I have written before about the beneficial effects of cooling the brain on survival and neurological recovery after a cardiac arrest. It has been shown that the sooner the cooling is started and the sooner the target temperature is achieved the better the outcome.

I have started intravascular cooling in the Intensive Care Unit on multiple occasions. If started in the ICU, then the cooling is may sometimes be delayed by more than an hour and the benefit of it is likely greatly reduced.

Starting cooling as early as possible, ideally, at the scene of cardiac arrest should be out ultimate goal.

Realizing, of course, this is easier said then done. Imagine paramedics trying to intubate the patient, perform CPR, establish peripheral access, transport the patient at the same time and, somehow, initiate cooling.

It could only be done if the induction of cooling was easy to perform on the field and efficient enough to have a measurable benefit on survival.

One of the methods is to start infusing cold saline through a peripheral IV. This could be done by paramedics and continued in the Hospital.

A novel technique, which we previously described, is to use a rapidly evaporating substance to cool the mucous membrane inside the nose and throat of the cardiac arrest victim.

The proximity of the nose to the brain and the shared blood supply between the nasopharynx and the brain makes it an “ideal” candidate for induction of hypothermia.

A recent study published in the Critical Care Medicine Journal compares two cooling methods (nasopharyngeal cooling vs. cold saline infusion) in porcine model of cardiac arrest. Both were initiated at the start of CPR.

The study concluded that nasopharyngeal cooling (NPC) initiated at the start of CPR significantly improved the resuscitation rate when compared with cold saline infusion.

After all is said and done, your nose might become a “vital organ” to save your life if you ever go into cardiac arrest.

Just a few days after I had posted a blog about the importance of organ donation and the barriers towards obtaining the consent for donation from the patient’s family, I found myself in a room full of strangers talking about withdrawing life support from their loved one.

The patient was a previously healthy female in her late thirties who was involved in a horrendous car accident. She sustained a severe head injury and remained unresponsive. The CT scan of her brain on day 4 showed extensive cerebral edema and developing infarcts. The prognosis for her neurological recovery was dismal at that point.

From an organ donation standpoint she was a perfect donor – previously healthy and young patient with an isolated head injury.

The family already knew that things were bad. I explained once again what was happening and why their loved one was not going to recover. It seemed like the family had already made up their minds and was considering withdrawal of care.

When I asked about organ donation, the answer was “No we do not want that”. I had to paraphrase the question and asked if the patient would have wanted this if she new that this is going to happen. There was a silence in the room for a few seconds and then one the family members said that she had never put an organ donor sticker on her driver’s license. As I mentioned before, the lack of knowledge about the patient’s own wishes regarding organ donation is one of the barriers towards a successful consent for donation.

I started explaining why organ donation is important and why they should consider it. As I was doing it, I felt uneasy and conflicted. I just told the family that their loved one is not going to get better and now I am trying to get her organs.

I remember some time ago in a similar circumstance, a family member started yelling at me: “You just want to take her organs, that’s why you doing this…”

I have to acknowledge that it almost creates a conflict of interest for the treating physician to approach the family about organ donation. The studies have shown that the success rate for obtaining consent for donation is, actually, higher when somebody independent from the healthcare team approaches the family.

I realize that feeling conflicted about being the treating physician and requesting consent for donation did not allow me to be more persistent with my request. Eventually, I had to acknowledge that the patient was not going to be an organ donor.

This is a very unfortunate situation. One life is lost in a horrible accident, yet we have failed to improve or even save the lives of many other people. Even knowing the barriers for obtaining the consent, I was not able to overcome them.

As a physician you have to be sympathetic and understanding. You also have to be respectful to the patient. A lot has been written about doctors’ responsibilities as healthcare providers and about patient’s rights as healthcare consumers.

What about patient’s responsibilities? Do they have any?

What do you do when the patient is being openly disrespectful and unreasonable?
You are supposed to take the “high road”, yet how much abuse should you take?

My patient was admitted with severe respiratory failure and ended up on mechanical ventilation. Subsequently, the patient developed pneumothorax (air in the chest) and extensive SQ emphysema (air under the skin). Later, the respiratory status improved and mechanical ventilation was discontinued. The chest tube remained in place due to a persistent air-leak (air escaping through the chest tube).

The patient was upset about the fact that the chest tube was still in and there was a facial "change".

SQ emphysema may temporarily change facial features due to swelling and air under the skin. Once the air is resorbed (days to a couple of weeks) the facial features return to normal.

Now, what do you do if you are being yelled at for providing treatment that is appropriate in the situation, even though, it does not fit with the patient’s plans (going home in this case)?

I explained, once again, why the chest tube cannot come out now and, when the patient went on a yelling rampage again, so I left the room. Right or not, sometimes, you have to have some respect for yourself.

There is nothing worse for the family of critically ill patients to receive contradictory information from different physicians. It causes an obvious distress among family members and very often leads to a “whom to believe” situation.

Situations like that are not uncommon when the patient after a complicated surgical procedure becomes critically ill and is being admitted to ICU. Sometimes, when recovery is unlikely and the patient or the family is requesting withdrawal of care, the surgeon declines to proceed to comfort measures only approach and insists on aggressive treatment.
Intensivists and Hospitalists taking care of these patients in ICU are often caught in the “crossfire” between family members and the surgeon.

A very interesting study conducted in Wisconsin and published in the Critical Care Medicine Journal examines the process of a surgical “buy-in”, or the nature of the contractual obligations between surgeons and their patients.

The authors describe the potential “obstacles” towards accepting the withdrawal of care by the surgeon. The feelings of guilt and failure by the surgeon in a case of an unexpected poor outcome were likely contributing to the failure to accept it. A poor outcome after an elective procedure had an even heavier emotional toll. This was in contrast to the medical doctor who often views a failure of treatment as failure of the patient or disease to respond to therapy.

Surgeons often assume, according to this study, that obtaining consent for the surgery could be viewed as a surrogate for bi-directional contract, with the patient agreeing to adhere to the postoperative care even if complications occur.

In my practice I have had to deal with situations when the patient is dying, yet the surgeon is refusing to accept the inevitable. Ultimately, it is the patient who is suffering, having to go through unnecessary and often futile treatment.

On the flip side of this problem, I cannot claim that I am always right and the surgeon is just refusing to see the obvious. I have been wrong about the outcome before and having somebody on the team with an opposite view on the outcome might, actually, be a good thing. After all, medicine is not an exact science.

I was sitting in my office finishing my medical records (which is painful enough) when I realized that I could barely move my arms. It felt like I had been lifting weights. But then I remember that I had not been lifting weights but I had been trying to restrain a patient (along with four nurses) who was going throught bad alcohol withdrawal.
It is always the same scenario. For some reason the patient with alcoholism loses access to the beverage of choice and day or two later goes into the withdrawal. In severe cases it could be life-threatening. Some patients could even have seizures.

I am always amazed how strong the patients with Delirium Tremens (DT) could get. We often end calling security just to pin the patient down. The patient from this morning was, actually, a female weighing no more that 70 kilograms, yet it took five of us to contain her.

Sedating patients going through DTs could be challenging as well. I ended up asking for multiple doses of intravenous Ativan and, yet, after giving 16mg with no effect on the patient’s agitation, I “gave up” and ordered the Precedex drip.

It worked like a charm.

Precedex is a newer sedative medication, primarily used in anesthesiology for cardiac surgery patients. The mechanism of action is via centrally (in the brain) located alpha receptors. This is similar to how Clonidine (blood pressure medicine) works, which makes it even more suitable for alcohol withdrawal.

Even, though, expensive and approved only for a short term use (24 hours), there is a study showing that Precedex could be used safely for longer periods of time. The same study also showed that using Precedex vs. Versed for sedation could be cost-effective.

The most common side effect of Precedex is mild hypotension. This too makes it a good candidate for patients with DTs since most of them are hypertensive.

More studies are needed to expand the spectrum of indications for this medication, yet, I bet you we are going to see it more and more in the ICU practice.

There is no doubt that Vitamin D and calcium, both found in milk, are important for your health. Vitamin D regulates calcium content in the skeletal system and is essential for strong healthy bones.

Recently, there has been an increased interest in Vitamin D and Calcium supplementation to maintain general health and to modify so-called cardiometabolic outcomes including high blood pressure, diabetes and coronary artery disease.

It is know that Vitamin D has a significant role in our body beyond just the skeletal system. Vitamin D is important in regulating vascular tone, fluid status via the renin-angiotensin system, anticoagulant activity and insulin resistance. All of these mechanisms play a pivotal role in developing hypertension, diabetes and coronary artery disease.

It was shown in several studies that patients with low Vitamin D levels are at a higher risk for coronary artery disease. It is logical to assume that supplementing Vitamin D and Calcium will decrease your risk of developing heart disease. More and more patients are started on Vitamin D and Calcium for that reason.

How strong is the evidence to support Vitamin D with or without Calcium to protect against the number one killer – coronary artery disease?

Surprisingly, the evidence is quite scant. Two recent articles published in the Annals of Internal Medicine provide a thorough review of the available literature.

After reviewing multiple publications the authors of the first study concluded that as a whole, there is not enough evidence to support Vitamin D supplementation to improve cardiometabolic outcomes including hypertension, diabetes and coronary artery disease.

It was suggested that, possibly, Vitamin D status is a marker of good health including positive associations with young age, normal body weight and healthy lifestyle, which would independently decrease your risk for heart disease. There is also a negative association between Vitamin D levels and a history of smoking, family history of heart disease and alcohol intake. It does not mean, though, that increasing Vitamin D intake will positively affect the outcome.

The authors of the second paper took a slightly different approach. They looked at Vitamin D AND Calcium supplementation for the prevention of cardiovascular disease.

The authors concluded that Vitamin D supplementation may have a beneficial effect on the risk for coronary artery disease in the general population (the keyword here is may). Calcium supplementation has no apparent effect on cardiovascular disease risk. The authors also emphasized that very few studies, actually, investigated the effect of Vitamin D and calcium supplements on the risk for heart disease in the general population.

As a physician, I recommend Vitamin D and Calcium to my patients to maintain stronger bones. More positive evidence is needed before I can recommend it as a prophylaxis against heart disease.

Previously, we examined the fact that trauma patients with no insurance may have worse outcomes than the patients with insurance. What about race? Is quality of care being affected by race?

A study published in the Critical Care Medicine Journal determines the correlation between the quality of care for patients with pneumonia and race.

Several previous studies indicated that black patients with severe infections like pneumonia or sepsis receive lower quality of care. These findings, if true, are very disturbing.

The study published in Critical Care looks at the quality of care for patients with pneumonia from a different perspective. Is it the quality of care within the same hospital that is different or the variation is explained by the difference of care between hospitals?

The quality of care, in this study, was defined by the timeliness of intravenous antibiotic administration and by the adherence to the national guidelines for the treatment of pneumonia. The intensity of care including admission to the Intensive Care Unit and mechanical ventilation was also considered.

In crude comparisons, black patients did receive lower quality of care compared to white patients. Looking further into this difference the authors came to the following conclusions:

The differences were primarily attributed to the variability of care between different hospitals. Black patients were more likely to receive care at the hospitals that provided lower quality of care, regardless of race.

In general, hospitals that served a higher number of black patients provided higher intensity of care, including more frequent use of mechanical ventilation.

There was no statistically significant difference in care provided for the patients with pneumonia within the same hospital. Different clustering of white and black individuals among hospitals could explain some of the differences in quality of care found in previous studies.

The findings of this study, even though somewhat encouraging, are still disturbing on another level. A significant variation in the quality of care that is dependent upon the hospital’s geographical location and the predominant race served is unacceptable and should be eliminated.

Organ donation is a very complicated and involved process. The essential part of this process is organ procurement or the process of taking organs out of the organ donor body.

According to the “Dead Donor Rule” the donor should be declared dead prior to organ donation rather than dying as a result of donation. Otherwise, it would be unethical or even criminal to harvest the organs.

How do you define death for organ donation?

The patient may be pronounced brain dead prior to donation. This means that no brain activity or measurable blood flow to the brain can be detected. The diagnosis of brain death is usually made on clinical grounds with an optional confirmatory test like a nuclear medicine brain perfusion scan.

If the patient is not brain dead, donation is still possible via a “Donation after Cardiac Death” (DCD) protocol. The essence of this approach is for the patient to be pronounced dead based on the cessation of circulatory and respiratory functions, assuming that brain death is imminent after that.

In the real world if DCD is pursued, the patient would be taken to the Operating Room where life support will be removed. The physician will have to document the cessation of the respiratory function and mechanical asystole (lack of heart contractions) for 2 to 5 minutes depending on the Hospital protocol.

Mechanical asystole means a lack of heart contractions and circulation. The patient still might have electrical activity in the heart. Lack of heart contractions associated with the electrical activity (pulsless electrical activity) is sufficient to declare death.

Lack of cardiac contractility is documented by the absence of Doppler flow over the arteries, absence of blood flow through the aortic valve on a cardiac ECHO, or by documenting the lack of circulation by an invasive arterial cannula.

The usual sequence of events, once the life support is removed, is respiratory arrest leading to cardiovascular collapse. The lack of breathing and circulation should be observed for at least 2 to 5 minutes before organs should be taken. This is necessary to assure that an “auto-resuscitation” or spontaneous return of vital functions does not occur.

This is a somewhat superficial and simplified review of the declaring dead process for organ donation. Educating the public about organ donation, death and organ procurement is an essential step to improve the rate of consent for organ donation.

Recombinant Factor 7 (Factor 7) is a synthetic version of the naturally circulating coagulation enzyme. Factor 7 exerts a potent hemostatic effect. Originally, it was developed for the treatment of hemophilia. Factor 7 has been used off label to stop bleeding in trauma patients and to correct coagulopathy in patient taking anticoagulants (Warfarin aka Coumadin).

I like to think of Factor 7 as tPA (thrombolytic) with the reverse action. It is a very potent medicine when used appropriately, yet the side effects could be devastating. With a potent procoagulant action, Factor 7 can cause thrombosis (clotting) in the cerebral arteries causing strokes and coronary arteries causing myocardial infarction. Thrombosis in the mesenteric and peripheral arteries was also reported.

The use of factor 7 for patients with blunt trauma showed reduced blood transfusion and massive transfusion requirements. There was no benefit when Factor 7 was used for penetrating trauma. In both groups of patients there was no mortality benefit.

In my personal experience, I used Factor 7 in an elderly patient with a massive blunt chest injury and uncontrolled bleeding. We were able to control the bleeding, yet the patient developed a disabling stroke attributed to Factor 7.

The application of Factor 7 for the treatment of intracerebral hemorrhage (ICH) is controversial as well. One study found that the use of Factor 7 may limit the progression of hemorrhage, yet there was no improve in survival or functional outcome. Factor 7 in this study was used regardless of the pre-administration coagulation profile. The patients not taking anticoagulants prior to Factor 7 administration may have limited benefit and potentially develop thrombotic complications, offsetting the beneficial effects of Factor 7.

A recent small study out of Texas published in the Journal of Trauma looked at the use of Factor 7 for patients with a traumatic brain injury and preexisting coagulopathy. The study indicates that when used in the appropriate setting (administered to coagulopathic patients with a head injury), Factor 7 was associated with an effective correction of coagulopathy, decreased transfusion rates with blood and plasma, as well as savings associated with the reduction in blood transfusions.

The fact that the cost savings were documented in this study is quite remarkable. Factor 7 is considered very expensive. The cost of 1mg is about 1000 dollars. I have been using Factor 7 in doses ranging from 90 to 120mcg per kilogram. A 70kg patient will get a dose of 7mg on average, costing about 7000 dollars. This is not cheap but any measure.

Having reviewed the literature and having some experience with using Factor 7 I came to the conclusion that Factor 7 has it’s role in the Intensive Care Unit primarily as a rapid coagulopathy reversal agent to facilitate the management of massive bleeding or life-threatening intracerebral hemorrhage.

I have attended multiple meetings in the hospital to facilitate the process of rapid coagulopathy correction with fresh frozen plasma in the patients with intracerebral hemorrhage. At the end of the day, I found that nothing beats Factor 7 when you need to reverse coagulopathy. The same goes for patients on Coumadin with traumatic subdural/epidural hematomas that require urgent craniotomy. In these circumstances it’s not just about saving money by transfusing less blood products, it’s about saving lives.

There are more than 100,000 people on a transplant waiting list in the US alone. Each year, only about a quarter of these patients will receive life saving transplants because of the significant shortage of organ donors. Thousands of patients on the transplant list die every year without a chance to receive an organ. The gap between the number of patients awaiting transplant and the number of organs available continues to widen.

Obtaining family consent for organ donation is a crucial rate-limiting step towards successful donation. The lack of understanding of the organ donation and organ procurement process by the families’ of the potential organ donors is one of the barriers.

A study conducted in Texas and published in the Journal of Trauma indicates that only 57% of families consent for organ donation. There were several specific barriers towards giving consent for donation identified by this study:

#1 Ethnicity
Hispanic families were four times less likely to give consent for donation. African-American families were seven times more likely to decline donation. During the past 20 years, African Americans and Hispanics represent only 12% and 11% of organ donors. Lack of understanding of brain death and the organ donation process were considered the likely explanation by the authors of this study. Specific approaches focusing on minority groups might improve the donation rates among minorities.

#2 Age and cause of death of the patient.
Older age (aged 50 years or older) and a medical cause of death of the potential organ donor were independent predictors for the failure to consent for organ donation by the family. The authors of this study indicated that the families of older patients would likely consider organ donation to be out of the realm of possibility. Many families were also unaware of the patient’s previous wishes and attitudes towards organ donation. It was found in the previous studies that the knowledge of a patient’s preference to donate increased the likelihood of donating by seven times. Efforts to improve donor designation, including the DMV organ donor program, might improve organ donation rates.

#3 Circumstances surrounding the request for consent
It was found that the sooner the family is approached about organ donation the higher the chances of obtaining the consent. Also, being approached by a member of the OPO (organ procurement organization) team, rather than by an independent member of the healthcare team also increased the rate of donation. Some large medical centers only allow specially trained individuals to approach the family about organ donation.

In conclusion, the rates of organ donation remain suboptimal. Identifying and eliminating barriers for successful organ donation will save thousands of lives every year.