“Doctor…She wants a chance. She wants to live!”

“Doctor…She wants a chance. She wants to live!”

How often have I heard those words? Or some version of them? The location of the conversations varies. I might be standing outside the curtain of an emergency room bay or sitting on a worn chair inside a cramped waiting room adjacent to the ICU. Possibly on the phone in the dark of my bedroom at some pre-dawn hour. Those words, coming from the mouth of a spouse, a child, or a sibling are usually imploring and pleading and occasionally defiant and demanding. But always beneath the surface, at its origin, is fear.

Critical illness, almost by definition, does not come on slowly. Occasionally it starts as a quiet whisper, allowing time for patients and families to absorb and adjust. But all too often, it presents as a roar. Infection takes hold and explodes. A vessel once open becomes completely blocked. A beating heart suddenly arrests. An aneurysm ruptures and bleeds into the brain or belly. An accident or trauma, completely unforeseen, literally crashes into a life.

The brutal and cruel physiological disruption these insults cause a patient are usually obvious to both the care team and the family. But the additional traumas to the family and friends left to make decisions in the wake of critical illnesses are more subtle.

Some choices can be relatively simple, like placing large IV’s or draining a collection of infected fluid. But what about issues of life sustaining or death preventing treatments such as ventilators for breathing, powerful infusions of medicines to make the heart beat quicker and squeeze stronger, a machine outside the body to filter and clean the blood the kidney cannot, or chest compressions and electric shocks when the heart completely stops? These decisions are literally of life and death. And as physicians look to surrogates to help guide our interventions, we often ask, “What would the patient want?”

“Doctor…She wants a chance. She would want to live!”

And there lies the dilemma.

A chance to live. It seems like a straightforward statement.

Critical care is an amazing field. With appropriate aggressive intervention we are often able to halt the progression of and stabilize dangerously low blood pressure or oxygen levels. We can cool a patient’s core body temperature to protect injury to the brain, perform emergency surgery to repair leaks in large arteries or perforations of parts of the bowel.

But what does it mean to say we want to live?

Is it just a heart that beats? Lungs filling with air while lying in bed? Skin warm and damp on hospital sheets? Liquid calories delivered to the stomach by a plastic tube? A hand held by family sitting at the bedside? Light filtering through a window, giving just a glimpse of what lies on the other side?

Or is it a heart able to soar with love or ache from loss? To breath in air while laughing or crying? Sweat dripping from a brow, stinging the eyes, while working hard in the yard on a hot and humid summer day? A stomach full, from one too many pieces of Chicago style pizza, or a brain buzzing from that first morning cup of coffee? To be able to hug or be hugged and feel the warmth of an embrace on the surface of your skin and on your spirit?

And there are an infinite number of possibilities between these two extremes. Our interventions are often good at preventing death. But not always as effective at helping us live. And what is living? To you? To me? In my thirties with young children still to raised? In my seventies with grandkids to watch grow? What is enough quality in life to lift our hearts up high, when our bodies are still tethered to the bed?

Most of us only glance at these questions. To see them obliquely. Set them aside to deal with tomorrow. And the sequence of routines in our day to day lives help us do that, beginning with the starting gun of the morning alarm. The routine drive to work where we put in our time. Then the race to a soccer practice or baseball game and dinner on the go. Help with homework, pay some bills, read some emails, off to bed and then repeat. On our way to the next job, the next raise, the next game, the next tournament. All with our distracting smart phones in hand. To photograph, to read and reply, to text and tweet.

These questions about what makes life worth living are complicated. Not only do they make us recognize our own mortality, they also force us to confront the lack of mindfulness in our day to day lives. To separate patterns and routines from what is purposeful and meaningful.

By answering these questions directly, we can create two powerful gifts. The first is for our families, loved ones and surrogates. Having discussions with them ahead of time decreases their burden, by providing a better understanding of what it is that makes life worth living. So they may be more prepared to speak for us, if and when we cannot.

The second gift is to ourselves. Not for the future, but for the here and now. As we recognize what gives us purpose and meaning in moments of mindfulness, we learn what we want to do, not what we feel obliged to do. And in doing so, we then learn what truly makes our hearts soar.

Quiet voices from the heart

 “Why don’t people’s hearts tell them to continue to follow their dreams?” the boy asked the alchemist.
  “Because that’s what makes the heart suffer most, and hearts don’t like to suffer.”

                                                                                                           -Paul Coelho, The Alchemist

If you clicked on this to read a medical vignette, my apologies. This piece is going to be a bit more existential. Or metaphysical. Or something less concrete. But I’d love to have you come along for this ride. For months I have written and talked about changes that were coming. I have shared the angst and discomfort I felt as I approached July and the change in my work status to part-time. And I have commented on the parallels to other moments of change in my life.  Change Redux,  How did I get hereCh Ch Ch Changes.

And now it is here.

It’s interesting how the best laid plans can change in an instant.  For more than a year, I have planned to hit the ground running by lining up some part time and consulting opportunities. Writing daily as the sun rises, working on projects and pieces.  All aimed at opening new doors in the near future.

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What do you do when you disagree medically on matters on life and death?

“This was published first in the Washington Post electronically on 7/29/2017 and will come out in print this Tuesday.  Click here for the link.  The comments so far in the paper have overall been quite emotional and angry in their response.  I am happy to discuss in more detail here on the blog and welcome any input or thoughts.  But the responses in the Washington Post highlight to me why we need to not only have more questions with our families on issues of end of life but to have more depth to them as well.”

The dilemma for the critical care team was not uncommon. An elderly patient in the midst of a life threatening illness and in severe pain, not understanding the critical nature of their current situation. A decision needing to be made about how aggressive to be. A doctor trying to convince the patient to pursue a rational approach, one based on understanding the limits and capabilities of life supporting interventions. This situation plays out in ERs and ICUs across the country hundreds of times a day. But two key factors made this situation unique. First, this elderly patient struggling to breathe, battling low blood pressure and in a tremendous pain was my wife’s grandfather. Second, the doctor recommending aggressive life supporting measures, contrary to the limits set by his advanced directives, was me.

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10 Tips For New Interns For Surviving and Thriving in the Intensive Care Unit

July is just around the corner. For hospitals it’s a dynamic time. A changing of the guard. Graduating residents moving on and new interns, fresh out of medical school with their clean and crisp long white coats, moving in. Out with the old, in with the new. The ICU rotation for medicine residents and medical students is stressful under the best of circumstances but always an additional challenge early in July. I remember as a resident, trying to glean from my peers who had already completed their ICU rotation, picking their brains for tips and tricks on how to survive and succeed. But often what we are looking for is not what we need the most. Acid base disorders and ventilator management seemed so daunting. But in hindsight, learning how to manage and treat specific diseases and conditions was not the hard part. Learning how to survive, mentally and physically, the rigors of the ICU and growing as a physician were much bigger challenges. Read more