Thursday, August 12, 2010

The ICU Hangover

Last night was the worst night in the MICU I have had so far in residency. It was not for any one particular reason but I found today when I woke from the 3 hours of sleep I enjoyed after that 32 hour marathon was something of an emotional, physical and spiritual hangover. Of the 30 or so critical ICU patients I was supposed to be watching over with the Intern on call and the new ICU admissions pouring through the Emergency Department I can't say we did anyone any real benefit. As a matter of fact I honestly feel we may have done some harm. Not in a medical sense. We kept everyone's electrolytes repleted. We managed pain with opiates and sedatives. We adjusted ventilators so that the blood flowing through their arteries did not become too acidic or alkaline. We pierced their skin & bones with radiation so that we could peer into their cavities & organs and predict the upcoming failures of their flesh. When faced with a pulmonary infiltrate or an elevated lactic acid we poured chemicals through their veins designed to kill the small invading bacteria or to artificially elevate their failing blood pressure. We flooded them with saltwater to keep their collapsing cardiovascular system functioning - 20 liters, 30 liters, more..... Their skin begins to weep this fluid into the sheets as their bodies swell and their skin stretches. The ventilator pressures rise to fight the fluid flooding their lungs and their bodies begin to rebel - coughing and gagging on the tube in their throat we placed there to control this expected 'complication'. We increase the sedatives to save them from the suffering all this would cause and throughout the night if we do all this just right the bedside ECG monitors and invasive blood pressure catheters reassure us that we are in control, that we are succeeding.

I woke this afternoon feeling unclean in some way - a sort of "morning after" shame you might feel after waking from a night that is mostly a blur - a memory that you struggle to bring into focus. After a cup of tea and some reflection I honestly feel that the only good I might have actually done last night was for a single frightened & frail hospice patient & their family. Not because I ordered narcotics to ease their pain or spent hours talking with them about the arsenal of treatments and technology we had at our disposal to try and somehow stop that inevitable train-load of pain. The best thing I did was to push back. The best thing I did was to question the decisions of those more senior to me - those with more experience, more knowledge and more authority. Medicine is very much a hierarchy and this does not always go over well, especially when the Emergency Department was being over-run with trauma, death and social dysfunction. The residents were being stretched to the edges of their ability last night to manage the chaos and you could see it on their faces. The attendings were under the pressure to oversee this all and guarantee not only the safety of the patients but the education of the residents and students. The nurses are trying to balance the demands of patients and doctors both. This entire system has a certain unspoken order and expectation regarding the flow of decisions. Hitting your brakes in the middle of this highway causes a lot of squealing rubber and usually just causes a lot more work for yourself in the end. Not only do you risk angering and infuriating some of the attendings by questioning their decisions and the system, you actually make more work for the overworked all around you while they have to readjust to your unexpected maneuvers. It is just easier sometimes to accept the admission, write the orders and the notes. Just order the drugs and move the patient upstairs to the ICU so the Emergency Department can start seeing one of the many sick patients waiting on the ambulance gurney in the hall screaming for attention. Despite all this, the best thing I did was to listen to my heart and tell those around me that this was wrong. Despite my pager's incessant intrusions alerting me to potential emergencies all over the hospital I took the time to say no, to make the calls, to argue my viewpoint and reasoning.

People are scared at the end, and too often the family panics and calls 911 in the hopes that the moment they have been dreading is not really here, that perhaps they can hold it off just a little longer. From the ER they get admitted to the ICU where they are absorbed into the machine of medicine because in this society we have decided that death must always be fought. People run from it at the end, which I can understand, but the I honestly feel that the only way to find the beauty and love at this moment is to embrace it. The end is always painful and no narcotic or benzodiazepine can change that. What I do truly believe is that being surrounded by those you love at that very moment in a familiar and peaceful place will offer lasting comfort and solace to those left behind with the memory. What I end up seeing too often is people facing that moment surrounded by strangers in blue scrubs breaking their ribs with well intentioned CPR while others are pressing needles into their flesh. The IV pump and ventilator alarms scream out as chemicals are being pushed through the veins of a dying person in hopes of restarting a stopped heart or perhaps trying to buy a few extra beats. Sometimes the family stands at the door and watches this orchestrated chaos of trauma inflicted onto a frail and dying body in some desperate attempt to fend off the elephant in the room. So far most of what I see occur in the medical ICU is the only aspect of medicine I have grown a true moral repulsion for.



Despite the cloud of fog the opiates had pulled around the mind of my dying patient last night she would occasionally try to lift her head from the pillow. In her eyes you could see the sadness, the fear and the utter exhaustion of these last few years or months. She had been fighting for so long and now the cancer and infections eating through her body had finally taken over. As the pain medications were increased and her organs failed she became more somnolent and disoriented and in these last moments her family truly felt the fear of standing at the edge. In that fear they had called 911 and ended up here, my Emergency Department, the doorstep to the intensive care unit. They fought within themselves trying to untangle the knot of confusion in their hearts and minds. What did the patient truly want? What did they want? Can this somehow be changed? Was there one more option? They felt helpless while the inevitable and unfair reality that the woman they loved was dying in front of them. It was not what they expected. It was not how they planned it. As the patient's mind failed the family was left with the burden of managing these fears and still making decisions for her. These decisions feel like life or death decisions but the truth is that it is not a life or death decision anymore but more of a death or death decision. They don't realize this and usually see the hospital as the "life" option. After all, our job is to "do more things" - to offer the alternative to death and it is hard to not want to fall into that trap as a doctor and try to offer them life. We almost convince ourselves as doctors that we have that power. After all, we have an arsenal of drugs and machines. There must be something we can do. Sadly, some of us probably believe we truly can. We also have a society that believes strongly in patient autonomy and despite the family's obvious struggle we lay this burden of choice on their shoulders. We tell them it is "their choice" and this paralyzes many. The last thing anyone would want to do is live with the knowledge and and memory that they chose to "give up" on someone they love. At the same time they see the suffering this can cause and are unsure if they are saving or torturing this person they love. We as doctors fear that we will sway a family to make a decision we want to make so we back away and believe we are doing best by leaving this choice in their hands. We "let them have time to think" about it. Last night I could not do that.

I did my best to be impartial. I did my best to honestly present the options of what we could do as if these options really might offer something real and of value to anyone, but it was a lie and I couldn't convince myself. I saw them struggling and suffering under this burden of choosing medicine or reality and finally I offered what I thought they really needed, my advice. I told them she would not survive this admission to our hospital. I tried convey to them the futility of our technology and the suffering it would cause. I told them that the antibiotics designed to fight her infection might likely make her worse for a while. We would likely need to give her fluids and medications to support her blood pressure but would likely end up flooding her lungs. That would necessitate a ventilator. She would become to weak to ever be taken off the ventilator and would end up getting some new antibiotic resistant infections in her lungs or bowels and we would then try more antibiotics. We would eventually take control of all her bodily functions and when the heart finally had enough it would arrest and we would use electricity to try and restart it. Her bones, which were brittle from the metastatic cancer, would crush beneath our chest compressions as we tried to pump her blood for her. I told them that in the end we would fail. I told them that this was not the way she, nor they, wanted to see her die and that they should return home with the hospice nurse and pain medications. They knew this somewhere inside but were frightened to open up to it, to accept it and let her go. I tried to alleviate their guilt and reassure them that by accepting this moment of death, by embracing it and allowing it to wash over them, they would be present and part of their mother's death, not a fighting bystander separated from it by our technology. No matter which choice they made death would always be painful, but this is the only way to avoid the suffering and possible regret. Letting go and accepting this was the only way to not miss this moment.

I had to call my fellow and attending. I had to tell the ER that we would not move this patient upstairs to our ICU. I had to have three different services in the hospital all speak with the family and confirm the truth. It took over 2 hours when the admission would have taken only 20 minutes. In the end they took their mother home and they felt at peace with the decision. I know I did. I felt this morning it may have been the only really good decision I was able to make last night. Now I have spent the 3 hours I have of waking time to write this and I need to sleep again so I can return to the ICU tomorrow and I am counting the days until I can be done with this rotation. My last MICU rotation ever. Like a bad drunk the night before and a hangover, I have lost the taste for this particular type of medicine right now.

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