distal
phalangeal fracture also with R 4th toe laceration.
Her GCS has been very
poor on presentation with pupil size 2 mm L and R with sluggish
pupillary response to light, E1 V-intubated M1. She was sedated with
propofol and fentanyl infusion, intubated and attached to mechanical
ventilation. Blood transfusion commenced as well as crystalloid
transfusion to keep the SBP>90 and MABP between 50-70. ICP and CPP
monitoring were in place and ICP target outline by neurosurgical team
to be < 20 mm Hg. Hb target set at 110. Over 24-48 hours, she has
been left deeply sedated to ease metabolic demands as well as pain
and patient response which can shoot up the ICP. It was initially a
difficult ICU management trying to juggle between replenishing fluid
secondary to blood loss from pelvic and other bony fractures and
maintaining reasonable but not high MABP to limit ICP level.
Days afterwards when she
was weaned off sedative agents, she didn't show much response to pain
stimuli or commands. It went to an extent where we thought could this
be a locked-in syndrome which would then mean a big disaster for this
patient and her family. MRI could not be done due to ex-fix of pelvis
and nobody would want to be absolute that those metal/steel/carbon
would run alright through MRI machine. A few complications developed
throughout ICU stay but she was managed well. From neurosurgical
perspective, the chance for this lady was quite bleak. Given her
young age, there is a possibility of recovery but to what extent
shall be a continuous mystery. Severe traumatic brain injury as
reported by journals give 25% a statistical figure of patients who
are able to live independently again. That would mean one in four,
but who knows the fate for this lady. Nobody can tell given hugely
heterogenous outcome from severe traumatic brain injury. This patient
remained in vegetative state up till now, able to breath but
mechanically supported, heart is till beating but loss interaction
with the world and surroundings. This relates again to the quest for
the meaning of consciousness and being alive.
This patient, looking
from the bedside seemingly loss her autonomy, and things which
normally define human being. She is alive but bodily dead or perhaps
very minimal response. I still remember one day when her sister came
and visit, looking her from the side, trying to console the heart, to
ease the beloved sister on ICU bed, rubbing mostuiriser, grooming her
to give this sense of human being, tears collected in this sibling's
eye. Father was on the way since this family was not from NZ. No
medical insurance, no travel insurance, this will be a second huge
burden that awaits the family.
SubhanAllah, life is so
fragile, what initially planned as part of working holiday plan
turned out to be permanent severe disability which shall be endured
for the rest of the life for the patient and the family. 28, what a
young age. This also poses a big ethical question from Islamic
perspective as well as from general ethical perspective. Should we
wean the support very early on, but we don't know what shall be the
possible future, should we support and be aggressive like what was
done? Again, it is going to be a constant battle in medical world in
trying to tie between medical care, resuscitation and what it shall
mean for patients and family as well as what shall be the best
decision.
This is one of many
cases encountered in ICU, insyaAllah, hoping to write more when time
permits. But for now, it leaves a big thing to ponder about the
reality of life and death, to assume resuscitation or to leave the
present to take its course. As a muslim, it reminds a lot about
ahsanu a'mala, people with the best deeds. The creation of death and
life is to see who among humankind are best in deeds. May Allah gives
us strength to learn this sign and to constantly better ourselves,
inculcating humanity in the heart, responding to His call and serving
people in difficulties. Oh My God, Grant us guidance, piety and
richness in our heart, as well as the love towards the poor.( du'a of
prophet Muhammad saw after the event and encounter with Abdullah Umi
Makhtum).
Abu Asr
7/2/2012
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