Patients(ce)

Patients take patience. On any day, interaction with a high number of people can be trying, especially for an introverted personality like myself. But patients are uniquely frustrating in that many of their disease processes are self-induced. This becomes difficult to manage in an outpatient setting, where patients have the capability of making lifestyle choices. By the time they reach inpatient status, the problems are sometimes beyond repair. I've had many such cases this week in the ICU, and have been struck by how preventable they all could have been.

Besides the typical obesity/hypertension leading to heart disease, and smoking leading to pneumonia and pulmonary complications, there has been some interesting cases of causality casualties. Here are a few examples from my last couple days:

• A young man so obese that the weight of his chest wall compressed his own lungs to where he couldn't properly oxygenate his blood. He needed a tracheostomy and a gastric tube and placement in a long-term care facility to lose enough weight to be weaned off of the trach.

• Two teenagers with multiple gunshot wounds to the chest following a gang fight.

• A Jehovah's Witness dying from complications of low hemoglobin post-surgery. She would walk out of the ICU if given a few units of blood, but instead will die within a day or so from heart failure from her steadily dropping hemoglobin.

• A patient with severe aortic stenosis who declined a valve replacement for years. Now she has consented to the surgery, but her heart is four times a normal size from the pressure exerted on it from the stenosed valve, which makes her a poor surgical candidate. Even if she were to survive the operation, her heart is too badly damaged to expect any change in prognosis.

• A young mother, brain-dead from an overdose of cocaine, meth, marijuana, and other drugs. She was brought in after crashing her car with her baby daughter in the backseat.

• A woman who wrote an alternative-medicine book on radiation poisoning, who failed to follow up with her doctor after he told her the treatment for her lung mass was radiation therapy. Now she is in the ICU with a lung completely filled with tumor and metastases to the liver and brain, causing intracranial bleeding. She didn't even want the CT scan that yielded that information. She died a few hours later, only 58 years old.

It takes a lot of patience to manage these situations; to explain to a family member that choices their loved one has made has caused irreversible damage. Families sometimes displace anger over the uncontrollable nature of the situation onto the doctor, and that takes a lot of patience to work through. You force yourself to be patient and thoughtful with the treatment, because it is unmotivating to try to heal someone who made such damaging decisions. You try to be patient and kind with yourself, acknowledging the frustration and discouragement that comes with an easily preventable death.

One thing I am learning quickly upon entering doctorhood...patients require patience.

Intensive Care

For the past 2 1/2 weeks, I've been working in the intensive care unit. I love it- each case is interesting, there is a lot to think about in terms of medical management of multiple organ systems, the nurses are very knowledgeable, there is a wide array of procedures to perform, and the hours are good. One of the things I've particularly liked about it is the communication skills that it takes to do the job well. I hadn't thought of this as an important requirement for this specialty; after all, a lot of the patients are completely unresponsive. What I forgot about was the families.

Communicating with families is probably the most important thing the intensivist does each day. The doctor has to manage patient care, in some cases making them well enough to walk out of the unit, in others, providing a comfortable death. He does a variety of bedside procedures and stays on top of every electrolyte and troponin and ventilator setting. But that's not really the intensive care. Intensive care is for the family, not the patient. Intensive care is a clear and detailed explanation of their loved one's disease, treatments, changes in status, and prognosis. It's obtaining a compassionate and clear do not resuscitate order. It's putting a dying patient on morphine so the only discomfort in their death is felt by the family, not the patient. It's being willing to be the only doctor in the hospital to recognize when medical management has failed, and to make the judgement to decline further treatments that have little chance to improve prognosis.

This is a very unique role for a doctor. Our job is to fight death by treating the entities that lead to it. Acceptance of death equivocates failure. After all, many other professions are measured by outcome. Teachers are graded on how many of their students pass exams, retailers by how much they sell, lawyers on how many cases they win, preachers on how many souls they save. Doctors are assessed by how many of their patients live. This places far too much responsibility on the doctor for patient outcome, rather than a recognition of human mortality. It's true that some physicians are better than others, but none of us can alter or reverse all disease processes. This outcome-based measurement doesn't allow for a practice that by it's nature cares for those with poor prognoses.

Many beds in the ICU are occupied by dead people. The only thing separating them from the morgue in the basement is a ventilator, balloon pumps, medications to keep blood pressure up, dialysis machines, defibrillators, fluids, blood products, and a crash cart. The thing is, death is temporarily optional in most situations. If your heart stops, we can start it. Lungs don't work? No problem. I can keep a body warm and a heart beating until family comes to discuss end of life care, but I have I saved them? No. Dead but with a living body, patients are suspended in a sort of physiologic purgatory until families indicate their last wishes.

And this is where the intensive care really happens. You place a patient on "comfort care" measures- morphine so they don't feel shortness of breath or pain. You take out the uncomfortable endotracheal tube and allow them to breathe on their own. Dialysis stops, feedings stop, medications are withdrawn. They die within minutes, hours, or days, with no discomfort. The loved ones are the people experiencing pain, not the patient. They are the ones that need to be updated daily on patient status, repeatedly explained prognosis and options to, and reassured that their loved one is not in pain and no, they couldn't have prevented it. Comfort care is for the patient. Intensive care is for the family.

Thus was my situation this afternoon. A patient brought in this morning, down for hours at home following a cardiac arrest. Minimally responsive, with a poor prognosis, the attending had a conference with the family to explain these things and let them know that we would watch him for 72 hours to get a better idea of his neurological status and possibility of recovery. That afternoon, the attending left to place a difficult central line, and the patient's oxygen dropped from 96 to 30, pressure dropped, pupils were dilated and nonreactive, no response to sternal rub- all signs of neurologic death and rapidly approaching cardiopulmonary death as well. Since he didn't have an end of life directive (at age 44, who would?), it needed to be ascertained quickly from his wife and daughter what their wishes were. And there was no other physician there. So, I put my big-girl coat on and was the physician, kneeling next to his wife, explaining his new signs and that a decision was needed more prematurely than we had anticipated. It was my first time explaining an impending death in order to get a DNR status, and it was an intensive experience for me to explain his deterioration, to say that the prognosis wouldn't change much despite more aggressive life support, and to try to help the family believe that his death wouldn't be their fault, even if they elected to turn off the ventilator. It was an intensive experience to look into this patient's eyes- glassy, fixed, and dilated, and know that even though I was watching his heartbeat on EKG, he wasn't alive.

No matter what I go into, this rotation has great value not only in learning to think critically about many organ systems at once, but in developing finesse for talking with patients and their families about sensitive topics, including end of life care. It's good for me to see that a good outcome doesn't necessarily equal life. I am grateful to see that just because another treatment is out there doesn't mean it should be initiated. It's good for me to know that I am capable of having difficult conversations. I'm glad to be more exposed to and comfortable with death, accepting that it's a universal truth and that I as a physician can't change that truth. I know these realizations from the intensive care unit are reflective of the intensive process of becoming a doctor.