Alcohol

Believe me , I like most alcoholics. They are generally nice , mellow people who would rather hurt themselves then other people . The problem ,they sometimes stop being nice.

Maybe it’s the time of the year or what but lately I have seen several patients with alcohol intoxication either to the point of killing their own selves or to the point of killing other people .

The ones who try to kill other people end up at psyche or jail but the ones who are killing themselves end up in ICU and under my care.

A 28 yo man drank himself to the point of coma . He stopped breathing for an unknown length of time . When he came to us he had diffuse brain ischemia including the frontal lobes. which is where our personality and executive function lies. Frontal lobes makes us humans . He needed to be intubated , started on pressers , and dialysis. Two weeks later he was still the same except being off pressers. Because of the brain ischemia we had a long discussion with his family which included a girlfriend . Btw he is an illegal immigrant whose parents were unable to come to USA so far . We did provide them the papers for visa etc.  The girl friend cried    throughout the meeting ,telling us about their two year old daughter and how they believed that he will recover completely and walk out of the hospital. Apparently they had been praying hard too . I could not help but ponder over the possibility that the daughter must have existed two week earlier too . I mean it’s a fair conclusion that the girlfriend and daughter were existent at the time of his inbibement of copious amount of alcohol.  Now of course me or the other doctors will not do anything which the family does not want but the patients prognosis is basically zero and we are spending millions of dollars and thousands of hours to keep him alive in a vegetative state .

There is another patient who has pancreatitis from drinking alcohol. He is in his twenty’s.

 His family is really remarkable . They tell me that the patient is basically a superhuman as far as his tolerance of alcohol is concerned . Therefore when he kept drinking to stupor everyday for two , three weeks they did not think it was a problem . He had done that many times before . “His father was like this too”

” Is his father alive ”

” no , he passed away”

“Okay”

Perhaps the family was confusing him with a certain kryptonian prince. Anyways , this time he ended up with severe pancreatitis and multi organ failure . Intubated , on dialysis and on top of everything ,in delirium tremens. We have no way of judging his mental status unti he comes out of dt’s but atleast his CT brain does not look as bad .

Of course he has three little girls and a wife.btw this one is a white dude who I think owns his own business, so this problem does not restrict to non whites.

THis reminds me of another pancreatitis patient who left against medical advice from ICU , continued to drink alcohol and came back to hospital next day just to die. Now, I have a problem with patients dying under my care. But Of course there is no problem which a couple of drinks can’t fix. No I didn’t say that. 

That patient left with his family , fully coherent and alert, probably bought vodka on his way home and drank till he could Not . I know sometimes you cannot stop a guy from drinking but maybe you, the family member need to try harder, especially when somebody just walked out of ICU .

Another Patient I saw I during my training . A young girl who came in with alcoholic fulminant liver failure . Her family swore that her boyfriend has given her some poison , though they agreed that she does like to drink a lot “but not too much “. Any ways we never found any poison but her blood was pretty much pure alcohol . She died too inspite  of emergent dialysis and everything possible which could be thrown her way.

So what is it with alcohol ?This drug kills more people every year then all the illegal drugs combined . Is it because people don’t think it is as dangerous . Is it just some Darwinian process.

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Dying 

 I remember a patient who was admitted to ICU during my critical care rotation . I was an intern then. He had no legs and one arm( can’t remember for sure if he had one or two arms but he lost both eventually).

He came in shock from a nursing home. Further investigations revealed that he had been in a vegetative state for several months . No family , a state appointed guardian and of course the physician assigned to him. The patient was a full code, meaning an attempt for cardiopulmonary resuscitation had to be made regardless of clinical scenario . 

The man was pretty much dead when we saw him . 

In three days he was coded three times. We, the ICU team wanted to make him DNR since we could not figure out why we were saving him again and again.

He lost his last remaining limb because of repeated lack of pulse and underlying diabetes and peripheral vascular disease.

It was an open ICU , meaning the primary doctor was still in charge .

His primary Doctor simply stated that according to his (the doctor’s ) religious belief life had to be saved at all cost. When we called the guardian She decided to let the primary doctor make that desicion. 

We saw the patient everyday of course  . Tubes stuck in every orifice. Mucous and phlegm being suctiond every 10 minute or so. The ICU  doc repeatedly attempted to change the patients code status but could not without the guardian or the primary doc’s approval.

The patient developed some intrabdomianl catastrophe . Needed to have surgery. We asked cardiologist for cardiac clearance . I still remember the expression on the cardiologist face when he came to see the patient. He looked at the patient , sat down ,shock and disgust showing on his face , deep in thoughts and said ” yeah, do the surgery , we haven’t stopped yet , why should we stop now”

‘Is he cleared for surgery’

The cardiologist stared at us with a grim face 

“You really want me to do an angiogram to clear him?” 

The worst thing was that we were not sure if  the patients was ‘locked in’ or in persistent vegetative state . If ‘ locked in’ He probably still could feel , see and hear everything but was unable to communicate .

It is much harder then people realize to determine if somebody is locked in or in a vegetative state. For example you ask them to blink their eyes and they do ,you make the diagnosis of locked in and feel you have achieved something. Now come back in 10 minutes and ask them again ,they don’t blink their eyes and suddenly your diagnosis is uncertain . Do it about twenty times and you remain with three possibilities . 

1 either the patient is locked in because he blinked his eyes initially

2 he is in peristent vegetative state because he is not blinking now and the earlier response may have been automatism or reflex.

3 he is mad at you for bothering him repeatedly.
My rotation ended . I found out later that the patient did develop some further complications a few weeks later and was finally unable to be  resuscitated.

Each month the patient lived the doctor and the guardian received a check . Not a fat one but nonetheless a check .  I wonder if that had anything to do with anything.

What’s  really important

So the doctor is taking care of a patient who in the ICU. Patient is intubated, has nasogastric tube and is on continuous dialysis. He was however awake for the first time today and was able to communicate with hand signals and writing on a board. Patient had severe infection and was on three different intravenous antibiotics, one of which was running at the moment.

When the doctor came to see him , the patients asked for his phone after the usual daily checkup. 

The doctor gave the patient his phone, offering to dial the number . To which the patient said no.

The patient took the phone and somehow managed to perform the most important thing he could think of upon waking up after several days in a coma .

Guess what?

Taking a selfie and posting it on Facebook!