My classmate Sundance – yes, the Sundance I’ve interviewed twice on video – recently shared with me a letter to her family about her inpatient rotation. She was kind enough to give me permission to publish it, and I’m sure you’ll see, as I did, what a great insider’s perspective it is*. As with everything Sunny does, it has childlike wonderment, artistry, and astute observation.
I hope you like it. -P
I know it seems nothing new that I am on “another killer rotation,” but this one is blowing my mind.
Even with the excitement of the ER — patients coming in with new stroke signs, hearts sending blood into new spaces, or the HIV clinic, where AIDS is made more complicated by depression, drug addiction, homelessness, etc. — my very few days in the ICU showed me the sickest patients I have ever seen.
The ICU, or Intensive Care Unit, is a special floor at Cline Memorial Medical Center. It’s ground zero for God-battling. Death has a lot of machinery to claw through here to take a life, and rarely does it win (for better or worse).
One day I even asked, “Where do people go to die? Do they die here?”
“Not usually,” a kind, baby-faced, coo-mannered young nurse named Josh told me. He had the tone of hesitant confidence that the most capable, competent, and insanely smart people have. Like Josh, they are often nurses. “Depending on the wishes of the family, they either go home, go to a normal hospital bed, or go back to the Skilled Nursing Facility.”
Death does not win here.
Which brings me to the sickest person I ever saw, a 63-year-old woman. Young, I know. I first noticed her snoring respirations at 7 AM, while gathering information on another patient with a triple coronary artery bypass. During rounds, Josh (cool as ever) began describing the patient’s story to the intensivist (critical care doctor) in a gentle tone that didn’t fit his words. Each point was the sickest, saddest, shocking-est thing I had heard in my years of training. The list went on and on.
“She has renal failure requiring dialysis, pneumonia with empyema (lung full of puss), UTI, diarrhea, septic shock, hypotension, elevated INR.”
The high INR meant that she had little ability to clot and could therefore bleed like crazy. She was DNR/DNI (orders for no CPR, no breathing tube) and her infection had her so out of it that she couldn’t hold her jaw up to breathe. The challenge to the team was figuring out where her sepsis was coming from.
Sepsis is a life threatening, total-body infection. It could be coming from her lung. It could it be coming from the pressure ulcer on her back that looked like a tennis-ball-sized crater revealing her spine. Or maybe her PIC line (an IV tube into a big vein) that had been in place for far too long (weeks, instead of days). Was it harboring infectious bacteria? Or was it her diarrhea, which continued to flow from her rectal tube?
The woman, when we examined her, was not there. Whether it was the multiple infection sites or the fact that she was nearly suffocating, she was non-responsive, even to pain. Her body was a strange sight: legs gone below the knees (the classic kiss of diabetes), abdomen and arms a strange deflated mass of amorphous tissue left over from an obese habitus. She looked like she was dissolving, melting away from the bottom up. The smell of her dinner-plate sized bed sore made me grit my teeth. I was grateful for my sterile gown and mask, and wished the mask was thicker and my stomach stronger.
As we finished up, like weird blue aliens in plastic protective gear, I backed away, done with this “almost person,” and hid my inner battle. My blue plastic body was present, helpful, involved, and attentive. But my mind was falling down Alice’s rabbit hole. How could she still be alive? How could this be okay with her family? How could so many things be going wrong with the body but the heart still be beating?
All I could do was exit the room, tear off my gown, wash my hands, put my short white coat and stethoscope back on, and say – almost to anoint myself – “That is the sickest person I have ever seen.”
She will be there tomorrow too. Unbelievable.
Post script: Clostridium difficile was cultured from her stool, and was probably the cause of her new septic presentation. Big-daddy antibiotics were started. She was put on a Bi-PAP machine to force air into her lungs without a breathing tube, and she awoke enough to struggle with her mask. Plans were made with the family to move her to “comfort care,” a way of discontinuing intervention and making her comfortable in preparation for a peaceful death.
In the intensivist’s words (insert heavy Indian accent here), “Her day must have not come, for she is still here.”
*Identifying information in this post was changed to protect the patient's privacy.