As the warm weather sets in we see less and less pneumonia in the MICU which can only mean one thing.

Liver season!!!

It?s so strange how liver disease comes in waves. Four beds, side by side, in the MICU have liver patients. I started calling my end of the hallway liver alley.

Which leads me to Liver land.

Liverland is a place where I like to believe my patients go when they are in the throws of hepatic encephalopathy. It?s somewhere between the initial changes in mental status associated with liver failure and actual hepatic coma. The patient watches you as you are performing patient care with a curious look. You?re flushing his IVs, checking his CVP, drawing blood from his arterial line and all the while he just watches with this half-way interested look. You could be a bartender mixing up some cocktails. He might make some garbled sounds and you answer him in an assuring voice. You explain what you are doing and he nods his head. You ask him if he knows where you are and he calmly whispers something incomprehensible.

It?s this apparent lack of anxiety that I find so comforting when caring for my liver patients. They are not in the MICU, they are in Liverland. I imagine that it?s a nice place to be. No fears or worries. Maybe it?s like revisiting a fun place from your childhood. Once I had a patient who was in Liverland but I could understand what he was saying. He seemed to think we were out on the town together??C?mon. Pay the check. Let?s get out of here.? or ?Where?s my cigarettes?? I swear I would give him his lactulose and he would sip it like a cocktail and say, ?This is delicious!?

This is in stark contrast to Lungland. Lungland (which I think is more due to the Fentanyl and Versed than the actual lung failure) is a demented and disturbing place. Just go to Bob?s dreams and you?ll read about what it?s like to be a bodiless head, in the back of a van with two people slicing you up like deli meat.

It?s easier to care for your patient if they are in Liverland. They don?t seem to feel much pain or discomfort. Thank God because their bellies are so swollen with fluid that it looks like they could give birth to a small farm animal. When they seem anxious or scared you just talk to them in a soothing voice and then they are calm. It doesn?t even matter what you are saying. As long as it sounds soothing.

With Lungland it?s different. The Versed gives them amnesia. They might be soothed for 5 minutes, but then they forget and the reality is that they have a tube jammed down their throat with makes them gag. Or they have delusions that you are draining their blood, or trying to harm them in some way.

So you snow them with more narcotics.

Which makes it really hard to wean them from the ventilator.

And the cycle goes round and round until they finally are ready to be awake and breathing on their own.
But then they realize that their lungs are permanently fried and they have a bedsore on their bottom the size of a three egg omlette.

So if given a choice I?d rather be in Liverland, although I don?t know if anyone has ever lived to tell about it.

When you enter Liverland one of two things will happen. You will either pass gently into the next world (if there is one), or you will reach the top of the transplant list, and are wisked away to the OR. You receive your new organ and then recover in the SICU!

I was explaining Liverland to a colleague as we were placing a fecal incontinence bag on our patient?s posterior region. The patient was tolerating the procedure rather well. (of course he was – he was in Liverland!) My colleague said, ?Like Mr. B from last week? He was in liver land, right??

Sadly, the answer was no. Mr. B (fake name, of course) was not in liver land. He was very lethargic, but his mind was still with us in the MICU. He was feeling the pain of his 100 pound fluid-filled abdomen. At one point he was crying out and weeping from the pain. I begged the doctors for more morphine to give him. Whatever they ordered, it wasn?t enough. The problem was that he was #1 on the liver list, and so they were afraid of over-sedating him.

(as I write this I am wondering why that would be a problem. By virtue of his MELD score and his lack of infection, he has secured his place at number one. If a liver became available and it was impossible to assess his mental status due to his receiving Morphine, would they really bump him and go to #2? It seems so cruel.)

I came back from three days off to find that Mr. B had bled out from his esophagus and died before his liver became available. I was very sad to hear this news. He never made it to Liverland. He understood that he was #1 on the list. I had actually explained to him, that because of his position on the list he could not get more morphine.

?I don?t care!!!? he cried. ?Just knock me out.?

So you can see why it?s good to be in Liverland.