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.