Cinderblock was originally published by InterText.
It's another late afternoon at work, all of us rushing around like mad to get things done so we can sign out to the on-call team and get home. Service on the Intensive Care Unit makes for pretty full days -- not necessarily breakneck pace all the time, but you go directly from one task to the next all the same, with very little downtime.
My part of the team is composed of three individuals: an upper-year resident, an intern and me, the medical student. There are three such groups making up the unit team as a whole, in addition to the critical care nurses and assorted medical techs, without whom the whole works would come to an abrupt, grinding halt. If you do the math, it works out to three or four care givers for every patient, twenty-four hours a day. The whole circus is overseen by the Attending and the Fellow, who somehow manage to give us enough slack to run things on our own while managing through some arcane trick of omniscience to know everything that transpires even as it goes down.
The three of us are working our way through the litany of routine afternoon tasks when news comes down from the Powers That Be that we're getting a transfer from an outlying hospital. Word is that the hit will be a 27 year old shooter with right-sided endocarditis. In itself an infected heart in an intravenous drug user is no big deal. It's serious, don't misunderstand, but not good reason in itself for transfer to our facility.
The catch is that her course has become complicated by septic emboli to her lungs, which changes the picture dramatically. With all those nasty bacteria in her blood and lungs producing their various toxins, she's developing full-blown ARDS, the adult respiratory distress syndrome. ARDS is bad news - your lungs suffer some sort of insult which causes the exchange surface to stiffen and swell up, and you die by slow suffocation.
There's also a brief mention that she might have suffered a miscarriage, but it's unclear if anything has been done to address that aspect of her illness. We're told that her boyfriend was recently diagnosed HIV positive. Before we even see her, it's sounding like a really ugly scene.
Some hours later, she actually arrives at our hospital. We meet her on the helipad only to discover that she's in the process of dropping her pressures, her sats, and you can damn bet her level of consciousness. At the time of her arrival she is very nearly in cardiac arrest. We manage to get her to the unit bagging her all the while, blowing huge volumes of pure oxygen into her lungs with a blue plastic squeeze bulb about the size of a rugby ball. The air goes from the squeeze bulb through a large-bore tube which passes through her mouth and into her trachea.
"What's her name," I ask, and amidst the confusion someone from the transport teams shouts, "Carmen."
"Okay Carmen," I tell her, leaning over her face so she can see me, "try to relax and let us breathe for you." She looks terrified out of her mind, eyes wide and jumping around crazily as she attempts to comprehend what is going on. Her blood pressure remains dangerously low, and we consider starting a norepinephrine drip.
Norepi's interesting stuff - it's the heart of the rush you get when you nearly fall from a great height, or you come close to killing someone in a blind rage. It does lots of funky things to your body, among them cranking your blood pressure through the roof.
We get the drip hung just in time for her to start to recover on her own. IV's started, lines working, numbers improving, then the magic word: Oops.
"Oops what?" I say, looking up quickly at the nurse who uttered it. "What do you mean, 'oops?'"
"Well, I just flushed your new IV with norepi," she says, looking sheepish. I look over at the monitor, and the flickering amber numbers there make the fact abundantly clear. It's okay though - Carmen is young and resilient. A couple of minutes later her blood pressure backs down out of the stratosphere, and she's looking sort of alright.
"Alright" is relative though. She's awake and terribly frightened, but she looks sick. Even though she's very weak, her reflexive efforts to fight us are starting to become an impediment to our various interventions. It soon becomes apparent that we're going to have to put her down. Her lungs are in sorry shape indeed, you see; and it turns out that our standard ventilator, which is a marvel of flexibility and clean design, simply lacks the brute power to develop enough pressure to inflate them. Her convulsive attempts at breathing are ineffective but are still enough to badly confuse the sophisticated computer which runs the machine, making the problem even worse.
In other words, for us to be able to manage her dire status we will have to paralyze and sedate her. We give her a bolus of a close relative of curare, and add in a whopping huge dose of one of Valium's myriad offspring. She drifts away from us in a pharmaceutical haze, rapidly becoming oblivious to the gross indignities we are committing upon her.
The boyfriend tested HIV positive, but we're told that Carmen's serology came back negative. She has children.
She also has stiff, horribly damaged lungs. Over the course of time, bacteria from her skin have gained access to her circulation by way of the needles she uses to inject smack or coke or speed or whatever it is that she likes to shoot. Generally speaking, getting a couple of bacteria into your bloodstream isn't such a big deal. You and I probably become transiently bacteremic every time we brush our teeth vigorously, a few bugs making their way from traumatized gums into our blood. Our immune systems laugh at this small innoculum though, effortlessly clearing it in moments.
Carmen, on the other hand, has been injecting her circulation with nasty skin flora in rather large numbers, and has been doing so for quite some time. The critters have taken up residence on the valves of her heart, causing the edges to heap themselves up into little septic mountains. Not only does this render the valves useless because they no longer fit together cleanly, but it seems that chunks of septic tissue have broken loose from them to seed her lungs. The bacteria make toxic products, and her own immune system only compounds the damage by trying to kill them off. Immunological warfare is a bloody business: your white blood cells make toxins of their own, all the better to kill with. The problem is that these products are indiscriminate, damaging native lung tissue as easily as foreign bacteria.
"Her lungs are about as flexible as cinder-blocks," the Attending tells us one morning on rounds. He is a man of wry wit and an astounding fund of knowledge. The discourse has turned to the perils of high-pressure ventilation, and the woefully few ways of mitigating them.
A little later, the team is gathered together in one of the reading rooms in the radiology suite to review daily films when the radiologist stops in startled amazement. He turns to look at us with big eyes, his quick-time repartee momentarily derailed.
"She's going to pop." he intones, pointing at an x-ray. "Look at these lung bases, here and here. She's a-gonna blow."
The Attending shakes his head ruefully at the rest of us. He'd told us the same thing upon her arrival a couple of days ago, when he and the Fellow first started jacking up the pressures on the ventilator.
Forty minutes after rounds, the grim prophesy is fulfilled. Carmen's lungs, after fifty or sixty hours of being subjected to pressures they were never meant to see, develop holes; at least one on each side. High-pressure jets from these holes cause rapidly growing bubbles of air to collect between the outer surface of the lungs and the inner surface of her chest wall, causing her lungs to collapse. The result is that her usable gas-exchange surface is acutely diminished, and the amount of oxygen entering her blood falls precipitously.
We have been expecting this and so the tools are ready, hung from the wall at the head of her bed with thick white bands of silk tape. The Fellow pokes holes in her chest wall with scalpel and hemostat, one on each side. We thread long flexible tubes through these holes into the offending bubbles, and the air from her thorax comes rushing out in a long quite sigh. With the next gasp of the ventilator her lungs reinflate.
Even with the chest-tubes vented to suction ports on the wall, some of the air escaping her lungs tracks its way through the various tissues of her chest. After a while it starts to show up on the daily x-rays, throwing her musculature into dramatic relief. I can actually feel it when I touch her. When I push down lightly on her skin the sensation returned is that of hundreds of little bubbles popping, which is exactly what is happening. The air begins to track its way down her arms and grim though it sounds, Carmen begins to take on the appearance of an inflatable toy.
A couple of nights later we decide that another vascular access might be prudent, so I take it upon myself to obtain one. She's a difficult stick, what with years of sclerosing her veins down with the impurities in the drugs she injects, but I somehow manage to get a good line on the second try. Instead of taking pride in my growing skill (or exquisite luck, in this case) I walk away feeling queasy and ill: one of the things you try when you have a hard time finding veins is slapping lightly on the patient's arm, as it often makes them stand out a bit more proudly. I try this on Carmen, and it sounds and feels exactly like slapping an air mattress, or one of those rafts you rent at the beach. I do it a couple more times than I really need to, just to convince myself that it isn't all in my head.
Carmen continues to pop her lungs over the next few days. First two tubes, then three. Next she has four. She's starting to look like - well, I don't know what she looks like, other than a very, very sick young woman. Metaphor seems inappropriate. I wander into her room late at night when I'm on call, just to look at her. With the sheets freshly changed and drawn up to her chin, I can almost forget the lines and hoses and the insistent cycling of the ventilator. With a bit of imagination I can almost see what she might look like in quiet repose. I can't quite make it though, because of the trach-tube protruding from her throat (placed yesterday so we could get the breathing tube out of her mouth) and because of the feeding tube running into her nose (which I so carefully placed, and then taped just so, so it wouldn't place undue pressure on her nostril, leaving a scar) or the fact that she's swollen up, literally turned into a balloon by the subcutaneous air.
I walk into the room and peer into her face, wondering what surcease from the world her drugs gave her. I look at her, appalled to see someone my age so horribly, direly ill. Carmen is going to die. I know it. We all know it. I catch myself speaking to her softly, telling her to hang on, and then I feel like a complete and utter idiot: we're giving her enough sedative to crush a horse. She's so completely snowed under all of our drugs that I might as well be talking to myself. When it comes down to it, I guess I am. The fact that I've become a parody of the worst medical dramas ever written isn't lost on me either.
Carmen doesn't so much have lungs anymore as gills. She lives by passive membrane oxygenation, just like a fish. We blow oxygen-rich air into her trachea, it passes over an exchange surface, and then out the chest-tubes into wall suction. The ventilator, a custom European model, hisses continuously day and night sounding like a pathologically pissed-off Kimodo Dragon on amphetamines.
One afternoon, about 3 o'clock, her sats start to drop again. We end up bagging her with the big blue squeeze bulb while someone calls for the Fellow. He rushes into the room, stashing his coffee on the sill outside.
"I think she's dropped a lung again," I offer.
"Well jeezus, it doesn't take much of an intuitive leap to figure that out," he says, "the question is where to go in." He is tired and frustrated, having been up all night with someone who had just undergone a lung transplant. He continues, speaking more to himself than anyone else, "Aw man, what an incredible disaster. Talk about a train-wreck..."
We get the stat chest x-ray, not to prove that we've blown another hole in her lungs somewhere, but to give us an aiming point. Not too many minutes later we have the information we want, and we start prepping her for her fifth tube.
"Pretty grim prognosis, huh?" I ask in a dazzling burst of medical-student brilliance, while helping him to set up the sterile field.
He gives me a ludicrous look, then glances quickly upwards as if appealing to the heavens for self-restraint. "Yeah. Like she has a prognosis. Sure." He looks down again, continuing to scrub her skin with antibacterial soap. "Do you know how many people there are out there who have survived lung damage like this?" I shake my head. "None. Zero. Big ol' empty set."
The conversation in her room has become increasingly macabre in the last couple of days. Various medical students and residents from other services filter in and out, some just to marvel. Word of Carmen has spread, and we take a sort of perverse delight in relating her clinical course to gawking bystanders.
Placement of the tube is quickly done, as the fellow doesn't bother with an anesthetic, reasoning that she's so heavily sedated that she can't feel anything - more deeply unconscious than the most profound sleep. This same reasoning has loosened our inhibitions about talking in front of her. Her numbers start to get better, and she goes back on the vent.
A couple of hours later the surgery resident comes by to place yet another chest tube. We could do it ourselves, but the surgeons do more of them, and often have better luck getting the end of it exactly where it needs to be. He brings his own instruments, and thus is far better equipped than we are when we place them emergently. He takes time to prep her skin very carefully, then sets about numbing her up with studied thoroughness. One of my classmates points out that the anesthetic isn't necessary, as Carmen is getting enough sedative every hour to make any one of us sleep for days. The surgeon looks up briefly, then goes back to work as if he hadn't heard. He works quickly and efficiently, and gets the tube exactly where we want it. He also meticulously re-bandages the other chest tubes.
I've been trading patter with him throughout the process, and with uncharacteristic bitterness he curses the poverty and ill education which seem to coincide with IV drug use. We speculate back and forth simplistically as to whether a stronger and more coherent family life could prevent this sort of thing, and dream up scenarios of parading kids from nearby high schools through her room to convince them that it can happen to them.
Carmen now has six good-sized hoses radiating from her chest, three on each side. The water seals gurgle to themselves quietly, adding their commentary to the symphony of sound coming from the assorted machinery which is keeping her alive.
I'm on-call that night, and around eleven o'clock I wander into her room to see how she's doing. To my complete and utter horror, she's moving her arms and rolling her eyes in pure abject terror.
"Carmen, honey - calm down. We're here. It'll be alright," I say, at a loss for anything less trite. I call for the nurse, and he rolls into the room with his trademark swift grin.
"I await your bidding, O wise one," he cracks, then stops cold when he sees why I called him.
"Can we crank the sedative up to forty an hour?" I ask him.
"Yeah, no problem," he says, becoming pure efficient business even as he adjusts the drip. He knows that he can't really take orders from a medical student, but he also knows that neither the resident nor the fellow will give him strife for doing the Right Thing. Carmen is trying to talk to me as I stand there holding her hand, but her words are voiceless because we've put the tracheostomy tube where it belongs, below her vocal cords. Still, I can make out what she's saying almost word for word, and a wave of sympathetic anguish courses through me. The increased dose of sedative takes effect, and she slips away from us once again. We adjust the paralytics, and then I creep off to stare at a blank expanse of wall, unseeing.
"Carmen woke up last night," I tell the team the next morning on rounds. "She was trying to talk to me." I am strident and depressed, speaking in short staccato sentences.
"This means she was probably light on sedative all day. It means she probably felt every goddamned thing we did when we put that chest-tube in her . . . that what we were doing amounts to battery. It also means," I stop and stare at each person on the team in turn, "that she probably heard, and quite likelyunderstood everything that was said in her room yesterday."
My voice is thick. The chief touches her hand to my shoulder quickly, and the Attending looks desperately unhappy.
"This is why," he says gently, "we shut the paralytics off briefly every day. So we can insure that our patients are appropriately sedated." He doesn't need to say anything more.
A couple of afternoons later, the chief tells me to round up my intern and resident and meet the team downstairs to look at x-rays. I find them in the lab and drag them with me to the radiology suite. There we are ten minutes later, wondering what happened to the rest of the group. The entire intensive care unit team is supposed to be reviewing this morning's films with the Attending and the Fellow, but the three of us are the only ones there. I try to page two different residents and get no answer, which is most unusual: the internal medicine types here tend to be pretty good about answering their beepers. They steadfastly refuse to respond though, and I sit doodling on the side of a metal rack with a grease pencil meant for marking on radiographs.
In a fit of black humor I crack, "maybe Carmen coded."
My intern grins quickly then retorts with a vaguely worried look, "Nah, we'd have heard 'em call it overhead."
Several interminable minutes later, we grow tired of waiting and decide to venture back up to the unit to see what could have delayed the rest of the team.
Sure enough, there are seven people in Carmen's room, and someone's wheeling in the code-cart even as we arrive.
"Glory be," I think to myself, stunned. "Yesterday's addled medical student is today's clairvoyant. Rapture and joy supreme."
I step into the room to see one person bagging her, another doing chest compressions, and two more; one at each of her inner thighs with long fat needles and very sharp knives. They are probing with the needles deep in the fold of skin where leg becomes groin, right at the edge of her pubic thatch. The team needs large-bore vascular access, and they propose to put a long snakey tube into one of her femoral veins. Their task is complicated by the fact that every time the Fellow pushes on the center of her chest, her whole body moves. Paradoxically they need him to continue because his compressions are the only thing that cause her femoral arteries to pulse, and they need to know where the artery is if they're to find the vein that runs alongside it.
Codes are dangerous. Obviously they portend Bad Things for the patient, but they can also be actively unsafe for the medical team. There's this crowd of very rushed people, many of whom are wielding needles, scalpels and the like. One unexpected move and someone other than the patient gets cut. These days that cut can be a death sentence: there are lots of nasty infectious bugs who'd love to have a nice relatively healthy host to grow in, and they're all collected en masse on used cutting surfaces hoping to jump ship.
This is the kind of code that never gets portrayed in television medical dramas. You know how it works on tv: there's a person with paddles in hand, punctuating the strident dialogue with pulses of controlled electrical fire. The patient convulses dramatically, and then wakes up to thank the team for their heroic efforts.
Carmen's heart isn't in one of the `shockable' rhythms though, so the paddles stay ensconced in their little electrified slots. We're just pumping on her chest, getting good vascular access, and giving her potent drugs. No one shouts out, "Clear!" or pleadingly implores the patient, "Come on, damn you, don't quit!" Instead it's the quiet urgency of folks trying to do their part of the job, knowing full well that in this case it's almost certainly a futile pursuit. There are no raised voices, no desperate thumps on the chest. Just protocol.
Drugs get pushed, and everyone looks at the monitors. The House Chief, who's directing the process, asks that CPR be suspended momentarily to check for a pulse, and to everyone's astonishment, there's a one to be found. One of the residents is counting out in clear high tones each time she feels it, "Pulse - pulse - pulse..." We continue bagging her, forcing air into her broken lungs with the blue squeeze bulb. We continue to follow the prescribed protocol of drugs.
Carmen's heart is beating slowly but regularly and we're starting to wonder if she might actually be able to pull out of it. Then the resident who had found it to begin with announces, "I've lost my pulse here." Ten heads swivel to look at the electronic heart trace on the monitors and the House Chief pauses for a second before she says, "Re-start CPR, please."
Thirty-five minutes later, we've run completely through the algorithm, and continued considerably beyond it. In spite of incredibly aggressive effort on our part, the numbers on the monitor continue their downward trend refusing to level off for even a few moments.
"Alright," the Chief says quietly, "let's call it. Any objections?" The room stands mute. We're done. We slowly step away from the bed, reluctant to stop even though we know full well that there's nothing more we can do.
. . .
Some time later, all the lines and tubes are removed and the linens are changed. The curtains inside the huge transparent panels which demarcate each room are drawn. I duck past the curtain to step completely into the room and find that it's totally unfamiliar in it's absolute silence. No gurgling waterseals for the chest tubes, no crying sigh of the ventilator, nothing. Just pure August sunlight pouring in through plate-glass windows. There she is, calm, and I can think of nothing. Her parents aren't going to come and see her before she goes to the morgue. They only visited once while she was still alive. Her dad tells us on the phone, "Nah . . . I saw plenty of dead people in 'Nam."
I can see through the glass that it's a stunning day out. The air is heavy and damp, and when I drive home I'll have to roll up the window on my side of the car so neighborhood kids don't drench me with water from the hydrant they've opened. There's exquisite, cold beer in my fridge. I take a last look at Carmen, wordless, and step out of the room to finish up my afternoon before I go home.