April 20, 2015

Intensive caring

I thought the Medical ICU would be depressing.

My first week went relatively well, with patients whose prognoses were good and no deaths. Patients got better, they awakened from sedation, they improved their lung function, they started to breathe on their own. We sent them to a less acute floor and occasionally, straight home.

The second week was rough. I almost cried on rounds more than once during the week. I seemed to have all the hopeless patients. Lots of neurology patients on service - people whose brains had bled, whose brains were so swollen and damaged they would have no chance of waking up. I spent very little time in their rooms, hastily examining them and leaving as soon as I could. Their bodies did not even require sedation to tolerate the ventilator; not a good sign.

It was disheartening. I had forgotten how spoiled I was in OB/Gyn, where many of our patients are healthy young women in the prime of their life, able to handle massive physiologic changes (or even extensive hemorrhage) and go back to normal within a few weeks.  Speaking to patients' families made it worse: here lay a father, a mother, a son, transformed seemingly beyond repair, kept alive by machines.  My eyes welled up when one woman heard that her husband's prognosis was unknowable, but that he would likely be forever changed. Every day was a confrontation with mortality and futility.

I pronounced my first patient death. I was afraid to look foolish; I felt again the imposter fear of the novice. Was I going through the motions? What if she drew a breath at the last second?  I was almost relieved that it was true, and she was dead. Her family had decided to withdraw care, and so they were all crowded in her ICU room around the bed as I listened. I turned to the nurse and asked him if he had the time.  "Time of death: 11:46," I intoned, trying hard to give my voice weight and gravitas and not to let it quiver.  A few days later, I pronounced another patient; it barely registered with me as I called his family, and I felt as though a small part of me had hardened.

Through all this, I learned to participate in the gallows humor of medicine...and truly know it as gallows humor. We laugh to keep ourselves from disappearing into the abyss of sadness and futility that lies behind the curtains of the ICU.  Each patient has their own particular tragedy, and to take them all in is to lose hope in the world. 

Today seems brighter. The patients are sicker than yesterday, but there are reasons to be hopeful. A few of the neuro patients have, against the odds, woken up. They still cannot talk to us yet, but their eyes follow me when I examine them and they mouth words to me around their endotracheal tubes. Some of the ones I felt sure would not make it are getting better, almost despite our care. In the end, perhaps that is the best lesson of the ICU: those who were going to get better do so, if we just give them the time and support for their body to do the work. Those who weren't going to make it pass away, despite doing everything we can to medically prop up the blood pressure and keep the lungs moving and keep the electrolytes balanced.

Today, I feel better about the fatalism of it all.  Maybe the goal is just this: try not to kill the patients who aren't going to die, and try to let those whose time is up die with dignity.