another long ICU story

Hi,

It's 5 AM, and instead of catching what little sleep I can while I am overnight in the ICU, I am awake, typing this entry. It is actually pretty quiet, much quieter than I was expecting, but I still can't sleep. I slept for about an hour and then got woken up to my alarm on my pager, set an hour too early. I have two pagers, my personal one and the ICU code pager, and I was so disoriented, I had no idea which pager it was, so I did what is instinct: when in doubt, jump out of bed and run to the ICU to make sure everything is ok. It wasn't till I got there that I realized I had mistakenly set my alarm clock too early. But, by then, the nurses had seen me and it was too late to go back to bed. It doesn't matter anyway; no matter how tired I am, it is impossible for me to sleep when I am in the ICU overnight. My adrenaline is going, people are sick, and I just NEED to know what is going on. I hope I outgrow it.

Yes, I am back in the ICU, back where I first started this whole residency thing. It is so much less scary the second time. Though I still feel harried all the time and like I know NOTHING, at the same time, I am more comfortable with things in general. Somehow, things don’t seem quite as scary, and I know that help is only a phone call away, if I ever feel in over my head. I also have confidence that I can now do the things I have to do, even if I don’t like it. I can intubate someone myself if I have to. I can put in a central line (put a big iv line into one of the major vessels that goes into the heart—yikes!) if I have to. I can do CPR if I have to. In fact, weirdly enough, I like it better than many of the outpatients I have to do. I like it better than genital exams or cleaning out ears or colonoscopies. Isn’t that weird??

Anyway, tonight has only been harrowing in that one of my own clinic patients is here in the ICU, and she’s dying. Already dead, really, and I can’t make any sense of my many emotions about it. She was one of my first clinic patients I ever saw. She didn’t like doctors, didn’t feel they did anything for her, but wanted to get whatever she could from them. She was a smoker who was ruining her lungs and heart by continuing to smoke, and had a terrible social situation. Through many office visits, I got her to open up to me and trust me. It was one of my biggest victories as an intern, the day she told me she felt I really cared about her. And though I have not been able to help her much, she attempted to quit a few times, which is more than she’s done before. She came to see one of my partners in clinic for what seemed like the 3rd pneumonia in three months. My partner called me to talk about it. It appeared on her most recent CXR, the radiologist found that pneumonia had returned in the exact same spot and wondered if it was an obstructive pneumonia. Meaning, was there a mass pushing on a bronchus and making her prone to pneumonias? I immediately was worried, because something in my bones told me yes, she did have a mass, and yes, it was a cancer. I asked my partner to admit her to the hospital immediately, because she has no phone and can’t get around easily, and I knew she’d need a big work up. We were able to find her and admit her. Her breathing got so bad, she had to be admitted to the ICU, where I was. We were happy to see each other, though at this point, I had spent a lot of time wondering if I should have thought about cancer sooner; had I missed some signs? Could she have been cured sooner, if I had thought of it? I was ridden with guilt and uncertainty. Meanwhile, she was running around telling everyone I was the cutest and sweetest thing there was; talk about making the guilt worse!

Anyway, to make a long story short; a CT was done, showing a mass, and what looked like liver lesions. The lung docs tried to biopsy the mass and couldn’t; everyone thought the safest thing would be to biopsy the liver through interventional radiology. The biopsy was done. Half an hour later, she was complaining of a pain in her belly, and her abdomen was getting bigger and bigger. She’s rushed back to radiology. It appears in doing the biopsy, they hit the hepatic artery, one of the major blood vessels in the liver, and she is bleeding like stink into her liver. They are able to stop the bleeding; but by then, she’s bled so much, she isn’t perfusing the rest of her organs, and her heart stops. They code her and successfully resuscitate and intubate her, but it’s a mess. Her kidneys have stopped, her blood pressure is incredibly low, all the clotting factors in her body are out of whack, and her chances of coming out of this functional is very bad. Meanwhile, she has very bad circulation to her legs; her smoking has caused some of the vessels in her leg to be very thin, and now that her blood pressure is so low, her right leg is ice cold and dying.

I have had talks with her in the past about what to do if she were to be critically ill. She has expressed numerous times that she doesn’t want to live if she can’t live independently. She’s rather die than go to a nursing home, never mind being on a mechanical ventilator. If she can’t live by herself, she’d rather we just let her die. I thought we were there. However, the kidney docs thought we could try emergency dialysis to get all the toxins our of her system and maybe we could reverse things. I am VERY dubious, but I’m the intern. I agree. 9 hour after that decision is made, it’s been a nightmare. Dialysis hasn’t done anything. Her blood pressure remains adequate only with 4 medications to keep it high, and with extra fluids poured into her. She is so swollen, she isn’t urinating, and she looks worse and worse by the hour. Her leg is ice cold and blue. The nurse is frantically trying to get me to try all kinds of stuff; bicarb, check blood gases, more fluids, etc. I tell the nurse she can do it, but I think it’s worthless. I feel that I should have just let her die hours ago. I should’ve stood up to the other docs, said, “I know my patient; her chances of getting back to a meaningful recovery is slim; let’s just let her die in peace”. But instead, in trying these last ditch attempts to save her, I am harming her instead. She looks horrible. She will now never recover to any meaningful existence. She’s basically dead, despite all the machines and nurses are doing in there.

But could I have denied her this last chance at life? It was a slim chance, but was it really right for me to say, let’s not even try it? Now that we have tried it, I know it didn’t work, and I know she looks even worse. But this is all hindsight. At that moment in time, before we started dialysis, if this were my mother, and I knew there was a slim chance, but still a chance, that this treatment could help her, wouldn’t I want the doctors to try? I don’t know. I know that because it was a complication of a standard procedure, an unexpected tragedy, we all felt we had to do something to save her. But was this the right response? I guess now we can tell the family, look, we tried everything. But also, part of me is somewhat relieved, that she isn’t recovering, though guiltily so (I am a very guilty person). For, if we did save her, to what would I save her to? She has cancer, I am sure of it. She’d have maybe two more years to live; years either with toxic chemotherapy and radiation, or years without treatment where she could die slowly, in excruciating pain. It seemed like a mercy to spare her that. But who can predict the future? Maybe she would have lived many more happy years.

It is somehow so much harder to watch your own patient die than someone you never knew until they came into the hospital. I tell myself I won’t cry tomorrow morning at rounds, when I have to tell everyone what happened to her overnight, and what I think we should do. But I know I will. For I know I will tell them to stop the treatment and end her life. I tried to help her in life, and don’t feel I was able to. I tried to help her in death, and I feel I failed her then too. I want to go into palliative care and give people good deaths; I certainly did not do that for her. My only consolation is that if she was running around telling people how sweet I was, she must’ve felt I was at least trying. I guess that’s something.