I was on call in Queen again yesterday...there were 3 admissions into ICU throughout the day...one was a 42 year-old man who had very bad pneumonia (was intubated) and was in septic shock...requiring maximum double inotropic support...his kidney shut down and he had very severe metabolic acidosis...we gave him bicarbonate correction and even managed to dialysed him...and he seemed to be improving after the dialysis...but eventually by 2am, i guess his whole body was so overwhelmed by the sepsis that he just deteriorated...adding another inotrope didn't seem to help...he finally died at 4.25am today...but at least i think this man had wanted to live..so did his mother and family...
But not so with my other admission...this idiot of a 29 year-old lady (let's call her S for stupid), was a mother of 9 children...had only recently delivered her 9th child less than 2 months ago..S came with symptoms of fever, dehydration and her blood investigations were suggestive of dengue...her ABG showed very severe metabolic acidosis and she was very tachypnoiec (she couldn't even complete a full sentence) by the time i saw her in the ICU...S would have eventually required intubation when she finally got tired from breathing too fast...and she would have needed urgent dialysis to correct her metabolic acidosis as she wasn't really responding to bicarbonate correction...and she was passing very little urine despite us giving her fluid...
Since S was still awake and able to comprehend what was happening to her, we told her that she'd need to be intubated her to prevent her from going into respiratory failure...and she'd need several invasive procedures i.e. central venous line and catheter insertion...but she refused...and so did her husband....and S actually insisted on at own risk (AOR) discharge...she said she cannot bear to be put out of consciousness and be intubated and had all the invasive procedures done to her..although we tried very hard to convince her that was the only way to safe her from dying...S replied that she'd rather go home and die in the presence of her 9 children....i called my boss and asked him what i could do...he said we can't force treatment onto a person who's still in his/her sound mind...somehow we managed to make her stay in the hospital in the hopes that eventually she would allow her to treat her...
So we transferred her to the general female ward...knowing that she'd collapsed in another few hours...though i was hoping that perhaps i'd be proven wrong...that perhaps she didn't need all the 'torture' we planned to subject her to after all...this is one time i'd hate to be proven right...she was transferred out of ICU at 6pm....by 10.30pm, the houseman on call from female acute ward (i supposed the specialist on call transfered her there) called me to say that S' husband finally agreed for intubation...i went down to see her...she was so tachypnoiec, dyspnoiec, restless and drowsy that i guess my question was pointless...but i just had to rub it in...so i asked her and the husband, so you want intubation now?...so we prepared for intubation...but before we managed to give her the medications for induction, she developed hypoxic fit (her saturation by then was only 88% on high flow mask 10L/min)...so we quickly gave the medications and i intubated her....saturation picked up...but her pupils were fixed and dilated...not a good sign...
The husband had the cheek to ask me to do whatever i can to save her...when earlier on he so arrogantly told me that if his wife didn't want any of our treatment, then he won't force her..there you have it..a couple of idiot...so i told him, i am and will do whatever i can....but it's probably too late already...and he broke into tears...anyway, i continued rescuscitating S...gave her more bicarbonate...asked the houseman to refer to the nephro MO on call for urgent dialysis...after about 15 minutes, S actually regained consciousness...i was actually shocked...i thought that maybe there was hope for her after all...she actually looked at me and responded to what i told her...so i asked her husband to see her...so i turned to help the houseman to refer that patient for dialysis...coz the nephro MO on call yesterday was a bitch...she gave the houseman such a hard time...grilling him for like 20 minutes and yet won't agree to the urgent dialysis...so by the time i went to check on S again, she was not responsive again...hmmm...something wasn't right....so i checked her pulse and shit...there was no pulse..no heart sound...
We started CPR....but i wasn't too sure how long it has lapsed since her heart actually stop....there was no proper ECG monitoring in the female acute ward...so an unconscious person might have been dead for like a long time before someone actually bothered to check the pulse and noticed that there wasn't any...so anyway, she wasn't revived after 30 minutes of CPR....and that was the end of the story for S...there was no pity...because she asked for it...and so she only got the fruits of her labour....as for her husband...he was a murderer...because he allowed his wife to die...i only pity the 9 children...few of whom might end up with a short life just like their mother....the husband cried when i told him we were doing CPR on his wife...all the tears in the world would not bring his wife back to life...and he didn't deserve the miracle of resurrection...not him..not a murderer....
Oh well, at least my last admission didn't die..and he was the oldest of them all...69 year-old uncle with chronic kidney disease...was probably uraemic...had Steven-Johnson syndrome...developed a few bouts of supraventricular tachycardia...but managed to stabilized his heart rate and rhythm...hopefully he won't deteriorate after my call...and i don't know if W (of Scenario A) is still alive...by the time i left the hospital, her blood pressure was already very low...well, at least then her husband didn't need to choose...
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