Life and Death in the ICU: A Reflection

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Medicine is difficult. We all know that. It is challenging for a number of reasons, many of which are the same reasons it is rewarding and worthwhile. It is intellectually challenging. It is rigorous. It requires dedication of body and mind. It pushes one to attain mastery of an array of difficult concepts and skills. Perhaps most difficult though are the moments when the tools and skills of medicine are not equipped to combat the disease on the other side of the battlefield. Sometimes medicine loses this battle. Sometimes it does not stand a chance. Those times, I must say, are the hardest.  

My Month in the ICU: Ups and Downs

Working in the intensive care unit, I have encountered some of these difficult moments and I remember them vividly. I am finishing a month as a senior resident in the medical ICU as I write this. It was an outstanding month. I loved it. The amazing breadth of disease pathology I saw was extremely engaging. I managed patients with diseases I only vaguely remembered encountering in some obscure corner of a lecture or textbook. Seeing patients with these interesting pathologies and having the opportunity to learn these diseases anew was quite stimulating. Caring for acutely ill patients also requires frequent procedures, and this month I continued to gain mastery in a number of them. Working with my hands was a lot of fun. Finally, caring for critically ill patients, treating them back to health and guiding their families through difficult times was very rewarding. The feeling of satisfaction that comes from sound medical diagnosis and treatment as well as the fulfillment that is borne from supporting a patient and family through a challenging experience are undeniable. They are some of the reasons many of us went into medicine in the first place, and why many will continue to do the same. My ICU experience was outstanding, to say the least. With all that said, it was also draining. There are always two sides to the coin, so I have to be honest and acknowledge the other one. This month has taken a lot out of me. From the physical toll of 28 hour shifts, to the mental tax of constantly making complex medical decisions on patients who are sick enough to imminently face their own mortality, critical care can be stressful. I will say that I enjoyed taking on the challenge that these tasks entail, and feel that in doing so I became a better person and a better doctor. But there are some moments that are difficult to bear, despite the silver lining of a lesson learned or a skill gained.  

A Difficult Patient Experience  

One morning I arrived at 6 AM for a call shift and met a patient who was quite ill but relatively stable at that moment. He was overall moderately healthy but had been admitted overnight to the ICU for an acute pulmonary issue. It seemed that the lungs were the problem at that time and he would improve relatively quickly with the appropriate treatment which was already underway. Later that day, his blood pressure began to drop to an unsafe level, so I placed a central line and we began to treat him with antibiotics for a presumed infection and medications to keep his blood pressure up. Then that evening, as if out of the blue, things took a dire turn for the worse. His mental status declined, and he began to have very labored breathing concerning for respiratory failure. He was intubated and connected to a ventilator. Blood tests showed that his body was producing an extremely high amount of acid, unfit for appropriate function of the vital organs. We placed another central line needed to acutely start dialysis to remove the acid and restore his blood to a safe pH. Initially this worked. But soon thereafter the acid in his blood began reach an even higher level, a level not compatible with life. Concerned for a source of severe infection which could not be treated with antibiotics alone, we performed CT scans of his chest, abdomen, and pelvis. They showed nothing, no explanation for his severe condition. None of his blood work or cultures could explain the severity of his condition either. It was a dire situation. There was nothing we could do. By the morning after I met the patient, he had gone into multi-organ failure. We knew the level of acid in his blood was going to cause cardiac arrest very soon. With continuous dialysis, maximum medical support for his blood pressure, and respiratory support with the ventilator, there was nothing further we could do. We had to face the terrible reality that in this rare case, medicine would not only fail to save his life, but could not explain why he needed saving in the first place. This, as a physician, is a tough pill to swallow. Yet, even tougher than that was seeing what the patient’s family had to go through. The man had two relatively young children, not much older than me. I spoke with them throughout the process, updating them on what we were doing and hoping to achieve with his care. The next morning when we knew that the patient would soon pass, I stepped into the room with a heavy heart. Delivering that information was hard. That’s the only way to put it. We deal with death frequently, but it hurts much more when it is this unexpected and this inexplicable. I will never forget his younger child’s reaction: first with shocked questions, next with violent sobs, and finally by shouting “He was walking around only one week ago! Why? How?” These moments are difficult, no matter who you are or how you approach them. I was truly sad for that family. I was heartbroken for the patient, who had been talking to me only 24 hours prior. Within two hours the patient passed away. It demanded much of my inner strength to comfort the family. I tried to empathize but knew that I could not truly understand the enormity or finality of their loss. The toll on me was considerable, but it was nothing in comparison to what they were going through. I could only hope that I had helped the patient and his family in some small way during this tragic time.  

Concluding Thoughts

In the ICU we deal with the extremes of life and death. We at times perform miracles, reviving patients from death after their heart has stopped beating or treating patients from the brink of death back to solid health. But we do not always win the battle against disease. This is a reality of medicine and life, one we cannot deny. I have learned and gained much from this month in the intensive care unit, but I know that some of these difficult experiences have also taken a piece of me. Yet that is part of being a physician. It is part of what makes it challenging, but also what makes it great. These experiences are ones you can only have in medicine—they can never be reproduced elsewhere. These are the experiences a young doctor will never forget. Despite the challenges, the tribulations, and the trying times, it is all worth it. I wouldn’t have it any other way.   The details of this patient encounter were altered to protect patient privacy. 
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