Goin' South

Goin' South:

Last night I had two patients, one 55 and the other, 71. They both were "cardiovascular disasters". The younger one had just had his second MI in 6 months, and had the absolutely worst Left Ventricular Dilated Cardiomyopathy that I have ever encountered, and in essence, was in cardiogenic shock. His ejection fraction is 10-15%. He had Diabetes, an AICD with a biventricular pacemaker, and had a history of a cerebral bleed 5 years ago. What he needs is a heart transplant, but isn't on a list for some reason. Cardiogenic shock has roughly a 55%-80% in-hospital mortality (current estimates). He actually looked improved, compared to 16 hours back, when he was admitted.

Mr. 71, was recovering from a GI Bleed (accidental Coumdadin overdose, when his prescription was delivered in error, to read 12mg daily, prior to admission). He suffered an MI, secondary to volume depletion; Heart-failure secondary to volume resuscitation, which lead to respiratory failure, and a few days on a respirator.
He has cardiomyopathy with an ejection fraction of 20%. He had prior revascularization of both carotids, and an Aorto-bifem bypass. A left femoral graft repair with subsequent graft infection, with need to replace graft, and at that go-around, he developed a Pulmonary Embolus, and had an IVC filter placed.

Today, he was hoping to go home. That went south at about 6am, when he said his right foot was painful and cold. At the start of the night, he had weak, but palpable pulses. The cold foot didn't even have a doppler pulse.
I paged and notified, those-who-must-know, but frankly, I felt pretty bad about the whole thing, knowing that his departure from the hospital, had just hit a major pothole on the road of his recovery.

Ready To Go Home

Ready to go home
What could possibly go wrong?
Don't ask me to sing it
It's a treacherous song.

First, you survived Sepsis
Cardiac Failure and more,
Diabetes Insipidus
And a high APACHE Score.

Your liver shut down
With your kidneys soon after,
We were preparing the pine box
Stored above on the rafter.

But like a cat with 9 lives
And the horse with no name,
You were the grand finale winner
In your survival game.

Then this morning at six
After you awoke from your slumber,
Your right foot was painful
And colder than a cucumber.

Bad tidings indeed
On that double bypassed leg,
If the gods had a solution
I'd be the first one to beg,
For some blessed reperfusion
And a miracle cure,
The vascular surgeon told me
We can't operate, that's for sure.

Because the man is a vascular
Disaster in person,
We repaired the graft in June
And in July it did worsen,
Infected it was, we had to pull it
And replace it,
I'm the surgeon who fixed it
And now I'd rather not face it.

Mr. Ready-For-Home
Poses a problem and a riddle,
We need to open that leg
But he's not fit as a fiddle,
His morbidity and mortality
Are at an all time high,
No matter what we do or don't
It's quite likely he will die.

I felt like an accomplice
But it was nothing like that,
I checked on him often
Every two hours for a chat,
And not till this morning
Till he moved to the chair,
Was there a hint of a problem
Of disaster in the air.

It's my day off, as I write
And I won't be there tomorrow,
I'm worried and concerned
For his pain and his sorrow.

Fibril_late;
10/12/09

Ready To Go Home II

Ready to go home
What could possibly transpire?
Let me first warn you
My predictions are dire.

Mr. Cardiomyopathy
Didn't stand a chance,
His 900-cc ventricle
Had done it's last dance,
After waxing and waning
A couple of days or two,
He kicked the bucket quietly
There was nothing we could do.

His wife and kids looked on
To the future, without the man,
His lifestyle choices
Take some of the blame,
They helped him kick the can.

Mr. Pulse-less foot
Had a rough couple days,
Vascular surgery attempted
Several, last ditch effort plays,
But the end result was removal
Of his leg below the knee,
Sometimes there are no winners
In the game of life, you see.

He went home a crippled man
But he's still alive for some good tomorrows,
Prosthetic engineering can help him
To waylay his endless sorrows.

Ready to go home
At the end of the night, I am,
Sometimes this healthcare business
Seems like, nothing but a scam.

Fibril_late;
11/7/09