The Train Wreck ICU Admission

A Little Background: 85 year old white male with a history of metastatic cancer to the bowel, liver, and lungs, primary site unknown, 65 pack year history of tobacco abuse, still smokes, chronic obstructive pulmonary disease (COPD), type II diabetes, severe peripheral vascular disease, active ETOH abuse, quart of gin a day, pedophilia, PTSD, benign prostatic hypertrophy, chronic GI bleeding, esophageal varices, peptic ulcer disease, recent small bowel resection, bipolar depression, schizophrenia, dementia, idiopathic cardiomyopathy with ejection fraction of 15% on a good day, severe congestive heart failure, brain natriuretic peptide (BNP) routinely 3000 pg/ml, hepatitis C, hemorrhagic pancreatitis, cirrhosis, chronic kidney disease (stage III), and neutropenia after completing 3 rounds of intensity modulated radiation therapy and chemo (vincristine, Cytoxan, doxorubicin and methotrexate regimens). Drug Eluting Stent deployed to the circumflex in 2004, aortic valve replacement with CABG x2 in 2006, bilateral fem-pop bypass, electroshock therapy, TURP and left ureteral stent placement.

The Patient presents to the emergency room today from nursing home with urinary catheter in place, shortness of breath, and flu like symptoms. He is immediately intubated and transferred to the ICU under pulmonary service. He is a full DNR (Do Not Resuscitate) with an iron clad advance directive. No defib, no compressions, no meds, no intubation (which we did anyway), no invasive lines, no nothing.

This is a teaching hospital, this is what we do…

“That is some concentrated looking urine … better send for a urine UA and urine culture and sensitivity ….. blood cultures too!”

Full court press folks. Wait till the Power of Attorney for Health Care shows up. Fireworks for sure.