A moment of reflection…

I sit here today, in this small, windowless call room with its low twin bed that is covered in untouched hospital blankets and sheets. Tonight is one of my last nights on a 30-hour call shift in the medical intensive care unit. Yet another mile-marker on this long journey of residency. My day began at the break of dawn, when I and another resident passed each other in the parking lot at 7AM – the only souls trudging to our cars at such an ungodly hour on a Sunday morning. But this is the life we chose.

The day passed as many days have passed in the intensive care unit – extubating one patient, intubating another, placing one or two central lines, and being present with families in a time of crisis and even in the face of death. It is a charged atmosphere. At one point, our hospital raised the Donate Life flag in honor of a young gentleman who had died and donated his organs to patients in need across the country. At another point, we gathered round in a patient’s room with family and chaplain to offer the only piece of caring we still could offer her – empathy, compassion, and prayers.

The families and patients in this unit have reminded me, over the past few weeks, of the primary reason I chose to become a doctor: to care for my patients. Patients roll into this unit on stretchers, many with breathing tubes in place, many so confused or sedated that their memories of this visit will merely be a vague sense – blurred brush strokes across canvas, lacking definition or purpose. But perhaps it is better that they do not remember – it serves as a survival mechanism, if they ever make it out of here.

All too soon, however, reality will hit. Some of these patients will be paralyzed for the rest of their lives. Others will never be able to eat or lie flat again, because they are at such a high risk for aspiration . Still others may never speak again because of malignant masses occluding their vocal cords. Hard to imagine, really, but it happens here every day.

Even with these tragedies, though, some patients will make it out of the ICU in good health, at least in a medical sense. But even they must struggle to overcome the effects of their prolonged hospital stay – weakness, anxiety, fear. Many of them will need rehabilitation, both mental and physical, for extended periods of time.

ICU patient walking in Johns Hopkins Hospital Critical Care Unit

In an attempt to prevent this, there is a new movement in critical care units to sedate patients less, to exercise them more, and to allow them to return functioning, mobilizing human beings as quickly as possible and even in the setting of the grave illnesses which brought them here. An article in the New York Times published in 2009, Get Patients Up, introduces some of the new and relatively radical approaches that physicians are using at Johns Hopkins, including mobilizing patients on ventilators. The idea is to allow patients to maintain their strength, to minimize muscle wasting, and to prevent long-term neuromuscular weakness that ultimately requires patients to participate in months of physical therapy to return to their baseline.

An article from Vanderbilt University in Chest 2010, Vasilevskis et al., describes an “ABCDE bundle” which is a strategy to minimize delirium and weakness in critically ill patients. It includes awakening patients daily, allowing them to breathe on their own without ventilator assistance for brief periods every day, coordinating their breathing and awakening, closely monitoring their delirium using consistent guidelines, mobilizing them early, and initiating physical and cognitive therapy. The goal of this bundle approach is to reduce the devastating effects of delirium and weakness which patients commonly struggle with after their ICU stays.
Although these ideas push the bounds of conventional ICU medicine, which include deep sedation and bed rest, they mark the beginning of a new and perhaps even more humane approach to care for the critically ill. Even more interestingly, these new techniques recall the age-old wisdom of Hippocrates. Primum non nocere. First, do no harm. By sedating patients with high doses of medications to treat their pain and agitation, by paralyzing patients to minimize the use of their respiratory muscles, and by restraining them to strict bed rest, we are in some cases harming them more than we are helping them. So let us take a fresh look at critical care medicine and remind ourselves that, at least for some of our patients, less is more.
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