Life and Death

Details for both these patients have been changed.

Being in the intensive care unit really reminds me that we care for those patients that straddle the ghostly boundary between life and death. Two patients are transferred to us from outside hospitals. One arrives with a catastrophic retroperitoneal bleed from a fall. She is bleeding into her back, but the surgeons in the other hospital do not feel comfortable operating and have no interventional radiology facilities. She has received a good amount of blood before getting here but requires further transfusions on arrival. I quickly intubate her for respiratory distress, put in an axillary arterial line, and send her to interventional radiology where the active bleeding artery is located and embolized. We all high-five each other, but upon returning to the intensive care unit, we find that the patient's lactic acid levels skyrocket from 2 to 10. Lactic acid is a reflection of ischemic or unoxygenated tissue. We don't know what's going on and decide to take her to the operating room where the trauma surgeons wash out the belly. Although we have a concern for ischemic or dead gut, there are no clinical findings. Nevertheless, upon returning to the intensive care unit, the patient's lactate drops quickly and the blood pH normalizes. We are able to extubate the patient, send her to the floor, and discharge her home in five days. We never find out what exactly went wrong; whether she had some small amount of peritonitis that needed a washout and antibiotics or whether we were just seeing a delayed reflection from the initial retroperitoneal bleeding. But occasionally supportive care without a definite answer is sufficient to get someone through a crisis.

On the other hand, we can know the cause of illness yet be unable to rescue a patient. A woman is transferred from a small community hospital several days post-operative from a gynecologic procedure. The outside hospital physicians initially believe the patient is simply having a slow recovery; bowel function does not return and the kidneys suffer a little, but these are not uncommon from an operation. Several days after the surgery, however, she is transferred to our hospital for consideration of dialysis. Shortly after she arrives, she has a witnessed cardiac arrest. The code blue team is able to revive her, intubate her, get adequate access, and send her to the scanner before getting up to the ICU. On arrival, her pH is 6.9 with a lactate of 20, nearly incompatible with life, and we have the looming job of resuscitation. Her belly is hard as a rock. The diagnosis is abdominal compartment syndrome; something in the belly is causing the pressures to skyrocket. We have to paralyze her, put in a dialysis catheter (my first), start broad-spectrum antibiotics, and normalize her blood chemistries as best we can. After she is stable enough to go to the operating room, the trauma surgeons open up the belly, and this time, they find dead gut. They resect as much of it as they can and leave the abdomen open. We don't know why she has such an intestinal injury or how it is related to her original surgery. However, necrotic bowel can lead to rampant infection, the abdominal compartment syndrome, and the cardiac arrest. Despite doing everything, the patient passes away the next day.

The similarity and proximity of these two cases made me think a lot about the intensive care unit. Two patients with intraabdominal catastrophes leading to a severe lactic acidosis had completely different outcomes. Looking back, we think that the first was salvageable, but the second was too late. ICU care, perhaps, is about finding those cases where a difference can be made.