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.

December Dwindles Away

As December comes to an end, I realize that the whirlwind of intensive care units in the hospital over the last 50 days has taken me away from writing. The table in the surgical ICU is cluttered with Christmas desserts and decorations today. A small Christmas tree, potted in gold, rests in the center – a flicker of golden red cheer among desolate white. Few families come to visit on Christmas. Maybe they, too, want to celebrate – and escape, even if for a day, the reality of this place. Ventilators, monitors, lines, tubes. They will be back tomorrow.

This will be my last holiday in the intensive care unit. And somehow, today, I view this as a privilege. To care for all of these patients throughout the day – many of whom are alone. To be here for them. Today, this is not my job – it is my gift. A small sacrifice. A 30-hour Christmas gift. I did something today which I rarely have time to do while in the intensive care unit – I stopped by my patients’ rooms and spoke with each one of them and their families, answered all of their questions, wished them the best. In my mind, I began to say farewell to them, and to the intensive care unit, as my last moments here approach.

Surgery calls…

And so we enter into the Q3 (every third night) 30-hour call of the surgical ICU. The most intense of the ICU rotations, not only because of the call frequency but also because of the patient volume. By far the saddest stories in the hospital. Young trauma victims, healthy before their tragedies, now completely incapacitated – and many with little hope for recovery. As December snow falls gently outside the windows, I slide into my Q3 schedule with ease. The hospital has become home for now – uncomfortable call beds, cafeteria food, monitors – they are almost comforting in their familiarity and hardly bother me anymore. And as busy as things are, it is still a nice reprieve from the chaos of the emergency department.

I am almost at the pinnacle of my second year now, with only 7 more overnight shifts left after today in a long stretch of 30-hour calls. As I trudge upwards towards the finish line, I take in the view from the windows at the top of the hospital. It is a place I will not return to for a long time after this. My retreat to the windowless basement of the emergency room is imminent, and I reflect on it all with mixed feelings.

Now I understand the origin of the word resident, a term coined when residents truly did live in the hospital. There is a learning process, through absorption over time, that takes place during an intense month like this that cannot be replaced by shifts broken up into 12 or 16 hours. But this is only the beginning and already I am growing exhausted, day after day. And so the count down begins.

Thanksgiving in the Hospital

I press on the gas, lean back against the head rest, rest one elbow on the consul, and glide along vacant lanes of highway. Speed, and the absence of traffic, is almost exhilarating at 6AM in the morning, as gold rays pierce through a lattice of cloud cover. One more day in the hospital, in this long string of days. As I walk through the tunnels to the entrance, weary faces pass in the other direction – worn but polished with morning light. Ready to leave. Comforted to be going home, even if only to crash on a pillow. I have a fleeting wish to turn in the other direction, but I suppress it, keep walking, pretend I don’t notice the lump building in my throat. Just another day.

A boy playing in a marketplace with a strutting old gobbler entertains Chichicastenango visitors by doing the son, a dance popular throughout Guatemala. Luis Marden, National Geographic.

Inside the hospital, it is not Thanksgiving. Small, lonely reminders of what is missing – a turkey poster on a wall, the festive sweater of a passerby,  a holiday song playing faintly in the cafeteria – make for a somber backdrop to the day. It would almost be better if there were nothing at all. It is not Thanksgiving inside these walls. It is on the calendar, if one were to look, but in here it is only a shadow, an echo, a memory reverberating through the sterility and the sadness. It is a day to remember – even to long for – all of the better, healthier Thanksgivings before this one. The ones to be thankful for.

The families in the hospital are quiet. Sadder today, if that is possible. One father, rubbing his eyes and rising from a hospital cot as I enter the room, says to me, “I’m with my little girl today. That’s all that matters. That is Thanksgiving.” Another anxious mother raises her eyebrows, “Do you think my son will be able to go home today? It is Thanksgiving, after all.” A grandmother greets me with her new plan, “We are going to reschedule Thanksgiving this year. Thanksgiving will be when my baby comes home. Then we will have a turkey to celebrate. Yes, Lord, we will.” A five-year-old boy begins the day by singing in his room. He ends the day in tears – no one in his family came to visit like they promised.

Holidays in the hospital are some of the saddest times I have experienced. Families, patients, and even nurses and physicians – their yearning for home becomes more poignant. An anxious longing to be elsewhere pervades the building. But we are all resigned. We imagine Thanksgiving beyond the windows. The empty roads are the only sign that something else, something better than this, might be happening in other places. But try not to think of this. Instead, think of it as just another Thursday. Another day in a string of days. The time to celebrate will come, but not today.

Man on a Wire

A 5-year-old girl rolls into the pediatric intensive care unit with a subarachnoid hemorrhage. She was playing with her brothers on the swings outside this afternoon, developed a severe headache, and collapsed on her front lawn. Before today, she was the picture of life: vibrant, healthy, young. Now her eyelids, fingers, and toes are painfully swollen from the fluid accumulating in her body. She breathes on a ventilator. She does not awaken. Deep in a coma, she waits for us to bring her back. Standing at the side of her bed, we rack our brains and wonder if it is possible.

Illness does not discriminate. Instead, it strikes as lightning does – a random, focused beam of electrons that swoops down into this world to take those it will. It does not avoid or target anyone in particular – and yet, the casualties abound. A 25-year-old with a heart attack. A 28-year-old with a carotid dissection. A 21-year-old hit by a bus. And then there is a juxtaposition to these casualties – Mr. Philippe Petit, man on a wire, who walked – danced, really – on a wire between the twin towers in 1974 for all to see.

Our lives are not unlike Philippe Petit’s walk. The only difference is that, if that wire is life, then we walk it until we fall – and, inevitably, each one of us will fall. Philippe Petit did not. I often wonder what it would feel like to wake up one morning and be on that wire, balancing in the wind on a thread thinner than a finger’s breadth. The intensive care unit is another kind of wire – a live wire, strung from one room to the next, from one beating heart to another, until the moment when one decides to stop…

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