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The old man and the I sea U: Being an essay on faith, fate, and evidence, after the manner of Hemingway Robert H. Bartlett, MD, Ann Arbor, Michigan
H
e was an old man who fished alone, but he would not fish today. His finger was red and swollen, so he went to the hospital. The hospital was made of warm red brick. It was a clean, well-lit hospital, with a feeling of order and reason. Dr. Manolin watched the old man sitting uneasily on a gurney. The man was old but quick, thin but strong, polite but direct. He was a good old man. His finger was red and swollen and tender. He had stabbed his finger with a fish hook, through a piece of sardine and into his finger. It had happened hundreds of times, but this time, his finger became red and swollen. Dr. Manolin gave him some pills, a shot of penicillin, and tetanus toxoid. On the next day, the old man did not go fishing but went instead to Harry’s Bar. He had a cold beer with frost on the glass. It tasted good on the hot, sweaty day. There was a woman at the bar wearing a silk dress. She had dark hair and very dark eyes and looked straight at him with promise and provocation, but his finger was hurting again, and he went back to the hospital. ‘‘Those red streaks on your arm might be serious,’’ said Dr. Manolin. ‘‘I’m going to admit you for some IV antibiotics.’’ The old man had seen the red streaks. He knew the hospital would make them better. The nurse who put in the IV had the sweet smooth skin of youth. His blood swirled back into the tubing. It had the consistency of honey and the color of cabernet. Good, rich blood. She reached up to start the drip. Instinctively, he reached for her tempting round ass. She put his hand away and said ‘‘in your dreams old man’’. Later, she brought him a cup full of pills. ‘‘This is your antibiotic; this is an aspirin; this is Colace; and this’’ (she brandished a small syringe and jabbed it into his belly skin) ‘‘is Lovenox, so you don’t get clots in your legs. That can happen to an old man in the hospital.’’ In his youth, the old man had broken his nose while boxing. From time to time, he had
From the University of Michigan Medical School, Ann Arbor, Michigan. Address for reprints: Robert H. Bartlett, MD, University of Michigan ECMO Lab, B560 MSRB II 1150 W Medical Center Dr, Ann Arbor, MI; email: [email protected]. (J Trauma Acute Care Surg 2014;TK:TKYTK. Copyright * 2014 by Lippincott Williams & Wilkins DOI: 10.1097/TA.0000000000000289
518
nosebleeds, and it bled during the night. It bled more after the morning Lovenox. Just before lunch, he vomited up a basin of something that tasted like rotten grapes and looked like coffee grounds. The nurse called Dr. Manolin who ordered an upper endoscopy. The endoscopy suite was cold and had dried blood on the floor. He felt a burning in his arm then a bitter taste in his mouth. He woke up half an hour later just as he was vomiting a large amount of salty water mixed with blood and stomach juice. There was more burning in his arm, and he awoke with a large plastic tube in his mouth and into his airway. Someone he could not see was forcing air into his lungs from a plastic bag. A face came into view. ‘‘Old man, I’m Dr. Yungensmart. You are in the ICU. The good news is your endoscopy was negative. The bad news is you vomited into your lungs, but we have all the tools to make you well, and you will be as good as new in a few days.’’ The old man tried to talk but no sound came out. He could see some clear fluid running through clear tubes from big bags into his arms. The doctor saw him looking. ‘‘That’s salt water. You always get it in the ICU.’’ The old man felt better. He had spent his life on the sea, and he liked salt water. ‘‘Old man, your blood pressure went up, and we started some beta-blockers. A guy your age should be on beta-blockers anyway.’’ Soon, his heart slowed down even when he tried to move or cough. He could tell his lungs were getting better. Every time he tried, he could suck more air into his lungs. Even an old man knows this is good. Later, Dr. Yungensmart was very upset. ‘‘Who put the old man on
CPAP?’’ he shouted into the room. ‘‘His tidal volume is 1,200 cc. Do you want to ruin his lungs?’’ He twisted dials on the breathing machine. Now, when the old man tried to breath in, the air stopped before his lungs were full. This made him short of breath, so he breathed faster. When he was breathing 20 times a minute, he still felt short of breath and started to panic. ‘‘He’s out of sync and overbreathing the vent,’’ said the doctor. ‘‘Give him some morphine and Ativan. Better yet, just paralyze him until we get this vent working.’’ He turned to the old man. ‘‘Calm down old man, you’ll be better soon.’’ The old man was not better. In his dream, he was adrift at sea, no land in sight. A huge fish was tied to his head. The woman from Harry’s Bar was sitting on his pelvis. Sharks were eating at his skin. Every time he started to wake up, a matador lifted his eyelids, looked, and signaled the picadors to put another spear into his neck. The matador wore a white coat and was slick and arrogant. He tried to call out, but something started the dream again. Every Saturday, Dr. Yungensmart held evidence-based teaching rounds in the ICU. Dr. Manolin always attended because he hoped to become a critical care doctor. When they came to the last bed, Dr. Yungensmart said ‘‘this old man has been here 3 days with aspiration pneumonia and ARDS. We had to go up on his FIO2 and PEEP to keep his sat over 90.’’ ‘‘He’s the old man I admitted last week,’’ said Dr. Manolin. ‘‘He’s a brave and tough old man.’’ ‘‘Well, we’ve got him on all the best evidence protocols, but he’s starting to circle the drain. For example, he’s on volume-controlled ventilation at 6-mL/kg tidal volume. We’ve had to go up to a rate of 30 but his PCO2 is still 55.’’
J Trauma Acute Care Surg Volume 77, Number 3
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
J Trauma Acute Care Surg Volume 77, Number 3
‘‘Is that the best way to run the vent?’’ asked Dr. Manolin. ‘‘Oh yes. The ARDSnet proved this is the best way to ventilate in ARDS.’’ ‘‘Compared with what?’’ ‘‘Compared with twice that tidal volume.’’ ‘‘Wouldn’t it make more sense to compare with pressure-controlled ventilation?’’ ‘‘We didn’t have to. They proved that 6 mL/kg volume controlled is the way to do it.’’ ‘‘Wouldn’t it be better to sit him up or roll him over? He’s been flat on his back for 3 days?’’ ‘‘No evidence.’’ ‘‘And wouldn’t it be better to wake him up, and let him breath spontaneously?’’ ‘‘No evidence. In fact, there are studies showing it’s better to keep these patients paralyzed.’’ ‘‘He’s really anemic. His hemoglobin is only half normal. His arterial O2 content is only 10.’’ ‘‘I don’t worry about the content as long as the PO2 is over 60. And there’s no evidence showing that anemia causes mortality. In fact, one study showed it’s good to be more anemic if you’re really sick. Besides, how would you treat the anemia? There’s a ton of evidence showing the more you transfuse, the higher the mortality.’’ ‘‘But that’s because bleeding causes mortality. Transfusion is just the measure of bleeding.’’ ‘‘Maybe so, but there was one study that showed that transfusion itself did not improve survival. Some people got transfused from 7 gm% to 9 gm% and didn’t get better. In fact, some of them got worse.’’ ‘‘But that’s just comparing two levels of anemia. And besides, wasn’t that the study that used the really old blood?’’ ‘‘Yes, but it’s evidence, and we’re sticking to it. In fact, our hospital has a policy not to transfuse anyone with a hematocrit over 21. It’s evidence based!’’ In his dream, the old man was still adrift in the open sea. The fish was gone. Just bones were left. Once he started to wake up, a shark was sucking his blood out of his groin. The blood had the consistency of water and the color of rose wine. The matador cut off his ears and gave them to a thin pale woman who liked rose wine. He could not breath. The sun was on the horizon and very bright. He could not tell if the sun was rising or setting. Then, the wind came up, and he drifted toward the bright sun. On Monday morning, an event happens in hospitals, which can be very good or very bad. It is called the tradeoff. On this Monday, it was very good. Dr. Yungensmart (who had been in the hospital all weekend) was trading off to Dr. Oldenwise, who was coming on for the week. ‘‘This old man has been here 5 days with ARDS. Last night, I had to start him on norepi. He’s maxed out on the vent and getting ready to box.’’
Bartlett
‘‘Why is he on norepi?’’ asked Dr. Oldenwise. ‘‘Hypotension. No urine output.’’ ‘‘But he’s anemic with half normal blood viscosity, his mean intrathoracic pressure is 20 cm H2O limiting his venous return, and he’s on beta-blockers. Why is he on a betaagonist and a beta-blocker?’’ Dr. Yungensmart said, ‘‘There’s good evidence that old men with heart problems should be on beta-blockers. And there’s evidence that you can raise the blood pressure with norepi. So, there’s good evidence for both. Our hospital has a policy that old men should be on beta-blockers. Very evidence based.’’ ‘‘Why is he on insulin?’’ ‘‘We started TPN, then his sugar shot up. I put him on a sliding scale to keep his blood sugar between 110 and 120. I’m sure you know all about the evidence on tight sugar control.’’ ‘‘But his last blood sugar was 40.’’ ‘‘Yes, we got out of sync with the TPN and the sliding scale. I had to give him an amp of 50%.’’ ‘‘It says here his weight has increased 30 lb in 6 days.’’ ‘‘Did they weigh him again? I didn’t order that. Well look, his ankles are not swollen.’’ ‘‘But he’s been lying flat on his back for 5 days.’’ ‘‘So, the edema is in his back. There’s no evidence that edema causes mortality. It’s just third spacing.’’ ‘‘But even the ARDSnet says dry is better than wet.’’ ‘‘Well, that was just a trend not real evidence. Whatever. I’m going to my lab this week.’’ ‘‘What are you doing in the lab?’’ ‘‘I think I’ve found the molecule that causes capillary leakage in ARDS.’’ ‘‘Histamine?’’ ‘‘Maybe, but I call it CD66, get it? Sixty-six. This week, I’m going to isolate the transcription factor. I don’t have to cover the ICU again for months!’’ ‘‘Whatever,’’ said Dr. Oldenwise.
cd
‘‘Indeed,’’ said Nurse Seenital with an enigmatic smile. ‘‘What we did first was to turn him prone to put his pulmonary blood into the little bit of normal lung he had left in the front of his chest. That raised his arterial sat to 95 for 6 hours, long enough to get his FIO2 down to 50% and his FIN2 up to 50%.’’ ‘‘It’s all about the nitrogen to hold the alveoli open,’’ said Dr. Oldenwise. ‘‘Then, we gave him Lasix until he lost a few liters,’’said Nurse Seenital. ‘‘That gave us room to give him 4 U of packed red blood cells. That let us turn off the norepi and got his arterial content up to 19. Of course, we stopped the beta-blockers to let his cardiac output go up.’’ ‘‘We put him on pressure-controlled ventilation at 25 cm H2O, and we stopped all the sedation; we even gave him some Narcan. By the next day, his tidal volume went from 5 to 15 cc/kg, his rate went from 30 to 12, and his CO2 went from 60 to 40.’’ Dr. Oldenwise said this as if it was a matter of routine. ‘‘But why use pressure ventilation instead of volume ventilation?’’ asked Dr. Manolin. ‘‘All the evidence is that 6-cc/kg tidal volume is the ideal mode for ARDS.’’ Dr. Oldenwise actually laughed. ‘‘What evidence? Think about it. You and I breath in the pressure-controlled mode. We generate enough pressure to provide the tidal volume we want. We do it often enough to keep our PCO2 at 40, and we breathe in to total lung capacity several times an hour. That only takes about 20 cm H2O inspiratory pressure, but that’s spontaneous breathing. With mechanical ventilation, there’s a risk of generating enough pressure to damage the alveoli, and in ARDS, the FRC is small, like a baby lung. So the smaller the FRC, the worse the compliance, and the greater the risk of overstretching the alveoli. Plateau pressure is the best measure of alveolar stretch. So mechanical ventilation should be controlled by pressure, not volume. Neonatologists have known that forever. Adult intensivists could learn a lot of physiology by visiting the neonatal ICU.’’ Later, Dr. Manolin sat down next to the old man and the woman. ‘‘You look good old man. What happened?’’
Three days later, Dr. Manolin came to see the old man. He was sitting up in bed, drinking a beer, which had been brought to him by the woman from Harry’s Bar. The woman had very dark eyes, and the beer was cold and good. Dr. Manolin found Dr. Oldenwise in the conference room, sharing a story and a cup of coffee with Nurse Seenital. ‘‘What did you do for the old man? He almost died.’’ ‘‘No, we almost killed him. There’s a difference.’’
* 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
519
J Trauma Acute Care Surg Volume 77, Number 3
Bartlett
‘‘I vomited some blood then I woke up here. I had some terrible dreams. What day is it?’’ ‘‘It’s Friday. You nearly died.’’ ‘‘We all die. We live well, then we die. I’m glad I didn’t die. Next week, I can go to a baseball game or go fishing. There is still time for living well.’’ He smiled at the woman. Dr. Manolin walked down the road from the hospital. He thought to himself,
520
‘‘the sea is only as good as the weather and the sharks. The hospital is only as good as the people who are there. I have seen the evidence.’’ Two weeks later, the sun was warm, and the sea was calm. The bells were tolling in the chapel. The old man decided to go fishing. While loading a sardine on his hook, he stabbed his finger. He put his finger in his
rum and sucked it dry. It was warm and good. He did not go to the hospital.
About the author Dr. Robert Bartlett is professor emeritus of surgery at the University of Michigan.
* 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
The old man and the I sea U: Being an essay on faith, fate, and evidence, after the manner of Hemingway Robert H. Bartlett, MD, Ann Arbor, Michigan
H
e was an old man who fished alone, but he would not fish today. His finger was red and swollen, so he went to the hospital. The hospital was made of warm red brick. It was a clean, well-lit hospital, with a feeling of order and reason. Dr. Manolin watched the old man sitting uneasily on a gurney. The man was old but quick, thin but strong, polite but direct. He was a good old man. His finger was red and swollen and tender. He had stabbed his finger with a fish hook, through a piece of sardine and into his finger. It had happened hundreds of times, but this time, his finger became red and swollen. Dr. Manolin gave him some pills, a shot of penicillin, and tetanus toxoid. On the next day, the old man did not go fishing but went instead to Harry’s Bar. He had a cold beer with frost on the glass. It tasted good on the hot, sweaty day. There was a woman at the bar wearing a silk dress. She had dark hair and very dark eyes and looked straight at him with promise and provocation, but his finger was hurting again, and he went back to the hospital. ‘‘Those red streaks on your arm might be serious,’’ said Dr. Manolin. ‘‘I’m going to admit you for some IV antibiotics.’’ The old man had seen the red streaks. He knew the hospital would make them better. The nurse who put in the IV had the sweet smooth skin of youth. His blood swirled back into the tubing. It had the consistency of honey and the color of cabernet. Good, rich blood. She reached up to start the drip. Instinctively, he reached for her tempting round ass. She put his hand away and said ‘‘in your dreams old man’’. Later, she brought him a cup full of pills. ‘‘This is your antibiotic; this is an aspirin; this is Colace; and this’’ (she brandished a small syringe and jabbed it into his belly skin) ‘‘is Lovenox, so you don’t get clots in your legs. That can happen to an old man in the hospital.’’ In his youth, the old man had broken his nose while boxing. From time to time, he had
From the University of Michigan Medical School, Ann Arbor, Michigan. Address for reprints: Robert H. Bartlett, MD, University of Michigan ECMO Lab, B560 MSRB II 1150 W Medical Center Dr, Ann Arbor, MI; email: [email protected]. (J Trauma Acute Care Surg 2014;TK:TKYTK. Copyright * 2014 by Lippincott Williams & Wilkins DOI: 10.1097/TA.0000000000000289
518
nosebleeds, and it bled during the night. It bled more after the morning Lovenox. Just before lunch, he vomited up a basin of something that tasted like rotten grapes and looked like coffee grounds. The nurse called Dr. Manolin who ordered an upper endoscopy. The endoscopy suite was cold and had dried blood on the floor. He felt a burning in his arm then a bitter taste in his mouth. He woke up half an hour later just as he was vomiting a large amount of salty water mixed with blood and stomach juice. There was more burning in his arm, and he awoke with a large plastic tube in his mouth and into his airway. Someone he could not see was forcing air into his lungs from a plastic bag. A face came into view. ‘‘Old man, I’m Dr. Yungensmart. You are in the ICU. The good news is your endoscopy was negative. The bad news is you vomited into your lungs, but we have all the tools to make you well, and you will be as good as new in a few days.’’ The old man tried to talk but no sound came out. He could see some clear fluid running through clear tubes from big bags into his arms. The doctor saw him looking. ‘‘That’s salt water. You always get it in the ICU.’’ The old man felt better. He had spent his life on the sea, and he liked salt water. ‘‘Old man, your blood pressure went up, and we started some beta-blockers. A guy your age should be on beta-blockers anyway.’’ Soon, his heart slowed down even when he tried to move or cough. He could tell his lungs were getting better. Every time he tried, he could suck more air into his lungs. Even an old man knows this is good. Later, Dr. Yungensmart was very upset. ‘‘Who put the old man on
CPAP?’’ he shouted into the room. ‘‘His tidal volume is 1,200 cc. Do you want to ruin his lungs?’’ He twisted dials on the breathing machine. Now, when the old man tried to breath in, the air stopped before his lungs were full. This made him short of breath, so he breathed faster. When he was breathing 20 times a minute, he still felt short of breath and started to panic. ‘‘He’s out of sync and overbreathing the vent,’’ said the doctor. ‘‘Give him some morphine and Ativan. Better yet, just paralyze him until we get this vent working.’’ He turned to the old man. ‘‘Calm down old man, you’ll be better soon.’’ The old man was not better. In his dream, he was adrift at sea, no land in sight. A huge fish was tied to his head. The woman from Harry’s Bar was sitting on his pelvis. Sharks were eating at his skin. Every time he started to wake up, a matador lifted his eyelids, looked, and signaled the picadors to put another spear into his neck. The matador wore a white coat and was slick and arrogant. He tried to call out, but something started the dream again. Every Saturday, Dr. Yungensmart held evidence-based teaching rounds in the ICU. Dr. Manolin always attended because he hoped to become a critical care doctor. When they came to the last bed, Dr. Yungensmart said ‘‘this old man has been here 3 days with aspiration pneumonia and ARDS. We had to go up on his FIO2 and PEEP to keep his sat over 90.’’ ‘‘He’s the old man I admitted last week,’’ said Dr. Manolin. ‘‘He’s a brave and tough old man.’’ ‘‘Well, we’ve got him on all the best evidence protocols, but he’s starting to circle the drain. For example, he’s on volume-controlled ventilation at 6-mL/kg tidal volume. We’ve had to go up to a rate of 30 but his PCO2 is still 55.’’
J Trauma Acute Care Surg Volume 77, Number 3
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
J Trauma Acute Care Surg Volume 77, Number 3
‘‘Is that the best way to run the vent?’’ asked Dr. Manolin. ‘‘Oh yes. The ARDSnet proved this is the best way to ventilate in ARDS.’’ ‘‘Compared with what?’’ ‘‘Compared with twice that tidal volume.’’ ‘‘Wouldn’t it make more sense to compare with pressure-controlled ventilation?’’ ‘‘We didn’t have to. They proved that 6 mL/kg volume controlled is the way to do it.’’ ‘‘Wouldn’t it be better to sit him up or roll him over? He’s been flat on his back for 3 days?’’ ‘‘No evidence.’’ ‘‘And wouldn’t it be better to wake him up, and let him breath spontaneously?’’ ‘‘No evidence. In fact, there are studies showing it’s better to keep these patients paralyzed.’’ ‘‘He’s really anemic. His hemoglobin is only half normal. His arterial O2 content is only 10.’’ ‘‘I don’t worry about the content as long as the PO2 is over 60. And there’s no evidence showing that anemia causes mortality. In fact, one study showed it’s good to be more anemic if you’re really sick. Besides, how would you treat the anemia? There’s a ton of evidence showing the more you transfuse, the higher the mortality.’’ ‘‘But that’s because bleeding causes mortality. Transfusion is just the measure of bleeding.’’ ‘‘Maybe so, but there was one study that showed that transfusion itself did not improve survival. Some people got transfused from 7 gm% to 9 gm% and didn’t get better. In fact, some of them got worse.’’ ‘‘But that’s just comparing two levels of anemia. And besides, wasn’t that the study that used the really old blood?’’ ‘‘Yes, but it’s evidence, and we’re sticking to it. In fact, our hospital has a policy not to transfuse anyone with a hematocrit over 21. It’s evidence based!’’ In his dream, the old man was still adrift in the open sea. The fish was gone. Just bones were left. Once he started to wake up, a shark was sucking his blood out of his groin. The blood had the consistency of water and the color of rose wine. The matador cut off his ears and gave them to a thin pale woman who liked rose wine. He could not breath. The sun was on the horizon and very bright. He could not tell if the sun was rising or setting. Then, the wind came up, and he drifted toward the bright sun. On Monday morning, an event happens in hospitals, which can be very good or very bad. It is called the tradeoff. On this Monday, it was very good. Dr. Yungensmart (who had been in the hospital all weekend) was trading off to Dr. Oldenwise, who was coming on for the week. ‘‘This old man has been here 5 days with ARDS. Last night, I had to start him on norepi. He’s maxed out on the vent and getting ready to box.’’
Bartlett
‘‘Why is he on norepi?’’ asked Dr. Oldenwise. ‘‘Hypotension. No urine output.’’ ‘‘But he’s anemic with half normal blood viscosity, his mean intrathoracic pressure is 20 cm H2O limiting his venous return, and he’s on beta-blockers. Why is he on a betaagonist and a beta-blocker?’’ Dr. Yungensmart said, ‘‘There’s good evidence that old men with heart problems should be on beta-blockers. And there’s evidence that you can raise the blood pressure with norepi. So, there’s good evidence for both. Our hospital has a policy that old men should be on beta-blockers. Very evidence based.’’ ‘‘Why is he on insulin?’’ ‘‘We started TPN, then his sugar shot up. I put him on a sliding scale to keep his blood sugar between 110 and 120. I’m sure you know all about the evidence on tight sugar control.’’ ‘‘But his last blood sugar was 40.’’ ‘‘Yes, we got out of sync with the TPN and the sliding scale. I had to give him an amp of 50%.’’ ‘‘It says here his weight has increased 30 lb in 6 days.’’ ‘‘Did they weigh him again? I didn’t order that. Well look, his ankles are not swollen.’’ ‘‘But he’s been lying flat on his back for 5 days.’’ ‘‘So, the edema is in his back. There’s no evidence that edema causes mortality. It’s just third spacing.’’ ‘‘But even the ARDSnet says dry is better than wet.’’ ‘‘Well, that was just a trend not real evidence. Whatever. I’m going to my lab this week.’’ ‘‘What are you doing in the lab?’’ ‘‘I think I’ve found the molecule that causes capillary leakage in ARDS.’’ ‘‘Histamine?’’ ‘‘Maybe, but I call it CD66, get it? Sixty-six. This week, I’m going to isolate the transcription factor. I don’t have to cover the ICU again for months!’’ ‘‘Whatever,’’ said Dr. Oldenwise.
cd
‘‘Indeed,’’ said Nurse Seenital with an enigmatic smile. ‘‘What we did first was to turn him prone to put his pulmonary blood into the little bit of normal lung he had left in the front of his chest. That raised his arterial sat to 95 for 6 hours, long enough to get his FIO2 down to 50% and his FIN2 up to 50%.’’ ‘‘It’s all about the nitrogen to hold the alveoli open,’’ said Dr. Oldenwise. ‘‘Then, we gave him Lasix until he lost a few liters,’’said Nurse Seenital. ‘‘That gave us room to give him 4 U of packed red blood cells. That let us turn off the norepi and got his arterial content up to 19. Of course, we stopped the beta-blockers to let his cardiac output go up.’’ ‘‘We put him on pressure-controlled ventilation at 25 cm H2O, and we stopped all the sedation; we even gave him some Narcan. By the next day, his tidal volume went from 5 to 15 cc/kg, his rate went from 30 to 12, and his CO2 went from 60 to 40.’’ Dr. Oldenwise said this as if it was a matter of routine. ‘‘But why use pressure ventilation instead of volume ventilation?’’ asked Dr. Manolin. ‘‘All the evidence is that 6-cc/kg tidal volume is the ideal mode for ARDS.’’ Dr. Oldenwise actually laughed. ‘‘What evidence? Think about it. You and I breath in the pressure-controlled mode. We generate enough pressure to provide the tidal volume we want. We do it often enough to keep our PCO2 at 40, and we breathe in to total lung capacity several times an hour. That only takes about 20 cm H2O inspiratory pressure, but that’s spontaneous breathing. With mechanical ventilation, there’s a risk of generating enough pressure to damage the alveoli, and in ARDS, the FRC is small, like a baby lung. So the smaller the FRC, the worse the compliance, and the greater the risk of overstretching the alveoli. Plateau pressure is the best measure of alveolar stretch. So mechanical ventilation should be controlled by pressure, not volume. Neonatologists have known that forever. Adult intensivists could learn a lot of physiology by visiting the neonatal ICU.’’ Later, Dr. Manolin sat down next to the old man and the woman. ‘‘You look good old man. What happened?’’
Three days later, Dr. Manolin came to see the old man. He was sitting up in bed, drinking a beer, which had been brought to him by the woman from Harry’s Bar. The woman had very dark eyes, and the beer was cold and good. Dr. Manolin found Dr. Oldenwise in the conference room, sharing a story and a cup of coffee with Nurse Seenital. ‘‘What did you do for the old man? He almost died.’’ ‘‘No, we almost killed him. There’s a difference.’’
* 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
519
J Trauma Acute Care Surg Volume 77, Number 3
Bartlett
‘‘I vomited some blood then I woke up here. I had some terrible dreams. What day is it?’’ ‘‘It’s Friday. You nearly died.’’ ‘‘We all die. We live well, then we die. I’m glad I didn’t die. Next week, I can go to a baseball game or go fishing. There is still time for living well.’’ He smiled at the woman. Dr. Manolin walked down the road from the hospital. He thought to himself,
520
‘‘the sea is only as good as the weather and the sharks. The hospital is only as good as the people who are there. I have seen the evidence.’’ Two weeks later, the sun was warm, and the sea was calm. The bells were tolling in the chapel. The old man decided to go fishing. While loading a sardine on his hook, he stabbed his finger. He put his finger in his
rum and sucked it dry. It was warm and good. He did not go to the hospital.
About the author Dr. Robert Bartlett is professor emeritus of surgery at the University of Michigan.
* 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
