A Cascade of Unfortunate Events

By Dr. Tirth Vasa

There are substantial realms, in which control is within our reach. In the 1970s, the philosophers Samuel Gorovitz and Alasdair MacIntyre wrote a brief essay that stayed with me throughout my career. The question they sought to answer was why we fail at what we set out to do in the world. One reason, they observed, is “necessary fallibility”some things we want to do are simply beyond our capacity. We are not omniscient or all powerful.

Once upon a time, I was a trainee, with a head full of hope and heart full of throbbing love for medical lore. As an anaesthesiologist in training, it is a part of curriculum to be posted in the ITU, at least for a month in each year, aside from doing work in OTs. This forms an important part of our curriculum, in order to imbibe care of a critically ill patient.

Due to understaffing of trainees, we are allotted to a 12 hour continuous shift, approximately 24 beds managed by 2 trainees supervised by consultants. We are stretched thin and tried, in terms of toil, mental and physical capacity. It’s a rite of passage that we learn to inculcate into our lives.

This story is of Mrs. Janus (*actual patient name not used), in the dry prose of a case report, was essentially the stuffing to a nightmare. In a small town in the countryside, she had been out with her fiancé, for a walk. There was a sinister car driving at full speed, which collided with the young couple, possibly drunk driving. The spouse sustained minor injuries which were not life threatening, but the young girl fell to the brunt of it. Out of her several injuries, her leg was involved in a life-threatening ‘crush injury’ which means that the entire limb was smashed to bits resulting in irreversible damage. Following instructions from an emergency response team, she was taken to a trauma centre where I worked.

Over the next two days, all of the girl’ s organs recovered—her liver, her heart, her intestines, everything except her limb. She was staying with us in the ITU, gradually recovering organ by organ. What happens usually after a severe crush injury, is that the muscles of the limb ‘die’ and release their contents into the blood in large amounts. These toxic substances ‘block’ a part of the kidney and are not excreted, thus choking up the normal kidney function of excretion. Luckily, we have the strong hand on this situation, with an underappreciated man made device, the ‘dialyser’. This takes up the function of kidneys while they are down, clearing the blood stream, until the kidneys recover from the insult. She required multiple cycles of dialysis, resulting in frequent cardiovascular issues and strong medications to keep her heart coping. For the medications to reach her circulation, we inserted a catheter on her neck called as a ‘central venous catheter (CVC)’ which remains one of the gold standards and recognising features of ICU care.

She was also put on mechanical ventilation and kept unconscious, while her body and mind battled the physical and emotional toil. We were well aware of the fact that we needed to harness each and every corner of our own knowledge, to keep her body struggling on the various machines. Amputation is both a physical disability and a psychological emergency. It leads to impairment of an individual’s physical function, sensation, and body image, and causes intense and diverse emotional responses. Patients may feel as if they have experienced death beyond the meaning of physical loss. In particular, those with trauma-related amputations may be greatly shocked by the unprepared loss and
experience greater difficulties in adapting. Therefore, patients in these cases require a more delicate evaluation and treatment of psychiatric problems. We were completely aware of these issues precipitated, but we had to first try our level best to keep her body safe and sound.

The entire limb was eventually, amputated. It was a necessary evil especially in a young patient with an entire life waiting ahead of her. We counselled her family and her distraught spouse for hours, going through all the stages of grief with them. I had myself never been put into this situation before but with the experience of a senior consultant, we eventually managed to make the call with her family.

For more than a week, she lay comatose. Then slowly, she came back to life, something akin to the real meaning of “if winter comes , can spring be far behind“. Her kidneys began sprouting the urine, her brain function improved, her lungs took charge and did not require the ventilator anymore. However, she still remained in ‘shell shock’, a post traumatic delirium state, in which she had brief periods of harsh reality and other spells of cloudiness of the mind. We were overjoyed at her recovery and worked with a zeal to getting her out of intensive care. We slowly removed all invasive catheters to prevent secondary infection, while the surgeons did her dressings daily, cleaning out all possible pockets of pus and blood.

What makes this recovery astounding isn’t just the idea that someone could be brought back from a state that would once have been considered death. It’s also the idea that a group of people in a random hospital could manage to pull off something so enormously complicated. To save this one girl, scores of people had to carry out thousands of steps correctly: placing her on ventilator; maintaining the sterility of her lines after inserting them gently, her wounds, the exposed leg; keeping a temperamental battery of machines up and running. The degree of difficulty in any one of these steps is substantial. Then you must add the difficulties of orchestrating them in the right sequence, with nothing dropped, leaving some room for improvisation, but not too much. She just needed time and effort to get well, and she was on her way.

It was at 3 a.m. at night, when a nurse noticed a catastrophe. The lady had been unrestrained as she was due to be shifted to the ward, the following morning. What happened was that, in her delirious state and foggy judgement, she tried to free herself from the shackles which bound her. She managed to find something on her neck to tug onto. It was her central line/CVC. She pulled it with all her strength, in order to obtain freedom from her ICU prison.

CVCs provide two conditions necessary for air embolism formation: (i) direct connection between a source of air and the vascular system, and (ii) a pressure gradient that raises risk of this air entering the bloodstream. Air introduced into the venous system travels to the right side of the heart and into the pulmonary vasculature. While small volumes of air entering the circulatory system can be absorbed by the body and may be asymptomatic, rapid introduction of air, particularly in high volumes, can lead to an accelerated surge in the resistance to normal cardiac function.

The volume of intravenous air necessary to be fatal in adults is 200 to 300 mL, an amount that can enter the bloodstream in a matter of seconds through any vein above the level of heart. The rapidly entrained air into her circulation immediately caused her to go into a cardiac arrest. My consultant and I, immediately sprang to full motion, and ran to her. It was a scene out of a nightmare. She lay there writing in a pool of her own blood, trying to find her fiancé, calling out his name. We immediately initiated cardiopulmonary resuscitation, put her back on the ventilator to help her breathe.

‘Futility’ is a contentious term that has eluded clear definition, with proposed descriptions either too strict or too vague to encompass the many facets of medical care. CPR is a hard, ferocious, bone-breaking clinical intervention. We resuscitated her without any breaks, in a strategized coordinated team, till the early hours of daylight. This is way past any time limit for CPR prescribed online or in text books. We just couldn’t give up our hopes, which rested on her survival. My consultant and I locked eyes briefly amidst the battle, and we knew that we couldn’t yield in. Healthcare professionals have become willing interventionists, and we cannot stop meddling, interfering, and attempting to fix.

We gave it our best, yet the monitors did not register any cardiac activity. She was gone, and we couldn’t cope with it. We all crumpled down to the floor after covering her up in dignity, while the nurses found us some drinking water to dilute the taste of our own salty tears running down swiftly. We now had to face the mammoth task of explaining to the patient’s husband, everything which had transpired. I felt myself thinking of what had gone wrong – had I not been skilled enough to find a peripheral cannula on her remaining limbs and removed the CVC early? Was I not competent enough? My consultant looked at my dishevelled state, both physical and mental, and asked me to clean up before counselling the husband yet again. I pleaded with him to let me sit it out, but he needed to train me to become an adept consultant in the future. I had to learn. We called the husband and requested him to urgently come to the counselling room, the gloomy whitewashed walls of a compartment of the hospital, where we often broke down bad news, in agony ourselves. The husband sensed something was wrong and rushed in from his pitiful sleep punctuated by dreams of being united with her. The cat had gotten to my tongue, but my consultant, lead the conversation by breaking down the bad news in a single guillotine strike, compassionately and gently as ever.

He crumpled down to the floor, unable to speak, in grief. The first stage of grief is denial, and he accused us of lying. He just wanted to see her again. He had planned his marriage to her, due the next month, once she obtained a discharge from the hospital. He had been holding her hand every day and narrating the marriage preparations in full swing, even though she was delirious and not able to fully comprehend anything. We had set ablaze all his hopes for the future in a matter of seconds, with the delivery of this news. We could merely cover her body with proper bed clothes. disconnect all the life supports like endotracheal tube, cardiac monitors, ventilator etc and wipe the face neatly to clean blood and other secretions. I ensured I did all of this myself, as the nursing staff needed to focus on their shifts ending to give a handover.

Breaking the bad news to the bereaved family needs special skill on the part of the clinicians. Unfortunately, there is little guidance on to the approach of this very sensitive matter. The doctors depend on their own experience rather than any training received in the medical school. A well-trained doctor in this field will be in a better position to handle the daunting task of breaking the bad news. It is high time to include this subject into the undergraduate medical curriculum.

I was shaken down to my bones that day and learnt about ‘necessary fallibility’ from my ITU consultants in the handover.