Faces and Futility

The patient, previously a John Doe, is now known. Family now present, when before there was none. A spouse, siblings, and young kids all around. Despite seventy-two hours in the ICU, his lungs have failed, his heart has failed, his liver has failed, his kidneys have failed. Too unstable for dialysis, his potassium level climbs higher and higher, despite attempts to slow down and mitigate its lethal effectCardiac arrest is no longer an “if” but a “when”, having reached medical futility.

Kids at the bedside, so young. Unaware. Watching. The face of their dad distorted by tubes in his mouth, IV tubing tugging on his neck, eyes yellow from jaundice, skin all swollen and puffy from edema. Family tension between his siblings and his wife percolates, as his heartbeat becomes more erratic and slow.

In the hallway outside his room, I have a hurried discussion with his wife. She is overwhelmed. Burdened by feelings of guilt competing with anger. Her sadness and despair are palpable. Their last words, their last fight, was days ago, before he was found in a locked motel room, with alcohol around him. Inside him. Poisoning him.

His heart stops while we are talking. We go into his room.

Kids at the bedside, so young. Unaware. Watching. The face of their dad distorted by tubes in his mouth, IV tubing tugging on his neck, eyes yellow from jaundice, skin all swollen and puffy from edema. His heartbeat no longer erratic and slow, because it is no longer beating. This outcome was already determined hours ago.

Compressions will not lower his potassium. IV’s have been pouring adrenaline non-stop into his heart and veins. All to no avail.

I tell the wife to hold his hand and say goodbye. We are not doing compressions. She does not argue.

Is it assent or consent? Medical futility? All of the above?

She holds his hand. She yells. She cries.

Kids at the bedside, so young. Unaware. Watching.

Years pass. I no longer see his face, distorted by tubes in his mouth, IV tubing tugging on his neck, eyes yellow from jaundice, skin all swollen and puffy from edema.

I still see their faces. The kids. They have not left me. I doubt they ever will.

 

Will The Adults In The Room Please Stand Up

Uncertainty.  In particular, diagnostic uncertainty, would keep me awake at night, early in my career as a freshly minted critical care doctor.  Patients who deteriorated without explanation or haziness on CT Scans without an identified cause, fanned the flames of my insecurity. The scenarios would leave me edgy and uncomfortable impacting my life outside the boundaries of work. Like most doctors, over the years I learned to co-exist with this uncertainty.  Human sickness and disease can be challenging mysteries.

Recently, a new kind of uneasiness has invaded my world causing all sorts of havoc. With the politicization of health care reform and attempts at repeal and replace Obamacare, uncertainty is rearing its head with a vengeance. Twitter and Facebook give minute by minute updates on which senators are a “yes” or “no” and where public opinion currently lies. The evening television roundup details rumors that have leaked from behind closed door meetings. The background noise of it all is deafening. Most discussions are focused on the future impact potential budget cuts or regulation changes. But the uncertainty created by our polarized and tribal politics on any path forward for health care reform is having a real impact now. Every hour of every day, both in the hospital and in my office where I interact with my patients.

Read more

We Failed Her

The alarm sounds, a painful reminder that it’s my week to cover the ICU. I take off my favorite sweatshirt, stripping away its warmth and comfort. I quickly jump into and out of the scalding shower, racing to get ready. Making my way toward the kitchen, I roll my eyes at my teenage daughter who is eating ice cream and waffles for breakfast. Her ride waits out front but before she can escape, I get a rare hug, her wet hair cool as it brushes against my cheek. I spy her melting, unfinished breakfast and I shovel what’s left into my mouth. The cold vanilla ice cream and maple syrup drips down my chin. Wiping away the evidence of my indiscretion, I get into my jeep with the top down. The twenty-minute ride is a guilty pleasure, with the spring air cool across my face. The coffee in my hand warms me from the inside out as I make my way to work. Read more

A Little Help From My Friends

The patient in front of me is trying to die. Elderly and frail, he is lying in the bed. His ribs outlined under skin that should be smooth. His temples are concave where they should be flat. Both are an outward display of internal damage from his lung cancer. More striking than his cachexia are the strained muscles in his neck and his pursed-lip breathing. He is working hard for each breath, drowning in the air around him. From his cancer or pneumonia or more likely both. It is my first night on call as a senior resident in the ICU.

It’s early in my second year of residency at the University of Chicago, where I am splitting my time between internal medicine and pediatrics. The ICU is outside my comfort zone, with its rapid pace, large volume of data to process, and the complexities of multiple failing organ systems to manage. I am both intimidated and inspired by those who seem to recognize patterns, synthesize information and anticipate problems with ease. I want to be like them. I want to face my fears head on. I have chosen to be here, to prove to myself that I can do this. I am capable of caring for the sickest of the sick. And now, in the middle of the night, without a supporting daytime cast of residents and attendings, I am anxious for my first test. And it happens to be the man in front of me struggling to breathe.

I want to be here. I want to be a critical care physician. I know what to do. Read more