ICU Tales: Part 1
Last summer, I spent a week rotating in the ICU of a major public hospital in the south. It was my first such experience. The following is the story of one fictional patient who is actually a combination of three patients I had during that week. Names, identifiers, and locations have all obviously been changed to protect these patients’ identities.
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The first time I see her, tubed and vented and lying in an ICU bed, the only thing I can focus on is the curious eruption of small growths that cover her shiny black skin from head to toe. Martha Wilson is a 68 year old African American lady, who had been admitted the night before by the on-call team. She has Neurofibromatosis (NF) Type 1, a rare genetic disorder characterized by cutaneous tumors that can occur anywhere along the nervous system. The reason she is here is not her NF. She also has a brain tumor, and when I first see her, she is already “circling the drain,” as they say in ICU lingo. Her tumor had been diagnosed about 4 years ago, but instead of seeking treatment, she chose, as many of us might have done in similar circumstances, to ignore it. The previous night, she had presented to the ER with blurry vision, weakness in her arms and legs, and one serious headache. An MRI of the brain showed a massive tumor occluding most of the left side of her brain. By morning, she is already on a ventilator.
I was in the middle of my second month-long rotation of my fourth year as a medical student. I was excited to no longer be at the very bottom of the medical hierarchy, and could taste freedom in the near future. Just one more year. The huge ICU was an exciting place in my mind, a good place to be as a fourth year: full of the sickest of the sick. The previous med student had told me during sign-out the day before that there were “tons” of opportunities to get in some procedures: central lines, intubations, bronchoscopies, etc. You just had to keep an eye out for codes and always be one of the first people in the room. I am hyped up just listening to him.
Our team starts rounds this morning at an ungodly 6am, a group of white-coated figures huddled around two COWS (computers on wheels). The ICU is an unearthly place that early in the morning. It is quiet. The inevitable ruckus of procedures and tests has not yet begun, patients are still asleep (or still in a coma), nurses are at sign-out, and the night has not quite loosened it’s grip on the floor just yet. As rounds begin, I listen intently and try to absorb as much as I can. The team talks in low voices, moving en mass from room to room, leaving behind a trail of new orders for labs, CT scans, MRIs, blood gasses, and invasive procedures. The nurses hurry to keep up with us.
Presentations are done in a systems-based manner. When we arrive at Room 308, the resident who is presenting the patient steps forward. He is a second year, eyes drooping and red-rimmed from being up all night. His hair is greasy, and his white coat stained with something brownish that may be blood. His voice is tired.
“Wilson, 308, admitted last night for headache, weakness and blurry vision,” he begins. He lists off her vitals: hypotensive, tachycardic, not breathing over the vent – a poor sign, all things considered. “Neuro status: unresponsive, sedated. Corneal reflex and gag reflex are present, but DTRs are hyperactive and she does have a positive Babinski.” All signs of degenerating neurological status.
The resident continues to trudge through the systems: respiratory, cardiac, GI, renal, endocrine, GU, musculoskeletal… It is all bad. His assessment: 68 yr old female with a history of NF1 and inoperable brain tumor. Prognosis: poor. Plan: keep an eye on her labs, make sure she doesn’t get too acidotic, adjust vent settings as needed, continue propofol drip for sedation, and wait for the inevitable. The attending nods, and says, “Ok fine. Let’s take a look.”
We file into her room, all seven of us, and stand around the bed where Mrs. Wilson lies. She looks peaceful. Beautiful. Not what I am expecting. Her dusky skin is punctuated with the small tumors, which seem to have been splattered onto her body like paint from a brush. The attending pulls the sheet down to her waist, exposing her for all of us to see.
“Check out the neurofibromas. You won’t see this too often. She’s a great case.”
A great case. An opportunity to learn. A chasm of expanding cells and exploding neurons. A dying woman.
I examine her along with the rest of the team. Listen to her lungs, the tell-tale crackles indicating fluid is building up inside. Auscultate her heart, which beats almost painfully slowly. Press down on her belly, feeling for fluid waves, masses or enlarged organs. Scrape the bottoms of her feet watching for the dreaded upward movement of the toes.
She sleeps on throughout the exam, blissfully unaware of our attentions, deep in a drug-induced coma. Many medical professionals have speculated on the body in a coma. Can patients hear or sense what goes on around them? We can tell whether or not most of the senses are intact based on the physical exam and the patient’s reaction to certain stimuli, but what about the deeper parts of the brain, amid the sulci and gyri, between the fissures and into the cortex, through the thalamus, past the basal ganglia and the cerebellum, all the way to the brainstem itself. We have ways of measuring brainstem activity, seemingly cruel tests that withhold oxygen from the brain, causing acidosis. If there is no detectable activity from the brainstem signaling distress, well, then you really are dead. But what happens in the meantime, when most of the brain has been shut down for a time?
“Let’s move on the cranial nerves exam,” the attending barks, jolting me out of my deep thoughts. “I’ve noticed that you guys are rather lacking in this area, so I’m going to use our patient here to teach you how to do a real CN exam. And I expect the full exam done properly from here on out, ok?” I sigh and think about when I can eat my next granola bar since lunch is clearly not on the schedule for today.
Starting with cranial nerve II – the optic nerve – the attending physician pulls open our patient’s eyelids, first the right, then the left. Shining a penlight into each pupil, he watches for constriction. Nothing. “Cranial nerves III, IV and VI are clearly unable to be assessed on a comatose patient, but just for teaching purposes, you would have the patient follow your finger with their eyes in an H pattern, and look for accommodation or nystagmus.” He briefly demonstrates.
“Next, we have cranial nerve V – the trigeminal nerve. It has three branches, each of which has a different function. Here, we’ll test the corneal reflex.” He grabs a piece of Kleenex from the box nearby, and jabs it into her eye, once on the right and once on the left. I note the almost imperceptible twitch of the eye. “Mmm, barely present,” the attending mutters. He continues on with the exam, scratching the skin over the patient’s forehead, eyelids, cheeks and chin with his fingernail, leaving long indents in her otherwise pristine skin and searching intently for a response. There is none. “Cranial nerve VII and VIII are obviously not testable in this patient, but we can test IX and X with the gag reflex. We do this by pulling the tube partially out of the airway until it stimulates the gag reflex.” He demonstrates and we watch as Mrs. Wilson’s body jerks violently to the sensation of the tube being pulled out of her throat. “Lastly, we can check CN XII by opening the patient’s mouth and examining the tongue for deviation, although most vented patients will have their tongues secured to prevent obstruction of the airway.” He pries open her mouth, and pulls the patient’s tongue to a midline position and then releases it. Dry and sandpapery, her tongue slowly sags to the back of her throat.
“Ok kids, the last thing we do is check reflexes.” He starts with the biceps and triceps reflexes, working his way down to the patellar reflex and the lower extremities. He pulls out his car keys and scrapes the bottom of her feet, leaving a shower of dry skin in his wake. There is a slight upward fanning of the toes. “An important reflex NOT to forget is the pain reflex. You must check this.” Grabbing a fold of skin on her arm, he pinches down hard, again on her belly, and her thigh. There is no reflexive pulling back.
“So that’s about it. I want to see you guys doing this on every patient. Ok, let’s move on.” Striding out of the room, he heads down the hall to the next patient, the residents following in a weary line.
I am the last one out of the room, and as I gaze back at Mrs. Wilson, I notice the marks of the cranial nerve exam still emblazoned upon her body, red circles where the pain reflex was tested, scratch marks on her beautiful face and the bottoms of her feet. The blankets lie in a pile at the bottom of the bed and her naked body stares back at me with undignified disgust. I quickly cover the evidence and scurry out of the room.
The Waiting Room 