Defying Augury

Although the acuity of the VA ICU patients is not as high as those in the "big house," we do occasionally get quite challenging medical mysteries. A patient with proven adrenal insufficiency by cortisol stim test simply cannot wean off stress dose steroids. In his month-long stay in the ICU, he kept on having recurring episodes of "sepsis." He has cyclic spikes in his temperature, drops in his blood pressure, and increases in his white count. He has multiple sources of infection including multiple indwelling lines, aspiration events, urinary infections, joint effusions, intraabdominal sources, and skin infections. Every time this happens, we increase his pressors, broaden his antibiotics, and put him on stress dose steroids. He gets better and after we get him off pressors, we start slowly inching back on his stress dose steroids and antibiotics. Soon thereafter, another episode happens and the cycle recurs again. It's frustrating because each bout of sepsis sets him back more and more, limiting his nutrition, accumulating insults to his organ systems. But we cannot keep him on high dose catabolic steroids and ultra-broad-spectrum antibiotics forever. His muscle mass has already wasted away and he's already had Clostridium dificile infections. We've consulted every service in the hospital and performed tests I rarely order like WBC scans. Yet he defies augury, and we simply cannot get him better. It's a sad story, and unfortunately, not an uncommon one in the ICU. It reminds me that modern medicine has its limitations.