January 18, 2013

two stories

I have a hard time writing about spending time in the intensive care unit, because generally it's not my favorite.  I'm much more of a keep people healthy and make them healthier than looking death in the eye and stopping it in its tracks, or at least holding it off for a while on a daily basis.  I'm glad other people want to go into critical care medicine because I do not.  That said, I want to be able to handle myself in a crisis, as they arise even in people who are pretty healthy.  I also think it's important in medicine to think about the ways in which people die, the process of dying, and learning how to help people confront dying and cope with changes.  This and more is why I chose to spend my January days in the Surgical Intensive Care Unit (also called the SICU), even though it sort of terrifies me.

Today I have two stories for you.  One was recounted to me by my attending this morning on rounds, and the other is about a patient I saw earlier this month.  I'm not sure why, but I want to see them side by side.

Story One.  Katherine is a 99 year old woman who has lived a very satisfying life.  She has four children and 10 grandchildren who live somewhat close by.  She has been generally healthy all of her life and decided when her husband died 20 years ago, to move into an independent living community for older people.  As she has gotten older and frailer, she has moved into a room on a hall with other residents of her community.  Everyone in the community is required to complete most of their activities of daily living (bathroom, eating, bathing, etc) with little to no assistance.  This suits Katherine just fine.  Every day, she wakes up and walks down the hall (using her walker) to breakfast, where she sometimes talks with friends or acquaintances, sometimes gazes out the window at the trees and birds outside.  After breakfast, she usually returns to her room or to a chair in the library to do some reading or knitting.  Then she usually has a small lunch - usually just a soup or salad - and returns to her room for a short nap in the afternoon.  She spends time with family or friends or catches up with them on the phone, attends dinner, takes a shower or bath and goes to bed.  She has noticed that she is less interested in talking with other people and has less of an appetite, but enjoys sitting in quiet and thinking.  One day, she gets up on at her usual hour, heads to breakfast and chats with a few friends over some oatmeal.  She returns to her room and instead of picking up her knitting, she takes a shower, puts on her favorite blue dress, her pearl earrings, and lays down on her bed.   Her daughter finds her later that day when she comes for a surprise visit.  Her daughter says that Katherine looked so peaceful and it felt as if she had just decided her time had come and she was ready to leave this life and move on.

~~~~~ *** ~~~~~

Story Two.  Tracy is an 18 year old young woman who lives with her parents and her younger brothers.  Until today, she has been pretty healthy besides struggling with depression which has led her to experiment with alcohol and marijuana with some friends on a pretty regular basis.  Her parents are very concerned and have tried everything they can to help Tracy.  She regularly sees a psychiatrist who prescribes her medication, and a counselor with whom she talks through some of the struggles in her life.  One day, a few days after Tracy and her boyfriend had gotten into a big fight, and a few days after she had increased her dose of her antidepressant medication, Tracy is having a conversation with her parents and then leaves to go to the bathroom.  After ten minutes, her father starts to wonder if she is okay and decides he is going to go check on her.  He finds her hanging by a belt above the bathtub in a suicide attempt, with vomit on her chest.  He immediately supports her, undoes the belt, and brings her down to the floor.  He screams to his wife to call 911 and begins CPR.  He feels like time goes on forever before the paramedics arrive and take over.  Tracy is taken to the hospital, found to have no serious traumatic neck injuries but very critical hypoxic (from not enough oxygen) brain injuries.  She is comatose and must be put on a ventilator to breathe.  Her parents struggle with the decisions before them - with the doctors saying that it's too soon to tell what Tracy's prognosis will be, but implying that no matter what it is, she won't be the same person she was before.  Her mother asks when they have to make decisions about more invasive measures, like a feeding tube or a tracheostomy (a temporary incision in the neck where a breathing tube can be placed to avoid inhaling vomit).  Her father asks if we need information about the angle of the belt around her neck, because if it would be helpful he could draw it - goodness knows he can't stop picturing it.

~~~~~ *** ~~~~~

I'm still processing these stories and thinking about why I wanted them next to each other.  But I think I also wanted to give you - and probably mostly myself - a sense of what's hard about medicine.  It's not just the long hours inside or the lack of time to eat or see the people I love, it's being confronted with impossible scenarios and the most critical and poignant moments of people's lives on a daily basis.

"but a mountain you're plannin' on climbin' ain't the same as the one you ain't.  
It ain't so pretty, nay"
- David Mitchell, Cloud Atlas
(book review to come)

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