the ICU

The intensive care unit is a very different place. The environment is good, the staff and nurses supportive, and all the doctors and residents who are on the MICU (medical intensive care unit) work really well as a team.

But the patients...they are so sick. Academic hospitals tend to have sicker patients than community hospitals. And patients in the ICU are the sickest of the sick. Here are some examples:

- 21 year old male who was binge drinking, past out drunk, vomited and then aspirated his vomitus. Found a few hours later by his brothers, and may have suffered severe lung injury as well as decreased oxygen to his body for hours.

- 70 year old male who had shortness of breath. His heart function turned out to be 1/6 of normal person.

- 45 year old female with metastatic breast cancer who was moaning, low blood pressure and high heart rate and fever. Symptoms were consistent with bad infection, and complicated by blood clots in all extremities. Died 2 hours after we transferred her to the ICU, from a heart attack.

- 60 year old male with shortness of breath and cough for 6 weeks. He was found to have lung cancer that occupied 50% of his lungs. We treated him with chemotherapy and helped him breathe with a breathing machine...but watched him slowly die, first by lungs failing, then with fever and infection, then dropping blood pressure, until finally his family stopped the suffering.

What I've learned is that, as much as we try to treat and save these patients, most of them will do what they'll do. If they are dying, no matter what we do most of them will still die. Medicine can only work its magic so far, until nature overpowers us.

We have saved people, too, though. The biggest thing we do for people is aggresively give antibiotics and fluids, and support their breathing if their lungs fail temporarily. The people who come in with raging infection that threatens to shut down all organs, we give them TONS of fluids, antibiotics, and hope that their body makes it through. And some do, and it really is a miracle.

The last gentleman I described above, the one with lung cancer, was one of the saddest cases. The wife finally decided to call all the family in, so that everyone could say their goodbyes. And then she gave the decision to withdraw support. He died 2 hours later. But they are only pronounced dead when a doctor says so.

I have never seen someone pronounced dead, and never learned how to do it in medical school or residency. It wasn't part of the training...and you don't study or prepare for it. But I was on call, and the nurse told me I was to pronounce Mr. S. I don't know how to describe walking into their room (not knowing what I'm supposed to do), with all of the family surrounding the bed. When I approach, they step aside to let me walk to the patient. And I do what I think I'm supposed to...I listen for a heart beat, feel for a pulse and a breath, and open his eyes and shine a light to see if his pupils react. Its very surreal, eerie, to be doing this to an already dead person, with the family watching me. I do these motions, and then simply say, 'okay', and nod with closure to the wife. I walk out with the nurse, and pronounce him: "Time of death, 7:50 pm." And I tell the nurse to ask his wife if she wouldn't mind answering some questions for me, whenever she is ready.

Its crazy. Mr. S was happy, jolly, eating when we first saw him. We knew he had cancer, and we saw that he needed oxygen by a face mask, but he was still alive and still talking with us. His wife was always there at his side. And we saw him slip away over the course of 2 weeks.

Afterward, I talked with his wife and 2 brothers, and we talked about his funeral home, if an autopsy was desired, if he is an organ donor. And then we reflected a little bit about him, how he didn't want to suffer, how it was hard to let him go. And they were thankful, I think, even though I barely knew him...I was just the doctor on call. It feels strange that I should be the one to give the final declaration that this person is gone.

I felt sad for the family, and a little numb that I just pronounced someone dead. I didn't quite know what to say to the family, or if I should've said more, or less, shown more emotion, or less. I felt like I was intruding into a emotional, very personal family meeting, and that it wasn't my place to say too much. Maybe they thought a doctor was coming in, performing the routine and doing his job, but I'll tell you it felt like a young, afraid, unsure man who just graduated from school had just put closure onto a huge chapter of this family’s life, and it didn’t feel natural to do so.