Month: April 2018
I’d like to tell you about my visit to the intensive care units at the Rockyview and Foothills hospitals in Calgary.
But the story really begins last fall, in a cozy café in Kent. I met a friend of mine there who spends part of her year in India. With rain streaming against the windows and steam rising from our teacups, I asked what drew her to India.
In India, she said, you see death.
Oh, I said. And then I thought (and I accidentally said this out loud), That’s a strange reason to like a country.
She smiled and said, I just mean that in India, death is more natural. It’s out in the open. You can talk about it.
And then we sipped our tea, ate a sandwich, and talked about death.
But this, of course, is not normal.
As Atul Gawande says in his wise meditation on aging and death, Being Mortal, “In the past few decades, medical science has rendered obsolete centuries of experience, tradition, and language about our mortality and created a new difficulty for mankind: how to die.”
Gawande offers a nuanced discussion on our culture’s inability to face death head-on, and our tendency to prioritize complex medical treatments over quality of life as we near the end. As one ICU team member remarked to me during my visit (we chatted in a quiet spot, removed by several feet from people attached to ventilation machines, heart monitors, IVs and more): You’ll notice that physicians do not choose to die like this.
But Gawande’s text also embodies a growing interest in putting humanity back into medicine. An interest that plays out in the intensive care units I observed.
Let’s begin the story of the ICU by looking backward.
Intensive care medicine has not been around long as a specialty – it’s a junior sibling in the medical family, having grown up in the latter half of the 20th century. Its purposes are wide-ranging: According to Care in Canadian ICUs, published by the Canadian Institute for Health Information, “ICUs serve a broad range of patients, from those with pre-existing conditions to those with unexpected injuries or illness, as well as those who need support before and after undergoing complex procedures.”
So what is intensive care, exactly?
In “A History of Intensive Care Medicine,” Jukka Takala defines intensive care as the prevention, reduction and removal of the temporary risk of death. Takala says that in intensive care medicine, “concentrated investment of human, material, and technological resources for monitoring and treatment are employed to defeat death and morbidity.”
This sounds promising. Removing the temporary risk of death.
How comforting to know that the risk of death can be removed. Picture poor Orpheus, comforted by the thought that he can cheat Hades. Thinking he can pull the beloved Eurydice from the underworld. Just don’t look back, Orpheus.
Picture the glint of a metal blade, slicing open the throat of Hades. If you’re careful, you can do it. Just be very very careful. Don’t look back.
It’s hard not to see, between the lines of Takala’s definition, the inherent human aspiration to immortality. The bald hubris of living one’s life aware of mortality, but believing that one can defeat death. That the messy business of exhaling that long, lonely, terminal breath is something I and only I can skip by. Escaping the gaping maw of mortality, but for the grace of god. The removal of risk. And life is always a risk; every time you walk out the door you take your chances, roll the dice, gamble and hope.
Death, it would seem, can be defeated through the employment of human, material and technological resources.
Of course Takala doesn’t mean that death is something weak and flimsy, the dodge ball captain who chooses players poorly. Takala is talking about defeat as temporary. The fleeting defeat of death. A hopeful holding back of the tide.
Intensive care medicine is about life; the sustaining of. It’s also about decisions. Teamwork. Compassion. It’s about the human body and its opaque complications. And sometimes the ICU is about death.
Which our culture sees as a failure. But as Atul Gawande reminds us, death is not a failure. It’s normal.
Let’s procrastinate a bit longer on discussing death.
Where does the concept of the intensive care unit originate? Takala notes that Florence Nightingale is often credited with establishing the first ICU during the Crimean war in the 1850s.
Nightingale gathered together the most severely injured soldiers in one area, so nurses and doctors could monitor them and intervene efficiently.
According to Takala, some believe the ICU originated from an early postoperative ward in Newcastle, England, in the early 19th century, which housed the sickest patients and those recovering from surgery. As one of the Calgary ICU residents told me, anesthesiology has played an integral role in the history of the ICU. These practitioners would often stay with post-operative patients if they needed extra care. Later, in 1952, a polio outbreak in Denmark also provided some of the inspiration for intensive care medicine, with nurses and medical students manually ventilating patients for days on end.
Beyond its origins, the ICU has come to rely on the innovations of a few maverick physicians.
Consider the case of Werner Forssmann (1904-1979), who, as a young surgeon-in-training in Germany, threw personal safety out the window in the effort to invent a method of catheterizing the hearts of patients at risk for cardiac arrest (again – eliminating the risk of death!). He lubricated a 65-cm-long uretreric catheter and inserted it through his own left brachial vein, checking with a chest X-ray that the tip of the tube had snaked its way into his right atrium.
Forssmann was later fired, after attempting this procedure on a patient. Only to be vindicated later, eventually sharing the 1956 Nobel Prize in Physiology or Medicine.
Forssmann’s willingness to sacrifice his own noble veins in the name of medicine is no doubt unusual. But the same spirit of dedication to medical care lives and breathes in the intensive care units of Calgary.
I expected that the first thing I would notice when I entered the Rockyview ICU would be a smell – I don’t know why. Did I think that here, where patients were the most critically ill, the odors of the healing environment would gather themselves up and swirl together, tornado-like, into a funnel of concentrated pungence?
At the Rockyview I remember the smell of spaghetti, heating in the microwave. At the Foothills, the smell of vanilla in one patient’s room … the vestige of a topical cream.
No funnel of foreign odors.
But there was no shortage of newness. The foreignness of an environment, signalled by the newness of words. Vocabulary that has shaped itself into a dialect over time, as a team of people work together in a specific environment. As they confer, intubate, teach and tend, they pour their words into the vessel of the ICU. And the words retain the shape of that vessel, like metal in a mold. Here is how they sound to tender ears:
Rounding (it is a verb)
Attending (it is a noun)
Fentanyl (it is a medication)
Sleep (it is a dream)
Pain (it is a measurement)
Bowel (it is a sound)
Grimace (it is a measurement)
Quiet (it is a jinx – don’t say “it’s quiet today!”)
Failure (it is a beginning)
Silence (it is a teaching moment)
Resistance (it is relative)
Tachy (it is pronounced tacky, but means swift)
Crackle (it is a prophesy)
Sundown (it is a verb: erratic nighttime behavior)
Physio (it’s your new best friend)
A good death (it is peaceful)
The opportunity to die (it is a gift)
Striving in adversity (it is the norm)
Excellence (it is the minimum)
Competence (it is your identity)
Just a quick note as we dive into the ICU: I refer to team members below, but I’ve mixed together team members from both the Rockyview and the Foothills. The comments are tied together by context, not geography.
My day at Rockyview begins with rounding (verb; to conduct a teaching conference or a meeting in which the clinical problems encountered in the practice of medicine are discussed).
The team moves from patient to patient, from room to room, spelling out the details that define that person while they inhabit the ICU. I am surprised by the size of the team – four residents, an attending physician, a pharmacist, a dietician, a respiratory therapist (RT), the nurse assigned to that patient, and a nurse clinician. And today, the writer in residence.
The ward at Rockyview is a double-lined hallway of individual patient rooms – each has a number above the door, so the inhabitants become, at times, Bed 1 or Bed 8. At first this seems impersonal; a human being who was riding the CTrain or taking a grandchild to swimming lessons the day before, becomes a piece of furniture upon which they will lie, falling in and out of consciousness, until they are well enough to leave the unit. Or not.
But as the day wears on I learn to appreciate the nomenclature. I understand the need for clarity. The sheer volume of details surrounding each patient is overwhelming. If I were in Bed 1, I would not want to be confused with bed 8. In any event, the “bed” terminology is used only occasionally. When discussing the patients, the physicians and nurses tend to use their actual names. Names, the human code; in intensive care, codes merge with names, technology is deeply personal, tubes flood the body and replenish the lungs, monitors turn the human inside out.
As I will discover, the inhabitants of the ICU are treated as people with rich, sometimes thorny stories – people who just happen to be stuck in a chapter where their bodies have stumbled, and are struggling to rise. The trouble is, you don’t always have time to dig deeply into the personal stories when patients arrive in distress.
One team member told me about a former patient who did not seem responsive when they spoke to them; in the initial wave of caring for a new patient, they assumed this person might have a brain disorder of some sort. Only to find out from the spouse that the patient had neglected to bring their hearing aids to the hospital.
Inhabitants of the ICU are often living out chapters that are circular, a groundhog-day loop where one problem becomes another becomes another. Repeat. And some of the inhabitants have been wedged into this particular chapter for a very long time. The chapter can be a highly complex read.
A common conversation with patients’ families involves reminding them that the original health issue for which the patient was admitted has not yet been resolved. It has simply dissolved like ink in water, reaching through veins and arteries, confounding the original diagnosis.
Back to rounding. We cluster around the doorway of the first patient’s room. He is enclosed by glass walls and an open doorway. His room is full of so much equipment that it blurs together and I have trouble distinguishing one apparatus from another. There are monitors, tubes – the sort you might find on a vacuum, and the sort that transport drugs, blood, bodily fluids. The nurses sit outside the room, giving the impression of a night watch. The diligence of the observation process here is mind-boggling. This is why they call it “intensive care.”
As the residents and nurses begin the litany of medical statistics describing the patient, the doors to the unit whoosh open and a bed is rolled in; the hallways are relatively narrow, so everyone squishes together, melting backward and filling the small spaces behind the ward desk or against the walls.
The bed passes and we flow back into our semi-circle, listening as the nurse, the resident, the pharmacist, the RT and dietician as they provide updates on the patient’s status. The updates sound like lists, and I grasp the syllables that sound familiar: septic, grimace, “ow,” fentanyl, bowel, hemoglobin, platelets.
And suddenly the discussion is over. I have the sensation of having walked through a brief but powerful wind storm.
Ten thousand words have been blown past me and I have understood the meaning of approximately seven.
I am shoulder-to-shoulder with the team, mere inches from a fifth-year resident and a pharmacist, we hear the same words and see the same people lying in beds. But I feel like a green-skinned creature masquerading as human among this group of humans. Their world is so finely tuned to this moment, to this particular hallway in this particular hospital, that their language requires translation. Between patients the attending physician steps toward me and explains in plain language what the patient is suffering from, or the medical challenges facing the team.
As the patient reports swirl around me, I notice that we stand ten feet from patients but refer to them in the third person. I notice that the language used is often highly technical, long strands of jargon and acronyms. But by the end of the day I am swept up in the wind storm of the team. I see only the overt signs of the gale as it blows by, but I sense the magnitude of the unseen air mass – the intellectual challenge of the diagnosis, the strength of the team, the desire to help. I have the sensation of switching sides, seeing the patient from the medical point of view. I see the appeal.
Yet you can’t help but wonder how much of the technical jargon is a protective mechanism for these humans who care so intensively for the most critically ill. One team member mentioned that ICU staff don’t always talk openly enough about the over-arching trajectory of the patient’s story. This person is chronically ill. They may not leave the hospital. We don’t always have as much control as we seem to, the team member told me.
Is this sense of control an illusion? Medicine was not always seen as a potential savior for the suffering. Let’s consider the succinct and practical advice of Greek physicians like Hippocrates, who wrote in the 4th to 5th centuries BCE:
“Now to restore every patient to health is impossible. To do so indeed would have been better even than forecasting the future.”
As Atul Gawande points out, prior to the middle of the 20th century, hospital staff performed more of a custodial role. Gawande quotes physician-writer Lewis Thomas: “Whether you survived or not depended on the natural history of the disease itself. Medicine made little or no difference.” No one pretended to understand the crystal ball.
But of course medicine has changed drastically since then. Witness penicillin, blood pressure meds, heart surgery, artificial respirators and organ transplants. Says Gawande, “doctors became heroes, and the hospital transformed from a symbol of sickness and despondency to a place of hope and cure.”
A vehicle for defeating mortality; a place of hope and cure. Which begs the question, what is hope?
The Oxford English Dictionary offers this definition:
- Expectation of something desired; desire combined with expectation.
It would seem that humans have a long history of hoping; the word “hope” dates back to ancient Old English, having belonged originally to Saxon and Low German.
To demonstrate the word’s meaning, the Oxford English Dictionary reminds us that “hope” is often personified, along with its Christian sisters, Love and Faith. The OED offers a quote from a Hannah More’s Sacred Dramas:
“Fair hope, with smiling face but ling’ring foot / Has long deceiv’d me.”
Hope, then, with the façade of optimism, but the limping truth of hesitation, slowness. Lingering.
More’s poem reminds me of a piece I read in the latest issue of The Longview, a creative writing journal published by medical students at the University of Calgary. The piece, titled “Dum Spiro Spero” (Latin: While I breathe, I hope), tells the story of the writer’s aunt, who has multiple myeloma, and who says, “The greatest curse my doctor gave me was hope.” The aunt regrets not being able to prepare for her death, and achieve the closure she needs at the end of her life. The narrator asks, “when did hope become tragic? When did it become dishonest and irresponsible for a physician to dispense hope?” The piece ends by acknowledging that hope is a Hobson’s choice, but erring on the side of optimism for physicians: “we, ourselves, must hope that hope can save patients, even when it can’t save their lives.”
But we were speaking of hope and cure, the evolution of the heroic physician from Hippocrates and his skeptical take on cure. The lack of control felt by ICU clinicians when the technical side of medicine falls short of the cure. The alternative, as one clinician noted, is to be part of the patient’s journey, as it bends and forks – even if it meanders in a downward spiral. Indeed, the team often open discussions around supporting the dying process. They sometimes have to tell people that if they go home at a certain stage of the treatment process, they will simply end up returning to the ICU.
They often try to give patients peace as they discuss options with spouses and children. And if the journey appears to be nearing its end, they support a peaceful death.
Some ICU inhabitants have thought about options. Some just want to go home and have a glass of wine; most don’t want to be lying here attached to machines.
But this is not always the case. The ICU chooses its inhabitants; it selects for those who want to fight, rather than go home and have a glass of wine.
For other patients, the ICU is a sort of non-place – a place they are unaware of, in the long run. One practitioner noted that most patients do not remember their time in ICU. They often don’t realize how sick they were. Is ICU, for these patients, a sort of dream world?
Their time in intensive care passes through their unconscious in shadowy sensations, nocturnal, curled up under a comforter, alongside the creaking of floorboards, the clunk of a furnace and the dark shapes in a closet. Part of the deepest interior monologue of the person’s life narrative. The murmured subtext of a life. That liminal space between conscious and unconscious.
Which makes me wonder about the difference between the two – perhaps because I spoke with a team member whose interests lie at the intersection of anesthesiology and critical care. We spoke for some time about the difference between consciousness and unconsciousness (do you see now why I get nothing done on my dissertation?). I had never really considered the different layers of consciousness – is it best to see them as a spectrum or as layers? Which is the top layer, though, and which the bottom? Where does one plot “suspended” on the spectrum, and where does “altered” or “disconnected” fit in? Where is the state in which patients exist in the ICU while not exactly conscious?
And where does one plot “delirium?” One of the serious challenges facing ICU patients, which clinicians strive to mitigate. The word “delirium” comes from the Latin word delirare, meaning “deviate from a straight track,” and was documented as far back as 2,500 years ago in the Hippocratic writings. The American Psychiatric Association tells us that delirium involves disturbance in awareness and attention; it can fluctuate and may involve altered perception; it is a direct physiological consequence of another medical condition.
In other words, it’s a confused, disoriented, scrambled state of mind. One of those adumbral layers wedged into the sedimentary depths of the human mind. Part of the interior monologue which may be forgotten, at least in part, when the patient goes home.
But we should return to the Rockyview ICU, where the team is still rounding. They are between patients now, a lull.
I follow the group of residents as they relax for a moment and chat. This is the water cooler moment, I realize, but there is no water cooler. There are no cubicles, no baffles, no white noise, dress codes or corporate value statements.
There is talk of sleep. The need for it, the desire for it. You can see it hanging overhead, thick and sweet, like cotton candy. You can almost reach it.
Some of the team have small children. If they would just sleep through the night! Remember the days when you slept for eight hours? This is the parenting moment, the classic realization that sleep is precious; it once was and now is not. But the discussion on sleep here is deeply layered. Complicated by shifts worked on call, around the clock, nodding off for a few minutes in sleeping rooms.
We move to the next patient. A resident speaks of respiratory failure, intubation, a trach is being considered. Tracheostomy. The physician indicates that the white count is coming down, and asks the residents why this change has occurred. It’s a teaching moment. The residents turn their eyes upward, take a stab at the answer. Their responses begin with phrases like, “As far as I can recall” and “To the best of my knowledge” and “From what I understand…”
It’s a reminder of how complex the medical profession is, and how long the learning process is. These residents finished their undergraduate education in medicine from two to five years ago, and have been working as residents ever since, rotating through specialties like family medicine, cardiology, psychiatry, internal medicine and OB/GYN (obstetrics and gynecology). Most of them will spend about four weeks in the ICU, and that may be their only rotation here; most do not aim to become intensive care physicians. They are expert medical practitioners; they can prescribe and treat and diagnose. But it takes years to become the physician who shepherds residents through the learning process. It takes years to understand the nuances of life in ICU. The looping progressions of acute disease.
The attending is talking about intubation now, the urban myths you see on TV (my ears prick up; I have seen this – a pocket knife is all you need, right? And a tube of some sort?). The myths seem ridiculous but the attending has heard of a doctor saving someone in a Chinese food restaurant using a Bic pen. The residents lift their eyebrows and smile appreciatively.
I wonder if some recoil at the thought of throwing down their chopsticks, pulling out their MEC Swiss Army knife and slicing open the throat of a stranger while fellow diners look on, 911 at the ready, chow mein roiling in their stomachs. Or would some of the residents here relish the opportunity, the burn of adrenaline, the moment where you rise to the challenge of giving breath to the breathless?
Speaking of breath, one of the RTs I spoke with said their job is rewarding, in part, because of the excitement of a code (cardiopulmonary arrest). It sounds a bit demented, they acknowledged, but when a code is announced and they assist with a resuscitation, it’s a pinnacle moment. The RT is at the top of their game, functioning at maximum capacity, a climber on oxygen, stretching to the summit of their knowledge and expertise: This is the moment I’ve been training for.
The Bic pen story slips into dénouement and then the act of rounding continues. More lists are presented and the team discusses possible changes and outcomes. The structure of the team appears to be relatively flat, without a noticeable hierarchy. The team is large but well synchronized. Their collective knowledge fits together like jigsaw pieces, as words flow between team members: warfarin, anticoagulant, delirium, tracheostomy, edema, shortness of breath, respiratory failure.
There is a rhythm to the lists and I begin to feel more relaxed. The patients here seem relatively stable, assisted as they are by the machines that huff, hum and beep alongside the beds. I will make it through the day; at noon I will eat my sandwich, interview some residents and make jokes about sleep deprivation.
A beeper goes off. A new patient, incoming from Emerg. Needing intubation.
The attending physician says, I need to go to Emerg. Would you like to come?
No, I think.
Yes, I say.
We make our way to Emerg, only to return; the patient will be brought to ICU. Intubation is one of the specialties of the ICU; this is one reason why a rotation through the ICU is appealing to residents wanting to specialize in internal medicine. They become proficient at skills like intubating and inserting arterial lines.
As the nurses get the new patient settled in, the attending physician asks which residents need experience with intubation. I can’t tell if the residents want to be selected or not. I think they do. The attending selects one. The team gathers outside the patient’s room, and the core team drifts in as the nurses work briskly to change the hospital gown and get the patient in position. The physicians stand in a circle around the bed and I hang back in the hallway.
I sense that in the ICU, chapters vary in length. Some are languorous, they take their time, stretching over days, weeks, months. Others clip by. Arrivals. Curtains. Intubations.
The rhythm is hard to predict.
The attending physician will tell me later that this is one of the most challenging aspects of medicine. It is unpredictable.
How does working in the intensive care environment affect health care practitioners? For an outsider, their work appears to be stressful, full of emotional moments, difficult decisions and weighty responsibilities.
Team members gave a variety of responses when I asked how the ICU world affects them. Some said they found the big emotional swings challenging. One said they didn’t cry at work but waited till they got home, where they could cry with their partner. One said they always felt guilty – guilty about being at home, away from work, and then guilty about being at work, away from home. Others found it humbling – it puts your own problems in perspective. Some said it required them to take better care of themselves physically and mentally. This environment is intense, and the intensity can be challenging, particularly when it extends across five, eight, twelve days in a row.
That intensity is mitigated by the team environment. There are nurses, RTs, physicians, residents, pharmacists, psychiatrists and more to help you with difficult situations. If you’re intubating someone for the first time, there’s someone standing beside you who has done it a thousand times.
When I asked the ICU team about the most challenging aspects of their job, a common theme was the possibility of not doing one’s best and letting down the patient, the family, the team. Here are some of the questions that keep them awake at night:
Could I have done more?
Why didn’t I see that coming?
Did I do the right thing?
What did I miss?
Several told me they had strong relationships with team members, in part because it’s difficult to share your experiences with someone who doesn’t understand the ICU world. Some said they used to take their work home with them, but decided that wasn’t feasible. You can’t think about it too much when you’re not there. One physician said they were able to empathize with patients without getting personally involved in their emotions – recognizing the importance of the patients’ and families’ emotions without losing themselves in those emotions.
Which makes sense to this potential patient – I would want my situation to be taken seriously, for it to be seen as meaningful, but I wouldn’t want my story to drain the physician to the point where they are unable to perform from their work.
The upside to working in ICU?
The sense of meaning and purpose that comes from believing you’re helping those who really need it. Both patients and families. And the extraordinary feeling when a critically ill patient pulls through. It could be a young mother recovering from influenza, for example. To be part of the team that helps her heal is an incredibly meaningful experience. And as the RT noted earlier, there is something to be said for the intense moments that arise in places like the ICU. They ask you to live up to your full professional potential, to think on your feet, to be deeply curious about each and every patient.
The day I observed the Rockyview team was a quiet one, something of an anomaly. This was my first clinical experience and I was somewhat relieved to arrive that Monday morning and see a half-empty ward. Later, a nurse explained why the atmosphere was so peaceful: some of the patients had not made it through the weekend. When the nurse told me this, I felt that quick flash of cold in my stomach, a subtle stab, somewhere on the spectrum between guilt and fear. I, after all, was not raised in India where death is familiar; I keep a comfortable Canadian distance from mortality. But some of the ICU had already rubbed off on me. I tucked away the feeling of guilt and fear, and took out my pen and paper. I would no doubt feel it later, once I was at home – perhaps while writing, or while drinking a quiet glass of wine.