TILIF #18: Uncontrolled

When I had cancer, I shaved my head. Hair was slowly falling out and it would have taken care of itself, but I bought into an idea that I learned from the lovely people at the local cancer center. That disease takes away many things - energy, appetite, future plans - but they all really boil down to a loss of control. You can't control when you go places, what you can eat, activities you're able to participate in, or whether the treatments will work. Taking back that little bit of control from the disease, even for something as superficial as choosing when my hair would go, felt freeing.

The other night, I was taking care of a very sick patient*. Even for the ICU, he was very, very sick and has been for quite some time. Pick an organ and chances are it's failing. There are all manner of tubes and wires coming from every part of his body. Part of what makes this so hard is that he was a totally normal child until a couple years ago, so "back to normal" is the unstated and possibly unreachable goal.

His family has done everything they could, even donating bone marrow for us to transplant. But everytime it feels like we're about to make progress, there's another setback, rare side effect or complication. This night, there were several things that went wrong; each could have been life threatening, but we were able to at least start addressing each of them by early morning.

Normally, this patient's mom is at the bedside, but when she needs to leave the hospital, grandma takes over. Grandma is fierce. She is a wonderful advocate for her grandchild, and doesn't stop pushing the team until she's satisfied. The issue that was most bothering the patient, and thus grandma, was his being itchy. Compared to failing lungs, kidneys, liver, immune system, etc., itchiness was admittedly not my highest priority, but it was grandma's. She was fixated on it, and after a while it admittedly became frustrating for everyone. This kid was old enough to understand that we needed him to stop itching, but he just wouldn't - to the point where he was bleeding. This only further upset grandma. Why couldn't we get something a simple as itching under control.

Grandma took a break and went to get food at around 3am. When she returned about an hour later, I sat down with her in the corner of the room and did my best to explain all the complicated interventions we were doing to stabilize the patient, also what we were trying to do about the itching. She listened politely and I braced for another lament about the persistent itchiness when she quietly asked, "Is he going to make it through this?"

I was blindsided. 21 hours into my shift, I stumbled through a non-committal answer to the effect of: "We're doing everything we can and we're going to take it one step at a time." We talked for a bit, but it was then that I realized that the itching was a symptom in more ways than one. It was one of the last things that the patient could still control and one of the few seemingly fixable things that grandma could fight for to help her grandson. 

TILIF: "Volcano penis" is the slightly more colloquial name for congenital megaprepuce, which is a fairly self-explanatory anatomical variation involving extensively redundant foreskin. 

Also, the oculocardiac reflex is yet another example of the unintelligent design of the human body. Basically, the nerves that innervate many parts of the eye send signals back to the brainstem through the ophthalmic division of the trigeminal nerve (cranial nerve V). The area in the brainstem that processes this information is really close to the processing area of the vagus nerve (cranial nerve X). The upshot of which is if you do surgery on the eye (or land a really unfortunate punch to the face), the signals can get crossed in the brain and your heart can suddenly slow down to the point that it can't support the body's needs, or worse, go into an arrhythmia and stop.

Finally, a quick way to see that a patient with an oxygen mask on is breathing is to look at the fogging pattern:

• No fogging: not exhaling humid air, thus not breathing
• Fogging but no defogging: exhaling humid air but not getting any dry oxygen to flush it out, so breathing but you should check the oxygen tubing/tank
• Fogging and defogging rhythmically: good to go!

*As usual, patient details have been changed to protect their privacy