Tuesday, August 17, 2010

Dying and not dying in the SICU

Working in the emergency department tends to give a person a thick skin when it comes to strangers' tragedies: catastrophic trauma, devastating strokes, massive heart attacks are all to be expected on any given shift. It's not that it doesn't affect you, but you have to learn how to keep going, to delay processing, because no matter how bad the situation is for the patient and the family there's always a waiting room out there full of people who still need to be seen.

However, this month I've been rotating in the SICU -- the Surgical Intensive Care Unit -- and it's been a very different experience. I really like the people I'm working with, and I've been learning a lot. But at the same time it's been a somewhat depressing experience. So many of the cases are almost unbearably tragic: the eight-year-old shot in the back and now paraplegic; the middle-aged man locked in after a stroke; the young man who shot himself through the head in front of his girlfriend and infant child and now lies in bed with his brain swelling through flaps removed from both sides of his skull; the young man whose spinal cord was severed by a bullet and is now quadriplegic, the man from Guatemala brain-dead after a stroke and sustained on a ventilator but, due to miscommunication with his distant mother, whose organs could not be donated and whose body could not be repatriated to his family.

Almost every day I spend my walk home trying to re-engage with daily life, where people walk around in the sun and almost nobody is at risk of suddenly collapsing in a coma. Often I buy myself ice cream.

Of course, I've already dealt with a fair amount of suffering and death along the way. In fact one of the most beautiful moments of my intern year revolved around a death. My patient was an elderly woman who was gravely ill. It was time to make a decision about whether to escalate medical interventions or transition her to comfort care; that is, focus on controlling pain and providing a peaceful environment. She had two adult daughters who were very involved and they asked that those of us on her medical team meet with the family to decide what to do. I still remember that meeting vividly. It was late, about 1:30 in the morning, and when I got to the family room it was overflowing with maybe 40 family members spanning four generations, from elderly to newborn. I remember sitting on a chair on a wood-paneled floor under low lights, in the middle of the room, surrounded on three sides as this family listened to my description of the medical facts, asked me questions, discussed the options, and with love and dignity decided to let the matriarch of their clan go to a comfort care suite where she died, surrounded by family, two days later.

But there's something about the surgical cases -- perhaps the suddenness of onset that characterizes them -- that seems to make them particularly demanding emotionally.

A couple of days ago I was taking care of a very ill elderly woman whose outlook was looking less and less promising by the day. Her devoted adult only son was spending hours sitting at her bedside, trying to come to terms with the fact that his mother, a vibrant active 85-year-old only weeks before, was now sedated, intubated on a ventilator, and acquiring new lines and tubes for antibiotics, pressors, and all the other interventions of modern medicine. As he told me himself, he was shocked and overwhelmed. We talked for a while, and I told him a bit about how I had recently lost my father. I wanted to do something to normalize the reactions he was experiencing, and I hope I helped ease things a bit for him. I think maybe it helped ease things a bit for me, too.

Years ago I was talking with a wise friend of mine about how curious the process of learning about sex is. It's a part of life that is central to adult life, to society, to biology, and yet we go for years early in our lives being only dimly aware of it, and spend more years trying to understand it. I remember jokingly wondering whether there was anything else out there waiting, another huge part of life that was largely unknown to us as young adults and would not be revealed until later. She answered, “of course there is: dying.”

I spend a lot of time thinking about my locked-in patient. He is utterly paralyzed, except for being able to blink and move his eyes up and down. He was estranged from his family for 20 years, but eight months ago had gotten in contact with one of his adult children. He has made it clear that he wants to live, that he wants everything done. Every morning, when I go to check on him, I make a point of standing in his field of vision. I address him by name, re-introduce myself, ask him if he remembers me. He indicates that he does with our convention for “yes,” by looking up. I touch him, squeeze his hand, ask if he can feel me squeeze his hand. One morning last week I noticed that he had had an enormous spike in his blood pressure overnight. The Neurology team said that was when they told him -- told him that he had almost no hope of recovery, that his interaction with the world would be forever limited to a few eye movements, that his only hope of survival was ventilators and feeding tubes and teams of skilled health care providers to keep his body from breaking down.

As a doctor, what is success and what is failure? We'll never “cure” him, but if he wants to survive in this state we can sustain him for a while. Every day we're privileged to be able to bring to bear therapies and interventions that would have been magical dreams come true to most healers throughout human history, but in this setting I'm not always sure whether we're doing good by deploying them. All I can do is to keep adjusting the ventilator settings, squeezing hands, talking to families, enjoying the ice cream on the walk home.