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Tuesday, December 07, 2010

Intensive care unit

Genap sebulan aku into my ICU rotation. Awal-awal dulu terasa cam asing gitu coz selama ni aku mana biasa 'continuity of care' in physical medicine. Lepas internship dulu, amik year off with some bits & pieces. Residency job terus started with surgical rotation (vascular & surg nites), then paediatrics which is acute care jugak (most patients are not that sick & contact with patients mostly sehari dua saja), then emergency medicine, then psychiatry (woooohh.. dreadful sangat). Psych tu kira continuity of care la, tapi mental health and aku tak minat mental health yg amat frustrating. Pas tu this year is my critical care year, which I started with 5 months of emergency medicine, then anaesthetics (tough sangat!), then those stoopid cover weeks at those 2 stoopid hospitals yg aku benci sangat-sangat, then now baru lah ICU. A really intense internal & surgical medicine. Sesuai sangat nama dia Intensive Care.

Disebabkan pindah-randah ni, aku tak berapa sempat nak cerita pasal my journey in ICU so far.. apatah lagi nak study for ICU. Yes, sampai now aku terasa sangat bebal setiap kali pegi kerja. Apsal gitu? Every single aspect of the patient counts, which in conclusion ICU comprises of pharmacology, physiology & pathology/natural Hx of conditions/symptoms in details.. tambah lagi satu bab yg paling aku lemah skali: social aspect of care. Oh ye, working in ICU reaaally kena build up muscles especially upper body. Nanti aku citer.

Ni nak cerita pasal some interesting patients care I've encountered with sejak start kerja ICU nih. Ni kumpul sejak sebulan dulu. Tak ingat chronology nye.

Minah young adult blom 30 pon lagi. Masuk ICU bcoz of cardiac arrest kat rumah. Punca mebbie severe diabetic ketoacidosis that causing severe metabolic acidosis yg menyebabkan jantung dia stopped for a long period. 2,3 kali kena DC shock in the ambos. 3 hari kat ICU tubed/ventilated, with consistent fixed non-reactive dilated pupils, then orbital oedema. 2 hari terakhir despite all the supports, developed hypernatraemia, diabetes insipidus, tachycardia. Bosses aku kata signs of brain death, most probably from hypoxic brain injury from the prolonged down time masa dia cardiac arrest tu. Which means, no perfusion to the brain & the brain no longer controls the rest of the body. The skin is only warm bcoz of the ionotropes & ventilator. All the supports cuma nak jaga all the organs independantly. So basically orang tu dah kira mati lah. Of course la macam-macam issues dgn minah ni. T1DM who's very non-compliant, dok dgn family pon family dia tak jaga dianyer DM & dia dah developed all the microvascular complications of diabetes termasuk diabetic foot with all the gangrenous parts on the toes. Geli kan.
Back to her condition in ICU. First time aku tengok intensivists buat clinical brain death examination. First time jugak aku tengok 4 vessels cerebral angiogram to prove that memang dah takde circulation to the brain. Brain dah lama mati so dia oedematous & stop circulation from the heart. Allah swt Maha Besar, Maha Berkuasa. Insaf aku kejap. Terkebil-kebil jugak aku tengok all these processes, seb baik bosses aku ajak aku to all these sampai la ke family meeting. The family didnt want organ donation. Fair enough even though sad jugak diorang rejected the notion. It is a very difficult topic. But unfortunately to harvest these organs kena buat within 12-24hours of the death, tambahan lagi kalau mmg dah 2 hari brain dead cam minah ni kan, which also the saddest time for the family. So bila dah gitu, family agreed on stopping the supports coz the minah memang dah lama passed away in ICU. Yup, kalau stop supports for living human they will probably die within days/weeks slowly. Tapi pasal dia dah brain dead 2 hari in ICU possibly, so bila switched off the supports (drugs & machines) tak sampai seminit rupa dia yg warm, pink mcm org tido tu terus berubah jadi rupa mayat yg sejuk, kelabu, keras. Memang bukti dia dah lama mati sebenarnya. Masa tu when we removed all the arterial/venous access takde setitik darah pon keluar. Masa tengok perubahan kaler kulit dia within seminit tu aku rasa cam muka aku pon sejuk jugak. First time tengok the process of death sedemikian rupa. Ye, aku dah banyak kali certify death, some even worse rupa mayat tu. Tapi tu hanyalah a snapshot of the mayat, not the whole process mcm ni. Sampai sekarang aku teringat-ingat the arwah.

One of the night shifts aku kerja 2wks ago, code blue neonatal just 1/2jam before aku abis kerja. Seb baik aku ingat lagi neonatal resuscitation course yg aku buat last year masa buat paeds. Bub lahir sihat, robust. Then was found unconscious not breathing no circulation, in bed with mum mebbie lepas breastfeeding kot. When the ICU team got there, the junior docs yg jaga the mum & the bub dah buat CPR & neopuss kat baby tu. Which returned the circulation quickly. Aku took over the airways using the neopuff after sometime while the senior docs were trying to get access. We got the circulation & O2 saturation right but baby was floppy, didnt even take any breath during each reassessment step. Last last paeds consultant intubated the baby, NATs ambulance sampai (ambo yg specialize in neonatal emergencies) & brought the bub to hospital yg ada neonatal ICU kat Melbourne city. Last time aku dengar from the paeds team minggu lepas the bub wasnt looking good, most probably ada hypoxic brain injury & the NICU/ paeds kat spital tu were withrawing the care already. How sad. Teringat aku si nurse in charge kat special care nursery yg bising-bising kat kami masa kami tengah still continuing resus. Dia boleh cakap baby tu tak bernafas sebab tak cukup carbon dioxide cuba biar je dia sendiri tanpa neopuff sure dia bernafas sendiri punye. Cheh, my reg kata dia rasa nak hentak kepala nurse tu masa tu jugak.

Ada patient yg ada cirrhosis (end stage liver failure), with complications. Masuk ICU pasal bleeding from oesophageal varices. Malam yg aku kerja tu, dia tak berhenti-henti berdarah. Keluar dari dia punya tube, mulut, NGT, IV line, IDC. Coagulopathic + oesophageal varices. The day before tu dah emergency scopes bagai. Seb baik time aku, kami bagi bags of pack cells, FFP, gelofusine, etc. Lama-lama dia stop bleeding. Tak tau apa jadi dgn dia coz aku ada break many days before returning to ICU again.

Ada sorang tu, overdose. Dah extubated time aku returned to work. Tapi pasal heavy alcohol & drugs user, heavy smoker sebelum ni maka dia withdrawing dalam ICU. DIa ada active hepatitis C. Masa dia tengah delirius/ withdrawing dia spitting to people, aggressive both verbally & physically. Code gray called & my boss re-intubated him. First time aku tengok kes gini. Selalu nye terus jab dgn potent anti-psychotics or benzodiazepines. Oh, baru teringat yg dia ni neuroleptic malignant syndrome coz dia overdosed on anti-psychotics.

Ada sorang visitor from the UK visiting the daughter yg baru lahirkan baby. Cardiogenic shock kat rumah & kena gi emergency angiogram. Brapa kali kena shock dalam cath lab. Sampai kat ICU, circulatory response very very poor despite maximal drugs of 60 adrenaline 60 noradrenaline & machine supports. Boss aku kata by the look of it mebbie dia akan mati within 3-5jam in ICU. Masa di family meeting breaking the bad news to the family, boleh pulak boss aku yg tidak bermoral tu gurau-gurau pasal baby dgn daughter patient tu sebab baby tu nangis lapar agaknye time meeting tu. Haaiishhh... Oh ye, si boss ni jugak yg buat lawak tidak bermoral masa tengah family meeting dgn arwah DKA yg aku cerita kat atas tu. Masa aku citer kat kawan aku, dia kata mungkin itu coping mechanism dia kot masa highly distressing situation. Kalau tak buat lawak dia plak yg akan mati coz intense sangat. Cheh, bagi aku dia tetap tidak bermoral time tu. Masa dia kecoh minah tu not organ donor lepas kuar meeting aku buat tanda sssyyyy then suruh dia sambung lawak dia bila dah dalam bilik doctor. Abis la kalau family minah tu dengar. Seb baik boss aku tu jenis happy go lucky tak marah kat aku.

End of last week. Malam pertama aku kerja. Best la tido beberapa kali, gilir-gilir dgn registrar. Time nak abis shift kol 730am pagi Sabtu tu, code blue. Pakcik tua ada pulmonary fibrosis & other medical comorbidities found unconscious not breathing no circulation. Nurses yg buat CPR. Aku jaga airways bagging the tube sementara anaesthetic reg, ED reg & my reg tried as much as nak cari access coz mamat ni dah peripherally shut down. Dia still kat ICU intubated but last time I heard my boss kata nak withdraw care coz dah ada tanda-tanda dia takkan baik & akan mati regardless the supports.

Sabtu malam plak. Baru je start the shift dah ada code blue. Minah ni brapa kali masuk ICU pasal of her chronic lung issues & still a heavy smoker despite of the condition. Druggie, alcohol, smoking & non-compliant to meds & care. Masuk spital kali ni pasal pneumothorax, mebbie her alveoli yg ada bronchiectasis pecah ke apa. Stable dah 2,3 hari sebelum code tu. Code tu pasal acute dyspnoea (takleh bernafas tiba-tiba). Buat XRay masa code tu, takde plak exacerbation of her pneumothorax, & the intercostal catheter kat left lung tu functioning well. Half hour into the code dia tetiba unconscious not breathing no circulation. So 6 orang gilir-gilir CPR while anaesthetic reg looked after airways. Bergelen-gelen kot adrenaline kasi kat dia. Still takde circulation. Aku looked after the bloods & drugs for intubatio. Then gatal-gatal nak join CPR coz aku tengok some dah penat. Yup. Memang penat buat CPR. You hafta exert your whole upper body to give the 1/3-1/2 chest wall depth with each compression, straight arms, it has to be 30 compressions & 2 breaths continuously for 2 minutes then reassess. Aku buat la 2,3 round gilir2 dgn all the docs. Woooh.. gila penat. Sampai now my upper arms & upper back sore. Pompuan tu is much smaller than me. Kami gilir-gilir 7, 8 orang buat. I cannot imagine org buat CPR sorang-sorang kat rumah, tambahan pulak kalau mangsa adalah sangat besar. Pendek cerita, after more than 1/2hour worth of CPRs medical team agreed on stopping the resus since she already had fixed dilated pupils & no circulations despite all.

Malam Ahad. Aku sampai-sampai je, ada new patient baru lepas code blue, middle aged BMI of 50 (berat dia >150kg) with all sorts of medical comorbidities including cardiac failure. Member aku yg kecik dp aku kata dia gilir-gilir dgn very few docs buat CPRs sampai tangan dia lebam teruk. Total of 45minutes of resus coz dia kept on in & out of circulation, dapat DC shocks lagi. Pagi Isnin tu boss kata mungkin dah ada some signs of hypoxic brain injury dah based on his neuro, circulation & numbers were doing. Dia jugak kata yg kemungkinan besar masa CPR tu the compression werent even reach the supposed depth coz of his large & rigid chest wall, hence the hypoxic brain injury.
Lagi sorang minah masuk ICU at the same time due to a large heart attack requiring urgent stents.
And at the same time sorang mamat tua just being released from theatre post emergency repair of ruptured infrarenal abdominal aortic aneurism. Beberapa jam lepas tu, a middle aged lady datang to ICU coz of overdosed of ibuprofen & antidepressants that she was found unconscious at home.
Woooo.. malam yang sangat intense bagi aku. Sore body tak abis lagi CPR pompuan tu malam sebelumnye.
Seb baik ada chance time out dengan helping the nurses in ICU to decorate Christmas tree & other decorations. By that time aku dah had enuf of everything & opted for paperwork depan computer rehatkan perut, otak & kakitangan aku. Huhuhu...

Haaa.. macam-macam kan keep my adrenaline pumping. Ni baru sikit. Ada banyak lagi kes-kes critical. Tu la yg bila balik rumah mandom semacam je. Heh.. study study study.. tak nak jadi bengap in ICU.

(gambar tribute to cartoonstock.com)

3 comments:

Lady of Leisure said...

huwaaaaa cayalah dear, go go go.. i know u can do it! hehe.. macam2 kes jugak u kene face hari2 yer.. i pernah tengok human patient simulator yang terbaring kat katil pun i dah macam sedih giler.. hehe, apatah lagi you tengok yang real kan.. tabik spring to u hehe

Nur said...

woahhh...meankutkan je bunyi..mmg kean betul2 cekapla kan...kalo x mahu patient tuh mati dulu.hehhe

A~ said...

cam ni la best lady. takde la kehidupan i kat spital tu bosan je. tapi tu la, long hour shifts & patients kat ICU selalunye adalah patients paling sakit dalam hospital tu, so setiap kali kerja memang letiiiih otak & badan. tapi puas hati coz of the beauty of the human sciences & kuasa Allah swt. insaf i sangat-sangat.

Nur, most of the time memang menakutkan coz kami slalu rasa tak berapa competent. but insyaAllah & alhamdulillah most of the time it turns out ok.

oh ye, makcik yg cardiogenic shock tu yg boss i broke the bad news kata nak mati dah tu, she actually turned the table & survived. good eh.

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