The Last Day

I finished my MICU rotation yesterday. As I walked out I couldn't help but think of the failures I had, the people I wasn't able to help.

The 60 year old Boeing factory worker and father of four. He came in with profound hypoxia (unable to oxygenate his blood) and despite everything we did, we weren't able to improve his breathing. He was diagnosed with acute interstitial pneumonitis, a catch-all term that hides the fact that we don't know the cause or the cure. He was completely healthy prior to this hospitalization. He and his wife had been vacationing in San Diego just a few months prior. He died.

The 28 year old deaf/mute mother who had never been in the hospital other than to deliver her baby a few years prior. She also presented with shortness of breath and was soon put on a ventilator. It turns out that she had the flu and her lungs also had been infected with bacteria (staph aureus). We weren't able to help her breathing. She ended up going on the heart/lung bypass machine (ECMO) to give her one last shot. She died.

The 50 year old husband who presented with liver failure due to a disease known as primary sclerosing cholangitis (PSC). He had been on the liver transplant list until he developed an infection and was sent to the MICU. Based on verbal reports, they had actually found him a liver but just a few minutes/hours later, he became sicker, and they realized he had developed an infection. He was taken off the transplant list temporarily, started on antibiotics, and sent to the MICU. He never got a new liver. He was surrounded by family and friends. When I pronounced him dead, his mother looked at me and asked, "Thats it? Is he gone?" to which I could only nod yes. He died.

During my time in the MICU, I took a day off to go interview for cardiology fellowships. As I sat there through the interviews, with my interviewers telling me how impressed they were with everything I had done, I couldn't stop thinking about all the people that I had taken care of the last few weeks that hadn't made it. Its easy to tell myself I did my best and that these people probably wouldn't have made it anyway, but that excuse rings false. I don't like failure -- its a selfish feeling. I want to be better. I don't want my patients to die.

"Give me your tired, your poor, Your huddled masses yearning to breathe free, The wretched refuse of your teeming shore. Send these, the homeless, tempest-tost to me, I lift my lamp beside the golden door"
-- from "The New Colossus" by Emma Lazarus (on pedestal of The Statue of Liberty)

I love the intensive care unit. I like taking care of the sickest of the sick. I like working through the pathology, trying to understand the physiology, and utilizing everything science has to offer to give these incredibly sick patients one more shot.

By the time a patient gets into the MICU, they are on death's door. They might be infected, be bleeding, unable to breath, and have trouble maintaining a normal blood pressure -- the sickest might have all of these. We hoist them onto their ICU beds, we remove their clothes, we attach numerous monitors. If they are agitated, we sedate them. We stick them in theirs arms, their legs, their necks, and their chest. We place tubes down their throats, up their rectum, and in their urethra. We give them drugs that have horrible side effects. If their hearts stop beating, we pound on their chest, shock their heart, and give them more drugs. And yet, I love the intensive care unit.

Most of these patients don't live very long. Despite everything we do to try to help, they frequently end up passing away. The mortality rate in our intensive care unit can approach 50%. And yet, despite the torture we put these patients through and despite the sobering final results, I love the intensive care unit.

Why? Why would I love working a place where I fail so much. Why would I want to put anyone through the things I have described above?

I can sum it up best with a quote from the Shawshank Redemption:

"Remember Red, hope is a good thing, maybe the best of things, and no good thing ever dies." -- Andy Dufresne

When patients come to the ICU, they and their family often don't know what they are in for. They might know they are sick but they might not realize just how remote the chance of recovery is. However, they hope. They hope they can overcome whatever it is that afflicts them. Some might call this false hope or even denial. They say that when patients get this sick, physicians should push for advancement of code status -- basically, try to get the family and the patient to withdraw aggressive treatment and accept that they will not overcome the illness. These people argue that treating patients this sick is futile and a waste of medical resources. They maintain that physicians are the experts in all things medical and thus are qualified to tell a patient and a family when further treatment is futile.

While families might not be medical experts, they are the experts when it comes to what the patient would want, what the patient values, and what the patient is fighting for. Maybe, the patient would be willing to go through anything in order to have that extra day at home with his family. Maybe he just wants one more chance and is willing to endure the torture. People have various motives and values and there is nothing I learned in medical school that would make me an expert on what people want. Instead, I tell the patient and the family in explicit detail what doing everything entails. If they want everything done then I do so.

I try not to think about the torture I am putting these patients through. I remember each of my failures. However, I try to focus on those few that do make it -- despite the long odds. The 70 year old with multiple medical problems that had to stay on the ventilator for over 30 days before we managed to get him off. The 40 year old whose heart stopped beating (PEA code) but who was resuscitated and went home with his family 6 days later.

If we succeed and the patient beats whatever illness is afflicting him, so much the better. If we fail, at least we gave him one last chance -- at a terrible cost, but a cost he and his family were knowledgeable of and willing to accept.

I hope my patients get better. I hope I am doing what they would want me to do.