Around Midnight in the ICU

Tuesday, November 22, 2005

Exhausted tonight...

Some days go on forever. Some nights we don't sleep. Some patients get an answer the minute they waltz into the emergency room. Some people get admitted. Some nurses come looking for answers they can't find anywhere else. Some diseases you can treat. Some symptoms don't make sense. Some families make you laugh. Some blood gets lost in the lab chute. Some CT scans get shot out of sequence. Some tears fall on deaf ears. Some faces are scarred. Some limbs are repaired. Some wounds never heal. I looked at the lab results two or three times in disbelief. They clearly showed the paucity of cells. Every line was down. Only three things I know of that do this, and they are cancer, cancer, and vitamin deficiency. Maybe the blood tests from three weeks before will help, the old man proffers as he hands me the papers. His mother is a cancer survivor. She battled squamous cell cancer of the sigmoid for two long hard years. She underwent a local surgery, resection of a tumor which was too deep to warrant complete removal. She did the chemotherapy, even though that nearly killed her. Then, she put herself through the radiation, gobs of it, as she tells me. That was eight years ago Sonny and I'm still yipping! Only the yip has been gone for about a month. She is too tired to walk across the room now. The lab tests from three weeks ago clearly show what I fear. The radiation has predisposed her to lymphomas. There are blast cells on her smear, indicating the conversion of a lymphoma to acute leukemia. The physician who reviewed this did not tell her about the leukemia. He told her nothing. The yip did not come back, so three weeks later she came knocking on my doorstep for a second opinion. Some physicians are cowards. They will sidestep the truth. Or they'll wait until their patient is sick enough to warrant a trip to the emergency room, where they officially become someone else's problem. This lack of yip dilemma became mine very quickly. No more dancing, so we all told her the brutal truth. Not very hospitable of us. Not very Texan. We told a woman who had fallen on our doorstep asking for help that there were no vacancies. There is nothing we can do for you. Go back home. Pray. Maybe, if the good Lord grants that miracle, you'll live another month. Arrogance, almost. But she knew, deep down inside. So she stays with me two days, a guest in this house, gets an opinion from the oncologist. When it's over, she leaves. She goes home to die. But I am not sad. I am hopeful for her. It's Thanksgiving, and she will spend it with her four children, twelve grandchildren, and two new great-grandchildren. Some people are afraid of death. Really, death is just the end of one journey and the beginning of another. That's the miracle. The yip comes back. If I don't believe that, a part of me dies with every one of these little old ladies in the emergency room. Some nights we don't sleep because we forget this. We become afraid of the darkness. But then I remember. I know that all of our days go on forever. I give thanks for this little piece of mind that holds it all together, keeps my sanity. Everyday, not just Thanksgiving.

Sunday, November 20, 2005

Seeing patients on Sunday

My first patient this morning is watching the Fox Pre-Game Show. He stares intently at the screen when I walk in the room. I pop my stethoscope out of my pocket and listen to his heart. His breathing is shallow and doesn't change as I impinge on the show. He can't see the screen with me in the way, but this doesn't seem to bother him. I lift off his sheets and press my warm hands on his stomach. The feeding tube site looks well-healed. Not a flinch. His expression remains unchanged. My nurse walks into the room. Are you ready for me yet, he asks. Yes, and then we roll the patient onto his side. The sore looks to be improving. His eyes are glazed, and remain fixed to Terry Bradshaw, our analyst de jour. He's telling us he thinks the Cowboys will win today. I imagine so, the nurse pipes in. We laugh as we roll him back. I ask him, what do you think? The patient stares blankly at the screen. As we roll him back, my nurse hits a button and Bradshaw is replaced by a rerun of Oprah talking about abandoned children. The patient continues to watch, passive, mute. In my house, that sort of heresy would have cost you, I laugh as I change the station back. He never speaks a word. It's as if he can see right through all of us, this eighty-seven year-old man with Alzheimer's. His heart is a ticking time-bomb, rattled by years of smoking and coronary artery disease. His back is covered with this sore, which has eaten into his bone above the sacrum. He feels no pain. He sees and hears nothing. Often, I wonder if he knows any of us are there at all. On Sundays, I return from rounds in the hospital to my family and some Cowboy football. His family rarely sees him anymore, resigned to this notion that he doesn't know they are there. I'm a football fan. You change that channel to Oprah, and I'll have your hide. Dementia has taken this man and turned him into a shadow. I pray that for him, every day is Football Sunday, that he does not see what has become of him. I pray that he does not understand for one iota of a moment that the infection in his sacrum is spreading. I hope he feels no pain. I pray that he understands that we have done our best for him, and that now, near the midnight of his life, there is no more, except comfort. I pray that he does not hold this against us, that we, his physicians, nurses, even his family, have all but given up on his condition. I pray that we can ease his suffering. And, as I walk out of his room, I pray that the Cowboys win today.

Thursday, November 17, 2005

A Midnight of Notes

Around midnight in the ICU, your head starts to spin. The sound of ventilators pushing stale air in and out of stale bodies begins to soothe you to sleep. There is the incessant rhythmic beeping of the heart monitors. The lights have been dimmed so that the sleepless beings can have a moment to pretend it is indeed night. Occasionally, the footsteps of a nurse or a patient's family echoes across the cold tile. As they pass each other, these steps resonate in questions which show no reply. There is only a near-deathly silence which grips you in its own screams. The silence, if it becomes too loud, can become its own alarm. If the air stops moving, or the telemetry monitors stop beeping, there can a come a panic. The alarms of nurses and respiratory therapists go off internally, and the entire machine roars to life. The lights come flying on. The overhead speakers crackle with the wails of the Code Blue in room eleven. Nurses who have been sleepwalking, arouse sleeping physicians, sweep them to alertness from their tussled call-rooms.
On these nights, I can come flying into the ICU at full speed. I wipe the sleepiness from my brow. I pray that this is the last time I am awakened tonight, but I know that this is only wishful thinking. I wipe the spittle from my chin and beard. I throw on my white coat. I run past sleepwalking nurses. I pass the huddled crying mass of family outside room eleven. They are oblivious to you until they see the coat. Then they have questions. I tell them not now as I float in sleep past them and into the room. Past the curtains, and I am awake again and at peace.
The room is chaos. There is a mass at the center. Extruding from the mass are multiple tubes. The largest goes from what used to be a mouth to a ventilator. The stale air hisses in and out mechanically. There is a tube above that which is connected to a wall-suction unit. This nasogastric tube no doubt represents strict bowel rest. All of these tubes are covered with surgical tape, obliterating the face of the mass on the bed. There are at least four other tubes which we strive to identify quickly before the words begin.
Then, there is the barrage. I always taught my students to breathe before this hits. The first step in the Code is to check your own pulse. Then, take a deep breath. One last breath before the wave of voices washes over you, drowning out the world around you. A bark of orders. A protocol to be followed. There is a history shouted across the room. The mass remains nameless and faceless, a conglomerate of vital signs, arrythmias, pneumonias, and blood. Someone is standing on the bed pounding a heartbeat. The machine is disconnected. An ambubag materializes and replaces it. Intravenous fluid is squeezed into the flaccid mass. Nothing. The sleepwalking and spinning nurses, and their respiratory therapists, an administrator, the interns, the residents, they all see the inevitable. They try a few more times. There is an ebb and a flow in the room, people backing away from the bed, clearing as the boxes charge. The body suffers several last jolts towards life. Then, the mass is at peace. The room empties and the family flows in.
As the lights dim, the peace returns. The family wails and whispers, but this is soon enough drowned out by the hissing of the ventilators and the beating of electronic hearts. I sit at the desk, and let the serenity of death wash over me. It is inevitable. The role of the internist is only to meticulously document the demise of their patient. I write my notes. The clocks strike midnight. Around midnight in the ICU, the world starts to spin.