Arctic Sun

Sometimes even medicine has rather poetic, heart-stopping concepts – Arctic Sun is one of them. Take a patient who has flatlined – died momentarily, if you will, with a motionless heart for up to 60

Gates of the Arctic National Park, Alaska, National Geographic

minutes – and freeze him down to a temperature of 93F (34C). Make him cold as death. It is closer to science fiction than it is to medicine – but it is fast becoming a procedure which we use for patients who have suffered a cardiac arrest. Overall, it seems to improve outcomes. The goal is to slow metabolism after a cardiac arrest in order to minimize damage to the brain and. heart.

Taking care of patients on “Arctic Sun” is difficult for physicians and families. It is a waiting game, at least in the beginning. There is very little we can do for the patient during this period except care for them as best we can and hope that they make it through. And then we watch – as they rewarm, information is slowly revealed to us about how effective the cooling process was.

The concept of cooling cardiac arrest patients emerged as early as 2006 in medical news, refer to articles such as Cooling Techniques Help Save Heart Attack Patients. Stories continue to emerge about survivors who have made it through Arctic Sun. Interestingly, cardiothoracic surgeons have been using the concept of cooling patients for repair of thoracic aortic aneurysms for several years – patients are cooled, then placed on a heart lung machine, and surgery is performed. The concept is now spreading to emergency departments and coronary care units across the country. Several articles published in 2009 Critical Care Medicine discuss some of the important aspects of “therapeutic temperature management,” as it is called.

It is a strange concept – to touch these patients at their coldest phase in the process is quite surprising. And to watch them go through the slow process of rewarming is equally strange – it is as if you are watching them come to life again. In any event, it provides us with still more evidence that we continue to push the boundaries of medicine – and of life and death – in this country. The name is fitting – these cooling gel pads can sometimes represent a sharp white ray of hope in an otherwise desolate land of poor outcomes.


The Brevity of Goodbye

All night, a young man lies in the emergency room. All night, I watch his monitor. It beeps intrusively until I silence it. But he is quiet. His friend stands at the bedside, holding his hand. I offer a chair but he tells me he cannot sit. People stream in and out of the rooms around them – vomiting, cursing, moaning, laughing. I pour fluids into him, hoping that I can reverse this. He is too young. But I watch his monitor, hour by hour, 2AM, 3AM, 4AM, until I imagine the morning light pounding against the walls of this concrete jungle. His numbers are more stubborn than I am. They will not change.

It should not have to be this way.
But it is.
He should not be in septic shock.
But he is.
He and his friend watch my face as I watch the numbers.
They will not change.

And so, as morning crests over the horizon, blocked by the concrete that surrounds us, I prepare. The chaplain comes. As I click the blade into place, inflate the cuff, check the light, his friend asks me if we can say a prayer first. Of course we can, I say. If I cannot help him then maybe a prayer will, I think. The chaplain grasps their hands and bows her head. I look away, tune them out. I need to concentrate. I cannot get swept up in this, I remind myself. Not today.

As his friend leaves, I dress in my gown and mask – an alien even to myself. I slide latex gloves over my fingers – a reminder that it is time. Suction, blade, tube. Push the etomidate, I say loudly to hide any lingering emotions in the crowd. Push the succ. Faces surround me. I hold his head in my hands – feel his strong jaw line at the base of my fingers. I give him oxygen, to the rhythm of my breathing. Slower, I remind myself. Slower than this.

I watch his muscles twitch. I watch his eyelids flicker. I breathe in once more. And then I begin. I grasp that curved blade, widen his jaw, push the tongue aside. I do not take my eyes off his vocal cords. These cords which must have said so many things over the last thirty years – but not nearly enough. These cords which may never vibrate, laugh, or whisper again. I slip the tube gently between them.

I wonder if his lips will ever be without a tube again. I wonder if this is the wrong decision – to deprive him of his words at this moment. An urge swells up in me to take the tube out, to let him say one last – something. Goodbye, perhaps. But what good will it do? I want to save him. But I cannot. All I can do is place that tube, a long narrow strip streaming oxygen into his lungs. All I can do is give him a machine to breathe for him as his body fails. All I can do is hope that he pulls through this, against the odds.

On Becoming a Physician

It is hard to imagine that someone can emerge from intern year – 12 months of chaos, little sleep, and hours upon hours spent responding to pages and putting orders in a computer – and know something, anything, about medicine. I did not believe in this training system until now, after my first night as a supervising resident. The knowledge I have absorbed over the past year is finally flowing, smooth as water, and I continue to surprise myself.

I recently had to go back over the last year and place a final signature on all the documents I created  – in three months that I spent working in the medical and intensive care units, I wrote over 300 patient notes. Over the course of the last twelve months, I have seen thousands of patients walk through the doors of this hospital. I have diagnosed, cared for, saved, and lost lives – too many to count. I have watched a new mother hold her child for the first time. I have stood by families whose children are dying under my care. I have watched patients my own age struggle to survive. I have cared for friends of friends, people whom I knew long ago in a different context. I have watched the world through the eyes of this hospital – every heartbeat, every breath, every minute.

And this hospital, in a very strange way, has begun to feel like home. I have spent so many sleepless nights here. I have cried behind its closed doors. I have watched rain, snow, and sun through its windows. I have spent time in so many hidden corners of this building – and I would like to hope that, when I have completed my years here, I will have left a trail behind me of a small spirit, a small presence, for my patients.

As I retrace my paths in this place time and time again, I realize – only in retrospect – that, without my realizing it, my steps have become more certain. Somewhere along the way, I stopped being afraid of the hospital. And somewhere along the way, I stopped being afraid that I was not capable of becoming a physician.

Last night, as I watched my intern in his attempt to draw an arterial blood gas, I guided him only with my voice. “Increase your angle, move to the left, increase your angle more, withdraw slowly. Keep it still.” And I guided him with ease until he was right in the vessel – blood filled the syringe. Success. Not by chance. He looked up at me, surprised at his success, as if to say, “How did you…?”

But he will not know the answer to this question until much later. The answer lies in the hours upon hours that I have labored to place lines on sick patients. The answer lies in the countless nights I have spent at my patients’ bedside, knowing that the nurses and my patients are relying on me. The answer lies in the life of the intern – giving up everything to prove to everyone else – and to yourself – that you are a doctor.

When no one in the intensive care unit can get an IV line on a patient, I use the ultrasound to find a vein and place one. When anxious nurses and interns struggle as a patient codes, I am the one who establishes calm. When a patient is sick, I am the first to come to the bedside – no longer as a haggard intern, but as a doctor who wants to make my patient better.

This did not come easy. And it did not come without a price. But, having come out on the other side, it makes me realize that there is some good we can do in medicine, in spite of all its flaws. There is something special that we can offer if we act as compassionate physicians. And the reward – gratitude from patients and their families – is humbling. It restores some of my faith in humanity – that we can all appreciate one another, work together to care for one another, and help to make the rough spots in life a little less lonely, a little more bearable.

Behind the Code: On CPR in the Hospital

Cardiac resuscitation – a concept which first entered the American health care system in the 1960s – remains controversial. In the pre-hospital setting, it is without doubt a good thing. Studies have shown that early chest compressions and defibrillation save lives. But its role in the hospital setting is far less well-established.

I recently watched the first episode of Boston Med when an ER resident runs a code in the hospital. It is relatively accurate in its depiction. Hospital codes are crowded and chaotic. They tend to degenerate into disorganized care very quickly. The most important thing, when running a hospital code, is to be a large, loud presence in the room – brute force is the only way to establish order in these situations.

Many families wonder whether they should make their family members DNR/DNI. If they were to watch a code, they might be more hesitant to go the “full code” route. It can be violent. The chest compressions often break ribs, and central line access and intubation are invasive procedures to say the least.

That is not to say that codes are pointless – and they do offer the hope of a positive outcome. An article published in The Washington Post, A patient’s death prompts a doctor to assess ‘Do Not Resuscitate’ orders , addresses this. It recounts the story of a gentleman who is DNR but is mistakenly resuscitated. Cardiopulmonary resuscitation saves his life, at least in the acute setting.

I just ran my first code in the hospital – a successful one. There is always a positive feeling in the room when a patient is resuscitated successfully – you watch the monitor as he regains a heartbeat, pulses come back. One life saved today, you think.

But for every one that is saved, many more die – the success rate of CPR is low. In hospital, approximately 44% of patients survive CPR immediately after the event but only 17% of patients survive to discharge. Overall success rates of CPR vary widely, anywhere from 2% to 30%. Interestingly, CPR success rates on television are as high as 75% – which clearly misleads people into believing that CPR can “fix” people.

Cardiac arrest is usually not the primary problem in patients – instead, it is only a sign of an underlying problem. In the case of the gentleman with end-stage cancer, his underlying problem was hyperkalemia, or high potassium. Other patients have underlying problems which are not so easily fixable.

Too many cardiac codes are performed on patients at the end of life. An article published two years ago by MSNBC, Most cancer doctors avoid saying it’s the end, criticizes physicians for not discussing end-of-life issues. Doctors tend to avoid these conversations – and although they may believe that it is for their patients’ sake, it is often more a result of their own discomfort with end-of-life. Patients should not suffer invasive procedures and endless days in the medical ICU during their last days of life, nor should they be made to undergo the valiant life-saving efforts of CPR once they have already passed away peacefully.

As physicians, we need to be more attentive to our patients and we need to address end-of-life issues openly, before patients are too sick to make informed decisions. This end-of-life discussion not only benefits patients by ensuring that their wishes are honored, but it also gives families the peace of mind to make decisions for their loved ones if necessary. This discussion is a difficult but important one. As patients, we should be proactive about discussing these issues with our physicians; we should also be proactive about discussing these issues with our families.

Tin Man: If I Only Had a Heart

As a physician, I have it easy. On most days of the year, as dusk falls beyond the hospital windows, I pack my bags, turn off my beeper, and head home. On my brief trip to the parking garage, with my patients still lingering in my thoughts, I can feel the strain of my tendons and muscles from a long day of work. I can breathe deeply. I can feel my heart pounding inside my chest. I can run.

This is more than I can say for my patients. Day in, day out, they reside in the hospital – most of them too ill to look out the single window in their room. The limited cafeteria menu is further limited by dietary regulations – low salt, low sugar, restricted protein. Cardiac diets, diabetic diets, renal diets – you name it; there are countless excuses for physicians to cross off, line by line, most of the edible items on the menu so that patients are left with what remains: unsalted soup, graham crackers, and jello. They spend most of their time alone in their rooms, waiting for the nurse to come in, hoping a visitor will arrive, praying that the sun will rise so that the bustle of daytime can distract them from the brooding thoughts of nighttime.

One young gentleman on the highest floor of the hospital is doing just this as I write – sitting in his room, waiting. He is waiting for many things, among them the principal reason for his stay: a heart transplant. His heart has failed him for reasons we cannot explain – the cause was not a diet overloaded with high cholesterol, nor was it the “couch potato” syndrome. He was an active, healthy man prior to his illness. Although a genetic component may have played a role – his son needed a heart transplant at the age of 6 – the cardiologists are unable to figure out exactly why. Idiopathic cardiomyopathy is the official diagnosis.

He is one of the few patients who manages to light the room with his smile and his spirit – but no man is entirely invincible in the face of mortality. Today, I took the time to ask him how he was doing. His eyes wandered to the corner of the room and welled with tears, in spite of himself. “It’s hard.” He went on to explain that his life as it is – bound to a bed or chair at best, unable to exercise or even walk, unable even to breathe without diuretic medications dripping through his IV constantly – is not a life worth living. He wants to twirl his grandchildren in his arms, continue to work as a plumber, and ride his bicycle across town.

And so he sits, waiting. Confined to this room and this life, possibly for months. Waiting for a heart that someone else can no longer use. As he warms to me, he asks if any patient has ever requested his old heart in a jar – almost like ashes after cremation. What a peculiar thought – but it fits well with an equally peculiar operation.

To open the chest of a dying patient, remove his heart, place it in a cooler, and fly it by helicopter to the nearest hospital – and to have a patient there, waiting, alive, and heartless. And then to take this lone, wandering heart that has traveled miles upon miles, and suture it to his vena cava, his aorta, his pulmonary arteries…. To place the electrodes on it as it sits quietly in its new, permanent location – his thoracic cavity – and to shock it into life, all over again.

To watch that heart start beating for the second time is a miracle. But I often wonder how it feels to awaken with someone else’s heart pounding inside your body. You have the same blood and brain and face, but that vital life source – the beating heart – is no longer yours. Or maybe it is. But it pumped a stranger’s blood for years and years, grew accustomed to their idiosyncrasies, accelerated when they became nervous, slowed as they rested in bed at night, skipped a beat when they first realized they were falling in love.

And so here you are with this new heart, borrowed from a stranger. Beating anew. Maybe it is not so different after all, this new thoracic cavity. Just another human being – laughing, smiling, crying, trying to be brave in the face of death. Except this time, as it pounds on, each single beat will matter. Each contraction is an extra beat – and breath – of a life you may not have had.

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