As Down says, the grey areas are what interest him most. Intensive-care guidelines are in place to ingrain the most effective procedures, and thereby reduce the stresses of decision-making in the chaos of a medical crisis. They are not infallible, however. One of Down’s patients is taken off ventilation but then dies from an “airway catastrophe”, even though the guidelines have been followed to the letter. Sometimes doctors might save a patient by deviating from the protocols, but how many more would suffer if they improvised more freely? In many cases there is not a single correct procedure to follow, and failure isn’t necessarily instructive. Good luck and bad luck play a part.
Down and his colleagues have no choice but to honour the wishes of an intelligent young patient who refuses to undergo blood transfusion on religious grounds, even though she is aware that her refusal might prove fatal. By good fortune, she pulls through. Conversely, an alcoholic patient declines rapidly and inexplicably on Down’s watch. Her symptoms suggest an abdominal collapse, but tests don’t find any evidence. Finally it is established that violent vomiting has ruptured the woman’s oesophagus, allowing acidic stomach contents to seep into her chest, lethally. The condition is known as Boerhaave syndrome, and Down berates himself for not arriving at the diagnosis sooner, even though the outcome would have been no different had the rupture been located quickly – the patient could not have survived an operation.
👏 Well done to UCLH critical care consultant Jim Down on publishing his second book, Life in the Balance.
His new book offers a real glimpse into intensive care medicine, its immense challenges and effects on mental health.
— UCLH (@uclh) February 23, 2023