Giving up

It is harder to withdraw care from a patient than to unsuccessfully treat him. There is a sense of "giving up" when you decide that the patient, and you, have had enough. You just can't treat him or her anymore. They are simply dying, almost dead, and there is nothing you can do about it. They are not conciouss, they have a tube down their throat, they are getting multiple drugs, and every now and then somebody moves them around, or gives them food through the veins, or cleans their shit. That, obviously, can hardly be called a life. Though it is, still, kind of, maybe, who the hell knows.

And then, after the patient only keeps getting worse, and basically it's your chemicals that are keeping him alive, in some form or another, and then all these infections do their thing, and decubitus ulcers every now and then, and when you get swollen as a balloon, and your balls are the size of a tennis ball, and you hardly have any lungs left, you can almost feel that this thing is not human. It was, at some point, not long ago, just a few days, but now everything seems helpless.

This was the case with Mr. B in bed 5. He was most probably drunk and hit by a car, and it all went downhill from there. At first we thought he might actually make it. At some point we even considered getting him off the vent so he can breath on his own. But then his lungs got crappy, and red stuff came out of his feeding tube, which was obviously blood. And then he couldn't keep his blood pressure up, and he needed three kinds of prsesure meds. Usually in medicine we try to keep people's pressure down, but this guy's blood pressure was so low we actually had to bring it up again. And of course infections didn't pass on this poor alcoholic, and his liver wasn't doing too great to begin with, and the last time i saw him blood was coming out of his eyes. Now you don't need to be a rocket scientist, or a doctor, for that matter, to know that this is a very bad sign.

Quickly thereafter we tohught it might be a good idea to withdraw care from this poor soul and let nature take its course. Although we can be very persuasive, this decision is not up to us, but up to his family, which was somewhere in mexico and either too busy, too poor, or without the right papers to cross the border and see their uncle. Eventually they did come, and did agree, and saw his gasp his last breaths, and then he died.

I saw him quite often during his last days on this planet. He always seemed in such pain and agony. Always breathing from the top of whatever lungs he has left, gasping for air. But today he didn't move so much. In fact, he didn't move at all. His room was quite still. I don't think there was one molecule of air in the room that was moving. Everything stayed in place.
That's the way life is in the ICU, that is usually how they go. They just do.

Having a patient die in the ICU is different than having them die in the wards. I say "different" and not "better" or "worse" because that's what it is - different. It is both better and worse. On the one hand you don't know them personally, because from the moment you got them they were unconcious (usually. If they get better to the point which they can talk to you and then die on you, you usually feel like jumping out the window). On the other, you don't know them, and the questions keep pricking you - who were they? what was their story? What do they look like standing and walking? Probably very different than the edematous face and bleeding conjunvtivae they sometimes have in the ICU. What were they like when they were kids? What did they want to do when they grew up?

I find myself asking these questions over and over when our patients comes and go. In the wards your patients are concious and go home, so there is less of a mystery. In here, it is all guessing. Sometimes it feels like a prodcution line. They show up, you load 'em on the bed, you start pokin' 'em 'n' movin' 'em and radiate their pants off with CT and daily X rays, and the occasional MRI, and then you have other people evaluate them, like a Neurosurgeon, or a Respiratory therapist, or a dietician, and all that jazz, and once you're done they are usually not dead, and you move 'em on to the next station, which is usually rehabilitation or what we call a "regular bed", meaning just hospitalization in the wards for a bit longer.

That's what it sometimes feels like when you are overworked, and not sleeping enough. Dr. Eden was my teacher, and he was (or is?) and anestehsiologist turned ICU. And on the first year of medical school he talked to us, and introduced me to an outrageous concept: "We don't heal people", he said, "we provide them with the means to heal by themselves". Now was is that crap all about? I tohught we are the big smart docs and our patients make it just because of us. My short experience in the medical field taught me otherwise. It's amazing how much we don't know, and how, like Mr. K, some people make it and how, like Mr. M, some people simply don't.