As mentioned in a previous post, at 7:10 on a Saturday morning, I assumed the care of two Trauma Intensive Care patients.  In bed #3 lay a restless, unkempt, dirty, alcohol-addicted Hispanic male, 42 years old, whose eye was kicked out by a bunch of young thugs. The contrast between him -- drunk, homeless, likely illegal, perhaps illiterate, yet very polite between fits of delirium  -- and the fine human beings who chose to take his eye out for entertainment fuels my compassion. Plus  informed perspectives on addiction and the many reasons for running away from society.

The unlucky kid in bed #4 had been adopted as an infant after being removed from his biological parents' custody for abuse. When he was nine, a car wreck had mangled his dominant hand. Now he's in the ICU because his hand slipped off the adapted controls in his car and he flipped the car. Twice.  He has a low cervical spine injury, meaning he should be able to breathe on his own eventually and shrug his shoulders, but no more.  That will come over time with therapy, but right now my goal is merely to maintain a decent blood pressure in this kid. 

After a spinal cord injury, shock due to vasodilation drives blood pressure down. Which may not be a huge threat to a young man like him (they are incredibly resilient), but cervical spine injuries are often accompanied by brain injury, and the brain wants lots of blood flow in this state.  So I titrate an adrenalin-like vasoactive drug, norepinephrine, that flows into a big vein in his right shoulder.  Goal: mean arterial pressure of at least 60 mm Hg. To provide perspective, if his blood pressure were 120/80, his mean arterial pressure would be about 93. So 60 is a very modest goal, but he's having a hard time keeping a mere trickle flowing to his vital organs. Unfortunately, norepinephrine has a nasty effect on the heart. Nasty like rogue irregular heartbeats that drop the blood pressure even more. So it's a balancing act; a little norepinephrine, but not too much. 

The man in bed #3 is motioning to me. I know if I don't rush in there he'll try coming to me, which I definitely do not want. When I reach his side, it's time for his pain medication (the opioid oxycodone) and sedative (the benzodiazepine Librium).  My hope is that this pairing will quiet him for a while and he'll stop attempting to escape, and perhaps he'll even eat his breakfast. The duo I'm giving him would knock most people flat out for hours. I talk him into laying back down and leave the room.

Minutes later, the bed alarm shrieks again, telling me he's making another run for it. Needing more ways to occupy his central nervous system's GABA receptors (the kind alcoholics keep saturated by drinking more and more) I walk to the kitchen and retrieve a cold beer for him. (Hamm's - the cheapest, worst-tasting beer made. Although alcoholics in withdrawal are rarely picky.) 

I stop for a moment to muse on the contradiction in what I'm about to do.  Nurses promote health. To this man, alcohol is poison. But not drinking is also dangerous for people like him because alcohol withdrawal is one of two withdrawal syndromes that can be fatal. (The other is benzodiazepine withdrawal, because benzos occupy the same GABA brain receptors. Which is why we treat alcohol withdrawal with benzos.)  I could withhold the beer, knowing its longer-term effects are killing this man, or I could give it to him, knowing it's cheaper and faster-acting than an oral benzodiazepine.  If I give him nothing, he may injure himself or me, and he may have seizures, among other bad stuff.  I still have  intravenous lorazepam, another benzodiazepine, for backup if the beer doesn't help. Principle loses to practicality, and I give him the beer.

The parents of bed #4 are here. What lovely people they are, talking to their son, telling him the latest family news, never questioning his comprehension.  It doesn't matter, really.  I show them the chest x-rays from yesterday and today to illustrate that his lungs are clearing and we hope to start weaning the ventilator support soon.  They are delighted to really see, not just hear about, their son's progress. 

By the end of the shift, my alcoholic friend has tried to persuade me into escaping with him, to putting down the rails on his bed so he can go outside, to getting him a cigarette, and to talking to the tall guy in the corner who won't stop bothering him.  All polite requests, all politely refused. Once recovered, he'll be back on the street as before, only with one less eye to watch out for miscreants and thieves.

The 17-year-old will leave the hospital for rehab, and probably do pretty well living in a wheelchair. Studies show that people with spinal cord injuries rate their quality of life highly, in fact, about the same as people without spinal cord injuries.  It's encouraging to know that happiness is not dependent upon moving our legs and arms, even if it is fairly obvious.

I walk out of the unit that evening grateful for a few chances to do good today,  for my own good luck (so far), and for polite people just trying to find their way through what comes at them.