What Life Support Really Means

Vents, CRRT, Medications

(Eeep! A prior version of this post only went out to paying subscribers, I think, and not everyone, so here’s the redo for everyone’s eyes! Sorry, still getting used to the back end of this program, and apologies for those of you who are getting it a second time.)

Hey there, it's Cassie again!

Thought I'd take a moment to go through and explain what ‘life support' really means, since it's a term that gets tossed around a lot but if you're not a medical person you might not have a great context for it.

At its broadest, life support is anything that you require to survive — makes sense, right? It's any therapy that if you didn't have — you would die.

Before I get into the explanatory weeds here — sometimes we're taking care of people's grandmothers, who're writing them notes on facetime or sending texts, and they've got breathing tubes in or they're on 3-4 pressors (blood pressure medication, more later) to keep their BP up, and they are very much alive!

They seem very lively! After all, they're gesturing to you and writing notes!

But…they're still on life support. And if any one of those therapies were withdrawn, they wouldn't survive on their own, without it. It's kind of a hard disconnect sometimes.

So let's go system by system — I'll start with the lungs.

You might remember my big prior post on ventilators and ventilation — if not, you can refresh — but basically, we put breathing tubes (endotracheal tubes, aka ETT) into people to help them survive.

Either they're not physically able to currently keep their airway open (and no airway means no air in lungs) or their lungs aren't functioning well enough to maintain their O2 sats (oxygen is a requirement for life on the cellular level) so we need to take that function over for them. (If you want to read more about vents and ventilator parameters, click that other link!)

As I've mentioned before in prior posts, you can only have a breathing tube in you for around 2 weeks, max. This is because (generally, there are outliers) the mere act of having a breathing tube in your mouth/throat — they're made with relatively hard plastic that can withstand bites — can cause mechanical erosion if left in too long.

No one gets sent home on a breathing tube.

Sometimes these can be downgraded to tracheostomies (the holes cut in your neck for breathing) and yes, sometimes people can go home with those — assuming you're still able to live at the settings that your home ventilation system can provide. (Some people can just breathe room air through trachs!) We don't send people home with trachs (or even really place trachs) in people who're requiring too much pressure (the PEEP, the force with which we're pushing air into people) because if that PEEP can't be maintained, the patient would die.

(The inflatable ring at the bottom of the photo above is what helps to seal the air/air-pressure in, but is also another internal point where pressure can create sores.)

Other mechanical objects that people can require to live include assorted CRRT machines — CRRT stands for continuous renal replacement therapy, and in general these people are very sick and also having breathing tubes/medication.

A CRRT machine is plugged into the patient via special lines into their veins/arteries and it siphons out blood, acting like a replacement kidney, processing out wastes and balancing electrolytes, before sending it back into the body.

You need your kidneys to survive, or something that can mimic kidney function periodically (like people getting dialysis). But what happens during normal dialysis is that you have fluctuations of fluid volume and can have swings in blood pressure. Some people are too sick to tolerate these (and indeed some blood pressure medications can put more pressure on kidneys) so CRRT allows the dialysis to occur slowly, steadily, smoothly all day long. (At my facility, and all that I've ever heard of, people on CRRT machines are 1:1 RN assignments, because of the dangers of something going wrong with the machine or its attachment point to your body.)

A lot of medications constitute life support — anytime you can't survive with out something intravenously, it generically, kinda-sorta is.

This is where we get into the weeds a lot when families call. They want to know what the vitals are, and sometimes some of them have some basic medical knowledge — so it's my job though to explain things as I share.

Just because someone's blood pressure is 120/80 doesn't mean they're ‘getting better' if I'm maxed out on four different blood pressure medications, plus albumin (a solute heavy fluid, that attracts fluid intravascularly to increase BP), plus frequent boluses of fluid.

(Small nerd aside: assorted blood pressure medications can: make your heart beat more quickly, more strongly, can increase pressure on your peripheral vasculature to bring circulating volume in, or can dilate your coronary arteries to promote out flow — there's a lot going on! and some drugs have more than one effect!)

The numbers alone don't actually illustrate the effort going in to keeping that patient alive — and people can't go home on four pressors (or even one, pressor, really.) It's not safe.

All of our ‘life support' mechanisms are just stop-gap measures to hopefully bridge assorted tissue functions until that tissue can heal (via infections clearing, or surgical remedies performed).

But I think/feel like sometimes, especially now in Covid-Times (tm), when we talk to families we tell them things in the abstract — yes, they've got a breathing tube in, etc etc etc, but we don't emphasize enough that that…truly is life support.

More than once recently I've had family members on the phone upset by the frame shift of realizing their family member was on life support, and so I've started talking early and often about that, so that the gravity of the current situation is clear.

By the time patients get to need ICU level care, requiring ‘life support' is basically a given — in fact you can't run any of these machines (or titrate medication like we do blood pressure meds) on a normal floor.

It's not that people don't get off of life support — they do! All the time! (Albeit less in covid situations, alas.) — but I think knowing that that's how sick loved ones truly are gives people time to adjust. And, if, sadly, things go poorly, then it doesn't seem to come out of left field.

It's hard out there for relatives right now — as thrilled as I am to not have visitors right now (because I like using their waiting room for my lunch break :P) — it's really difficult for people who aren't at the hospital to understand all of what's going on, how busy we are in certain rooms, how many of us are in there and how often, and how much modern medical equipment is running in the room with us simultaneously, under our supervision.

I think sometimes that it's easier for people to believe ‘we did everything possible' when they're in there, seeing us, do it, you know?

Because TVs and Movies and people like Benny Hinn (to shout out a faith healer from back in the day) really lie about what life support entails, and makes everyone's recovery look miraculous. Everyone's got some cousin's (who they haven't seen in twenty years) story, or found some website on the internet (Lord, save us all from Dr. Google) that talks about an astounding recovery.

Families always say they're hoping/praying/waiting for a miracle, and what I kind of want to say sometimes (but absolutely NEVER EVER WOULD because it wouldn't be therapuetic) is that a miracle is already occurring.

That miracle is this machine. Or this medication. Or me.

The miracle is happening, right now, this very moment. Your loved one would already be dead without our interventions happening here.

But we still might not be enough, and so for that, I'm ever so very sorry.

— Cassie