The Hurt Locker

Working in the medical  ICU (MICU) and my own experiences as a resident this last month had me thinking about my own "Hurt Locker". It is a decades-old colloquialism recently made popular by the movie - slang for being injured, as in "they sent him to the hurt locker". The medical ICU can be fickle and unpredictable and this volatility is part of what is unnerving. One day you can have multiple "sick" patients all getting better - just perking along while your pager rests silently on your waist. The very next second you can get 3 pages simultaneously, all from different ICU floors, about your patients or those that you are "cross-covering" for because they are "desaturating", "bradying down" and then either becoming hypertensive or hypotensive despite any medication you give them. You never know where the ground is safe to step on and you suddenly find yourself avoiding the cracks in the floor as you walk along to the next emergency.

Amidst all this is the nagging question of whether or not we should even be doing what we are doing here in the ICU. The people here are usually far past the end and barely resemble people anymore. Their faces, limbs and colors are distorted by the 12 extra liters of fluid we have pumped into them or the various punctures sites we initiated. Perhaps it is just the skin breakdown from being immobile for weeks and the chronic disease that was killing them before they arrived. They are covered in tubes and wires with everything they need being pumped in at a controlled rate through natural and unnatural orifices and every waste product being funneled out through a tube into some collection bag to be measured, analyzed and disposed of. They are all sedated into a coma like state to avoid the pain or panic. All these bodies, no longer resembling people, totally supported by our chemicals and with the slightest nudge they start rolling downhill and you start running after them and sometimes you just wonder why.

I started my call day feeling thankful for the quiet pagers and peacefulness at 5:30am that allowed me to "pre-round" on the few patients remaining on my service. As I finished reviewing lab results from the night before and getting sign-out from the resident on call the previous night, I began anticipating my day ahead and the new admissions I would see over the next 30 hours. I compare the feeling at the start of a call day to walking into a minefield or defusing a bomb. I can't imagine any other experience that would feel similar except perhaps being a police officer walking into a darkened building that you know holds certain unknown danger. That is what medicine feels like at a big teaching hospital like this it seems. At least in the Emergency Department and as I am now learning - the ICU feels particularly fickle. You clip a blue wire and everything is okay, nothing changes; or the room around you bursts into searing flame with debris cutting through you. That is the hard part, you never know which you will get. You just walk through some vaguely familiar corridors of the hospital with 3 pagers on the waist of your scrubs and a stethoscope around your neck and hope for the best. You catch yourself answering people's questions differently, as if superstitious, when they ask you how your patient's are doing or how the night is going. Sometimes you go down to the ED and scour the patient board trying to anticipate the next disaster so that you can prepare for it, but other times you hesitate even going near that wing of the hospital  for fear that your presence will cause someone's lungs to suddenly deflate or their blood pressure to suddenly drop bringing about the next ICU crisis. Instead you walk cautiously, trying to not upset the nature of anything around you, as if walking through a minefield.

You get a sinking feeling in your gut every time you peek into a patient's room and glance at the monitor above their bed. You fear seeing a heart rate of 42, perhaps a systolic blood pressure of 68 or maybe an oxygen saturation of 83%. Luckily, the first half of the day my patients remained stable, some even improving, and the pagers were mercifully silent. After rounding I started all my "pre-work" for the coming shift. I usually complete all my notes in anticipation of the day's events so that I only need to dot the i's and cross the t's the next morning. All patients need a note from an MD every day in the chart and trying to write them after being awake for 32 hours is true misery so I try to get as much done while awake in the afternoon that I can. After that task, I clean up all the orders on all my patients in hopes I can anticipate and avoid the nursing questions that would arise at 4am setting off my pagers. It is frustrating because the nurses are perfectly capable, sometimes more so, of dealing with the myriad of small items that come up in their daily patient care routines but they are not allowed to order, change or alter medications and treatments in any way without a doctor's order. So, after all my patients have "just in case" orders written for benadryl, stool softeners, tylenol or a sleeping aid to soften the beeps and whistles of the ICU during the night I can try and get some lunch.

Yesterday it was sunny and warm and I took a walk around the hospital grounds for the first time ever on a call day. My pagers were blessedly silent for about an hour after my work was done and I made the mistake of relaxing. This is where the minefield analogy comes in - you can have a sense of relaxation or safety one second and the very next instant a blaring beep is screaming from one of the pagers on your waist. Your stomach drops as you expect the worst while you quickly slide each pager from it's holster while pressing the buttons until you find the one blinking. You recognize the number... the Emergency Department. You call the number back and the other resident you are working with tells you to get there now. You run down the hall, across the parking lot, from wherever you once were and into a resuscitation room filled with people, beeps, machines and blood all over the floor. You see wires hooked to a slab of pale bluish-pink flesh under a bright light. There are tubes running into multiple orifices either filled with clear liquids, blood or perhaps just failed attempts at tubes on the floor with the blood, gauze and disposable wrappers that remind you of medical confetti surrounding some morbid float at a parade. You see blood spurting from a groin puncture and place your gloved hand on it to apply pressure while someone tries to rattle off a short story of what you just walked into.

The details rarely matter and they all start to blend together... a patient with heart failure that suddenly became short of breath . . . a cancer patients that started bleeding from the tumors eating through their body . . . a kidney failure patient that has been missing dialysis to do methamphetamine . . .  an emphysema or lung cancer patient that suddenly can't get enough air to stay pink . . . In the end it does not really matter. At first all you care about is seeing that their are enough wires, tubes and IV lines for the drugs. The first glance is to the plastic tube in their throat that someone is pumping a bag into. You are hoping it has reached their lungs as you watch for the blood or frothy sputum you expect to rise and tell you that this organ has gone on strike. The respiratory therapist twists dials and nobs on the ventilator until you can pump enough oxygen in at a high enough pressure that it somehow finds the blood vessels so that the exchange of oxygen and carbon dioxide can again take place. You simultaneously focus on trying to get that little muscly organ in their chest to start squeezing effectively and fast enough to pump a few of the remaining red blood cells into their starving organs so that they can carry their meager load of oxygen where it is needed. Which pressors are already on board? Which drugs do you need? What dose? Is it about to stop? Do you need the defibrillator pads on? You glance up and down the naked body taking stock of how many IV lines you have in place and then hope there are enough entry points for the drugs, fluids, blood and lab tests you need to draw. You make way for an ultrasound machine, a portable x-ray machine, nurses, medical students, everyone buzzing around doing their job, directing another, etc... then you see the blood pressure begin to creep up and you don't know if you should be happy or disappointed.

Their eyes are still gray, distant and dilated and fixed straight at the ceiling, but still you push harder. The blood arrives from somewhere in the basement and the first results from your initial lab tests return. As expected... there is almost no oxygen in the blood, way too much CO2 and the fluid that is supposed to sustain life is turning acidic in their veins. With this new info you order your second barrage of artillery, readjusting trajectory accordingly for the impacts of your last feeble shots. Slowly the blood pressure continues to rise. The oxygen level creeps up now too; 83.... 87....91....92. You feel a weight slowly lift momentarily while you stand there looking at the disaster of tangled IV lines, needles, blood, syringes, empty vials and discarded rubber gloves all over the gurney and floor. You try to understand what is happening, what you have done to this point, what effect it has had, where this will likely go next and what you will then do. You wonder why you are doing any of this when you look at their cloudy eyes staring up at the ceiling. Is the person that was looking out of those eyes this morning even there anymore? How long was that brain without oxygen? How acidic has the blood become? You don't ponder long because the next decisions have to be made. As the numbers on the monitor start to improve the people start drifting away. Like bystanders at an accident scene along the highway when there is no longer any more gore and the cars have stopped smoking.

You now allow the remaining staff to continue with the cleanup. They get the lines untangled, draw new labs, get some sheets not soaked with saline and blood and transfer the patient upstairs to your ICU. You sit at a computer and try to document a short synopsis of what just happened, why, what you did and what you are about to do. Just as you start typing and two more pagers go off and one of your stable ICU patients and another that you are "crosscovering" suddenly dropping their blood pressures and desaturating. You grab your white coat and head for the elevator and repeat. You look at the clock, 2 hours have passed.

One minute you are in your own head, thinking about residency, the lack of any personal life, asking yourself questions or perhaps having a rare moment of peace in the hospital when you can actually contemplate what it feels like to be a doctor. The next second chaos is breaking out all around you, people are dying and you feel inadequate, overwhelmed, responsible, irresponsible, panicked, angry, frustrated, frightened & numb - all at the same time. It suddenly passes and you are in the cafeteria with a cup of coffee and a bowl of tapioca pudding trying to find an endorphin rush from sugar and caffeine. You make morbid jokes with the other residents about death and dying. You all laugh. Your pager goes off again. Your heart jumps. You repeat it again until you start to see the sunrise coming through the windows and you realize you have been up for 24 hours now. You prepare for "rounds" as best you can, trying to put together a story that sounds like you know something about anything and that you can justify your choices for all the drugs, ventilators and tests you ordered for the last 30 hours. You feel grateful that most of your patients are still breathing. You also feel grateful for the ones that are not breathing - because that is less work for you to do. You think about this reaction and realize you should feel ashamed for having such thoughts, but you don't. You are just tired. Then you feel a little disgusted with this entire process and yourself. You think about who you are now and who you were 6 years ago. You wonder what happened? You wonder if this damage is permanent, if you will have phantom pains in your soul like an amputee does in their missing limbs?

After making it through rounds you finish your notes from the night before. You "sign out" to the next on call team with bags under your eyes. You try to wrap up your patients as best you can in your sleep deprived state knowing that what you leave undone and unkempt will simply make the night hellish for the next on call residents as they scramble to put out all the fires on your patients while they try and manage their own - just as you did for the team that was on the night before.

When the morning is finally over I come home and try to find a pace of normal life again. It is quiet. There are dishes in the sink but no beeps or machines whirring and it seems strange. No pagers going off. It is still. My mind is still spinning though and I am delirious and drunk without sleep and I realize I need rest but I resist. I cram my face with some greasy leftovers from my fridge and finally fall onto the couch to take a nap, but not for too long because I need to go to sleep tonight 8 hours from now. I close my eyes and all I see are sterile surfaces & EKG tracings in the darkness of my mind. Small lights blipping on and off in the blackness. Scenario after scenario continues to run through my mind and I panic inside, as if a reflex now, unable to control it and forced to watch it - so I open my eyes and focus on the piece of art on my wall to make the images disappear. I grow more tired and close my eyes again the same things happens again, but this time I drift off to sleep and the 3 hours I get are filled with nothing but replays of the previous night's panic. I wake up foggy, unnerved & unrested. I crawl off the couch and shake the last few images. My mind finally starts to clear. I make a cup of tea. I sit on the porch. I start hearing trees & dogs again instead of pagers and heart monitors. I later sit at my computer and try to write a little in hopes that I can somehow drain this all out as if I could somehow bleed the poison off.