Monday, August 24, 2009

death and the icu

so, i haven't written in awhile, and im coming up on my last of eight calls this month in the ICU (intensive care unit). there are two icu's we rotate in as interns, the cardiac icu (CCU) and medical icu (MICU); this month i've done two weeks in each unit.

as my first inpatient month, the cardiac icu was a bit of a shocker. the first week, i worked 95 hrs and was a bit overwhelmed by the experience even if i wasn't super busy admitting patients. like learning a foreign language, it took a bit to get used to the EMR (electronic medical record) and ordering system they have at bayview, and figure out who to talk to to get things done. i have a better grasp of how the whole hospital works after a month, but im sure i still have a lot to learn.

i actually have really been enjoying critical care. one of my friends laughed when i told him this, and said "yah, the patients don't talk!" that's part of it, maybe, but i really like patients most of the time, and often, patients' families, some of who can talk A LOT.

part of being in the hospital so much as an intern makes me feel disconnected from what's going on in the outside world. even though i try to read some news websites while im at work, i am pretty much clueless about what's going on, including at first, all the talk about "death panels" in the media. i mean, it's pretty sad when i learn about death panels from someecards.com or rely on youtube clips like bernie frank's diss of this woman who compared obama health care reform to nazi germany to see how misinformed so many people are about what is actually going on. that's not necessarily the point of this blog though, so i'll stop here, and share some patient stories with you.

from the cardiac icu:

an elderly man was admitted to the cardiac ICU with a heart attack. our attending was excited because it might be a manifestation of stress cardiomyopathy, which can happen when people experience some kind of huge stress, whether it be a crazy surprise party or a death of a loved one. it ended up not being that, but i talked to him a lot anyway one morning when i went to check on him before rounds. his wife had passed away at home hospice a few weeks prior to his heart attack, and he was still in grief. he talked about how they had been married for almost sixty years, how she had made him happy, and how he hoped he had done the same for her. he also shared how proud he was of his daughter, who had taken both him and his wife in when he couldn't take care of his wife's needs as much anymore, and how they had all been there together when she passed away. then, he joked that nobody really wanted to listen to the ramblings of an old man anyway, and i replied that i did, if he wanted to talk. he decided that he wanted to rest, but thanked me for listening. he was later discharged from the hospital in pretty good condition, and i was really impressed with his daughter who was managing to keep it all together while her parents were nearing the end of their lives. i hope she gets to hear from him how proud he is, because she was a real patient advocate for her father, refusing tests that wouldn't change management and that would also make him uncomfortable. they had decided together that he did not want to be resuscitated or intubated (have a tube put down his throat and be connected to a ventilator) and i really think this is such an important discussion to have while you still have your wits about you and you can communicate what you'd like to happen with someone close to you.

on the flip side, from the medical icu:

a middle-aged man was admitted to the medical icu after being found down at a nursing home. it was difficult to piece together what exactly happened, but our best guess is that he had an episode of low blood sugar, causing him to go into seizures and eventually asystole (flat-lining). he was successfully resuscitated but never responsive. he ended up having continuous seizures for days before high doses of multiple anti-seizure medications could control them; his mri showed multiple infarcts (aka dead matter). he had no family, so a friend was located who eventually agreed to act as his medical decision-maker (aka surrogate). it's definitely a tough situation to be in, and we have not withdrawn care yet, even though the prognosis is really poor and he's being kept alive by machines.

and finally, i did experience my first death during a code, or resuscitation, in the unit. i didn't know a lot about the patient, but he was supposedly very functional, living and taking care of his wife with dementia, and his death was really sudden and a big shock to his family. he came in in a really bad way, and we all thought he was going to die, but then suddenly the curtain to the room was being pulled and the crash cart was being pulled in and the code was going, an X-ray was done and it came up with the lungs in complete white-out, blood was pouring out of the endotracheal tube, and it was over.

i've had patients die before, but for some reason, this time felt different, even if i wasn't his primary caretaker, and just participated a little bit in his care before he passed. we talked about dealing with death at one noon conference earlier this year and what stuck in my mind from that time was how often you just erase the patient's name from the board where you keep the census and then fill out the death certificate and forms and then that's it. that's kinda what happened in this situation; i followed my resident who told the family that their loved one had passed, there was crying, and then a short visitation with the body after he had been cleaned up by the nurses. then his name was erased from the board, and we went on doing our other work, rounding on patients, putting in orders, admitting new patients to the unit. later on in the night, we were discussing the case with another resident who came to visit, and i almost couldn't even remember his name when we were trying to find the X-rays to show him. i felt terrible about it for a second, but then i reminded myself that i only knew him for less than an hour, and what i did know about him wasn't anything at all about his life, but just his death. this was sad to me, but that's what sometimes happens in the unit, and i hope he is resting in peace.