Alright,
so I’ve been lax.
Way lax. I know. I’m sorry.
I’ll try to pay you for your patience, if you’ll bear with me a little bit - really.
I want to tell you something about The Unit. In this particular case, it’s the MICU - Medical Intensive Care Unit. I’ll tell you straight up, I love critical care with something bordering on insane passion. There’s something about the urgency and the necessity for quick, articulate intervention that just really blows my proverbial skirt up. Not that you’d know it from talking to my folks, though. I often stop by their place on the way home from work to read the comix, drink a beer and maybe even scam some of my Mum’s excellent cooking. Make idle chitchat, trying to get either of my folks to tell me a bit about their days right up until someone asks, “So tell me about your day.”
At that point, I generally grunt and reach for a cigarette. Maybe tell ’em one of Graham’s sick jokes from rounds, but otherwise I generally refuse to say much. I don’t really know why.
I’ll also tell you that I stood here for a good eight or ten minutes looking for the right thing to put on the Stereo while I try to write.
First I thought I wanted something angry, but then it dawned on me that I wanted something aetherially beautiful and sad. It took a while, but then it sorta popped right off the shelf at me - the Fauré Requiem. It’s appropriate. You should listen to it sometime.
The totem for the MICU should be the Horsewhip.
I’ll show you why -
3 April
It was sometime after two in the morning, and I was sitting out on the patio off the cafeteria having a cigarette. My first admission of the night actually hit the unit sometime around seven-thirty, and George (my boss and back-up for the night) and I had spent the intervening seven hours working to resuscitate her and get her stable. We’d finally reached a break-point, so I seized the opportunity to go downstairs and just sit for a few minutes doing nothing.
Sometime shortly after she arrived around seven or so, my pager went off, and when I answered I found to my surprise that I was talking to a good friend who told me that he was up on the ninth floor waiting with his sweetie for her daughter to come out of surgery. “I’ll try to get up fairly soon Gar,” I told him, “but I’ve got a critically ill patient here and I don’t know how long it’ll take to get her stabilized.”
So I sat there watching the cigarette crumble away before me as it dawned on me that I’d totally blown them off. – Or maybe that isn’t the right way to put it. It’s not like I neglected them, but rather that I had been busy, and the woman I was working with was my direct responsibility. The bottom line though, is that my friends sat cooking up on the floor; certain, I think, that I couldn’t be bothered with them.
“Well, crud,” I thought lamely, and lit another. I was chatting with a couple of nurses from another floor when the pager went off again.
In case you’re wondering, I don’t mean that it sounded or chimed or beeped. The fucking thing went off, like a gun, the way it always does. I scrolled the display to the message window, saw the number there, and wilted. It wanted me to call 3252, the number for the high-acuity side of the emergency department. It seemed unlikely that they were calling just to chat and find out how things were going.
A couple of minutes later I was sitting up on the North end of the E/D with one of the upper-year residents.
“We’re really not sure what’s going on,” she told me. “Evidently she heard a ringing in her ears, sat down hard on the sidewalk and went down hill from there. By the time she made it to the referring E/D she had a blown pupil and wasn’t breathing much, so they intubated her. The CAT scan they sent with her sucked, so I repeated it; but I’m not terribly impressed. Have fun.”
I admitted her to the intensive care unit, played with the settings on her ventilator until I got the numbers perturbed in the special way they’re supposed to be for someone who has taken a big neuro hit, and talked with her family.
By seven or so in the morning I had more information, but only because we’d persuaded the interventional radiologists that they really needed to come in from home in the middle of the night to play with us. The radio-active ones snaked a catheter into a big artery in her groin, and threaded a skinny little hose up to her aorta and through her heart, clear up to the arteries supplying the brain. They then proceeded to shoot radio-opaque dye into those arteries while watching the whole thing on a live-action x-ray machine.
I got to watch, in glorious hi-res black and white as her brain’s arterial tree lit up all at once. Neat-o stuff, except for the fact that the tree was missing a couple of goddammed big branches ’cause they were blocked off by something.
“She’s critically ill,” I told the family. There were eight of them gathered in the little conference room off the edge of the unit. “I don’t know if she’ll be able to survive this. I’m very, very sorry.”
I looked at them expectantly, awaiting some confirmation that they understood what I was trying to tell them.
Her husband piped up, “But is she waking up yet?”
I thought Aw, hell, and tried again. “Mr. Jacobs - I don’t think she’s going to wake up from this one…ever.”
We confirmed it later that day, after doing a bunch of seriously high-tech imaging. This time we looked at brain itself, rather than the vessels which supply it with blood. She had somehow managed to stroke out her entire midbrain, along with a vast chunk of one of her temporal lobes.
The nursing staff was incredible. They spent hours talking with various family members every day, explaining what we were doing, and what it meant.
I’m still not sure that her family ever really understood though, even when we said it as plainly as possible. “I think she’s going to die from this. I don’t think that there is any chance that she will ever wake up, even a little bit. I wish I could give you better news, but I can’t. I’m very sorry.”
11 May
It took a while, but she died.
The whole goddamned thing was sordid and depressing as hell. First and foremost was the fact that this young, healthy mother of four had spontaneously stroked out her midbrain for no good reason. On the suck-scale, that’s up there with the high-vacuum that they pump down for particle accelerator experiments.
Then there was the nursing thing. No, I’m not referring to her care. I followed her through three different nursing settings, two of them ICU’s. The nurses were excellent the whole way through. And for those of you who are thinking, damn, but he’s a facetious bastard, you’re right, I am. Not this time though. They were incredibly goddamned good. Period. No, the nursing thing went along the lines of this:
Picture some young, vibrant incredibly dedicated nurse sitting down next to marcus while he slouches in a chair, scribing droll prophesies of doom in the chart. She says, “Wow. I feel so awful for her husband. He’s there at her bedside so much, on the edge of tears all the time.”
“Yeah. Um. . . ”
Indignity. Outrage at my lack of feeling.
“ . . . You don’t really know the whole story.”
Guarded and wary expression; mistrust of anyone who could be so gentle at the bedside yet such a coldhearted bastard when out of the family’s earshot.
“It’s not really fair, you know. I’ll tell you that up front. I’ve had more time with the rest of the family than you have.”
Confusion.
“Her younger sister’s first question for me was whether there was a possibility that this could be the result of domestic violence. The answer, by the way, is ‘no.’”
More confusion.
“The standing threat was that if she ever were to leave him, he’d kill her. She was routinely shaken, and periodically beaten. Even the kids would comment about it to their grandparents. The vascular injury pattern is wrong though, according to the neuro folks, for that to have been responsible for what happened to her. It’s too diffuse, just wrong. Her younger sister told me that she thought that this was her way of finally finding release from him.”
Look over at deflating nurse, continue onwards. “And now he has dollar signs in his eyes. Asking, day after day, if we think the minor car crash she was in at Thanksgiving could have had anything to do with it. Once again, the answer is ‘no,’ same reason.”
Intern heaves a deep sigh, then manifests grin of pure evil. “He’ll be in for one hell of an ugly surprise when his personal injury lawyers read the chart though. I documented the family’s concerns in my admit note, the very night she came in, before we had any of the studies back, before we knew anything. Heh. No case.”
Vibrant nurse’s face goes through contortions, ends in grim set.
Intern speaks up again. “But remember that he’s your patient too, however flawed, okay? Take care of him too.”
She was two years younger than me.
“So what about the horsewhip -” you’re wondering. Yeah, alright - fair question.
I hadn’t really gotten the whip out at that point. Our interventions were all appropriate and called for - no flogging. Suad, one of my counterparts, had already had far more practice with the leather than I, but those are her stories, not mine.
Nah. It wasn’t until a couple of call-nights later that I really got to break the sucker in.
13 April
I was sitting there in the unit, looking through catalogs. You gotta know where to look, but they’re around, along with copies of The Weekly World News from a couple of weeks back, Cosmo, and Elle. If you really need to know, I was looking at Volume One of the Victoria’s Secret Spring 1997 edition. I was, er – reading it for the articles. Yeah.
I’d just made a pot of viciously strong coffee, much to the surprise of the nursing staff. Not that they were terribly worried that it was strong, but rather, they have strong empirical reason to believe that physicians suffer from some bizarre congenital defect which renders them incapable of making coffee. We seem to have no trouble drinking it, but as a general rule, we tend to look at an empty carafe in utter confusion.
The typical picture is that of a doc who reaches for the thing, and only gets half a cup.
Whichever unfortunate soul it is might shake the container halfheartedly and scratch their head, bewildered. “It’s empty,” we think to ourselves. “Gosh. I wonder how that happened.” Then we walk away, cleverly putting the empty carafe back on the hot burner. Sometime later, we jump in startled amazement when the damned thing shatters from dry heat.
We never do stop to wonder how it is that the carafe ever becomes full.
I, however, had a Life Before Medical School, and was consequently familiar with the principle that if you’re the poor bastard who happens to finish the coffee without brewing another pot, the rest of the office will get together and desecrate your cube.
Still the nurses looked at me with vague, apprehensive mistrust as I manipulated the sacred coffee-making apparatus. I showed them, though, by making coffee which was strong enough to walk without assistance. Indeed, I had to belabor it with a stick before I poured it into my cup: it had been reaching around in search of something hard enough to cut the glass which confined it.
Anyhow, there I was, feeling self-satisfied over my incredible skill at creating black caffeine death whilst perusing the interesting, er - captions in the aforementioned Victoria’s Secret catalog. The charge-nurse, who’d been incredibly nice to me on my last call sauntered up behind me, scaring me so badly I that nearly spilled my very strong, very hot coffee all over my crotch.
She’d actually written admitting orders for me as I worked the third patient I’d gotten in about forty minutes. “Lessee - you want her to have this med, right?”
“Yeah.”
“And what about the epi?”
“Max it out, may titrate down but keep systolic better than a hundred.”
“And the antibiotic?”
“Ummm - she got a dose at the referring E/R around 20.30. Hit her again now and make it every six hours after that.”
When I looked at the chart a couple of hours later, there were my admitting orders, already written and carried out, just waiting for my counter-signature. I couldn’t believe it. I mean, the nurses don’t have to do things like that. The Gods of Karma must have smiled on me that night, because the nurses saved me. Then again, they always do.
So she startled the piss outta me. “What?” I complained, folding the lovely young ladies on page 16 down onto the table.
“We’ve got one coming in from the North Hills,” she said.
“So hit me. What is it?”
“Metastatic CA.”
That’s the way we say it, you know. See-ay. The Big-C. We almost never say `cancer.’
“Oh, that’s fucking lovely. Why’s she coming here?”
“We’re not really sure. She’s sick. They think she might be septic.”
“How about that. Do tell.”
She looked off to the side and kinda cleared her throat as if embarrassed. “She’s in MAST trousers.”
“What?” I shrieked, “Why?”
“Apparently they can’t keep her pressure up any other way.”
“Aw, goddammit. What the hell do they think that I’m going to be able to do for her? What’s her primary, anyhow?’
“Cervical.”
“Is it bad? Far advanced?”
“Yes. They told me in report that she has an advance directive, but her husband wants it disregarded. He wants everything done for her.”
“Hell. When’s she getting here?”
“Twenty minutes.”
The MAST device is this bizarre contraption which envelops each of your legs and your abdomen. It’s sorta like those nifty air-splints you sometimes seen in rescue films. Essentially, it gets wrapped around you and then inflated with air. The theory is that if you squoosh most of the blood out of the legs and lower-half of the body that there will be all the more to perfuse the chunk that we’re so uptight about, namely the brain. The acronym actually stands for something - military anti-shock trousers, I think.
The fact that someone was about to put a person into an ambulance with these suckers on implied bad things. Their usual setting for use is in scene runs, where rescue teams need to do something to try to keep the patient alive while they’re transported. Their use here meant that someone was desperate or incompetent.
A short while later, she arrived. They had the trousers inflated, and the patient canted back so her head was lower than her feet in an effort to keep her blood-pressure up.
Under the direction of the Attending, I started running huge quantities of fluid into her, and got another pressor drip running. We got back the first blood-gas result, which revealed that she was dangerously acidemic.
Your body is generally pretty good at keeping the pH of the blood right where it wants to be, at a comfortable 7.4. Insult the system badly enough, however, and that pH starts to drop.
I gave her a lot of bicarb in an effort to correct her pH, and was rewarded with a slight improvement in her numbers, and after a little while was able to deflate the MAST device slowly and get it off of her.
Went about the usual routine of obtaining good central venous access, choosing to access her central circulation by way of her femoral vein. Bollixed my attempt to get a catheter into one of her arteries so we could transduce it directly and find out what her blood pressure really was, and had to be rescued by the second-year resident who was backing me up.
After about two hours, I finally had a moment to stand back and really look at her. She was young, only forty-eight, but looked a lot older. Metastatic cancer takes a lot out of a person. She was intubated and unconscious, as she had been the entire time. I had a line for fluids and drugs in her right groin, and the arterial transducer in her left. Her body was making absolutely no effort to breathe over what I was giving her with the ventilator.
“Oh, Mrs. Horst, what are we doing to you?” I wondered aloud, quietly. “Do we really have to do this?” I asked one of the nurses. “Am I helping her even a little bit?”
She had been out talking with Mr. Horst and a couple of their kids. “You’re treating the family now. He doesn’t understand.” An alarm dinged and we looked at the monitor simultaneously.
“Shit,” I said. Her blood pressure and heart rate were plummeting. “Okay. Let’s get some atropine and three amps of bicarb into her now, and I’ll need pacer-pads.” The pads were in my hands before I even finished the sentence - critical care nurses are fast.
I got the anterior pacer patch placed, and then helped to roll her on her side a bit so one of the nurses could get the other one onto her back. While we connected leads I announced that she could have a second amp of atropine. Diddled around with the current a bit, and soon enough had capture. Yes, what we were doing was sending amps and volts and things through her thorax to make her heart beat at what I considered to be an acceptable rate. It’s like the pacemakers that people get implanted into their chests, only more crass. After several minutes, her heart decided to do things on its own, and we were able to turn off the pacer.
“I can’t believe we just did that,” I announced. “This is not good. I need to talk to the family.” Up until that point, I hadn’t had a chance - I was too busy trying to keep Mrs. Horst from crumping on us right then and there. I reviewed the records which had come with her from the outside hospital. Her most recent films, three months old, showed that she had cancer everywhere. It was choking her kidneys, invading her spine, and replacing her liver. Her aorta was completely surrounded.
I couldn’t believe that she had survived this long. There was absolutely no possibility for regression, remission, or pause.
“As you know, she’s very, very sick. We think that she has an infection in her blood, so we’re using three of the strongest antibiotics available to try to treat her.
“Here’s the thing: even if she didn’t have her underlying cancer, I’d be telling you that her condition is extremely critical. I can try to treat her infection, but unfortunately, there’s nothing that I or anyone else can do for the cancer which made her so sick to begin with.
“I think you need to know that her heart just tried to stop. I used a temporary pacemaker to keep it going, along with some very potent drugs, but I think that all I’ve done was delay her death.
“I’m sorry to have to put it to you this way, but we need to decide what we’re going to do if that happens again. I think . . . ” I looked at them all, and took a deep breath. “I think that if it happens again, we should let her go.”
Mr. Horst looked up at me, then at his kids. “Okay. Maybe -- ” He sighed. “I guess so. But keep doing everything else.”
I kept at it for another five hours. She was on three pressor drips, each of them running at the maximum dose. I was giving her huge amounts of fluid. In spite of this, her blood pressure hovered around eighty-five. Her fingers were dead white, circulation cut off by the action of the pressors on the vessels which supply them with blood. She would loose the fingers. I had no notion as to the condition of her central nervous system, but it couldn’t be good.
The whole exercise had been horribly futile from the very beginning. I went to talk with her family again. Fortunately, the nurse had continued to lay groundwork, explaining our interventions, Mrs. Horst’s (poor) responses to them, and the implications of those responses. I knew what I had to do, but I had no earthly clue how to go about it.
Speak plain english, I thought to myself as I left the unit to head to the little family room where they waited. Say it clearly. Remember who your patient really is, and do your best for her.
“Her condition is getting worse. We’re having a very difficult time keeping her blood pressure up. There’s another drug I could add to the three that I already have going, but --” I looked down at my hands. “It won’t help.”
“It’s my understanding that Mrs. Horst has a living will.” Her husband nodded, not meeting my eyes. “ . . . that she didn’t want to be put on life-support when the end was near.” Mr. Horst looked at me then. “What we’ve been doing for the last eight hours is life-support of the most intensive nature. Even so, we’re losing ground.” I stopped then, out of words. Plain english, I reminded myself. “Is this what she would have wanted?”
Her daughter looked at me, then at her father. “Daddy -- ?” she asked.
“No,” he said. “I guess . . . No. No, it’s not.” He paused. “Should we – stop?”
I nodded. “Yeah. I think we should. Why don’t you give us a few minutes to get everything situated and make sure she’s completely comfortable. I’ll pull some chairs into her room so you can sit with her, if you like. I’ll turn off the medicines that are supporting her blood pressure, and then let you back, okay? Do you have any questions - any at all?”
An hour and forty minutes later I watched the remote monitor screen show the last traces of electrical activity in her heart cease altogether. I had turned off the monitor in the room, because I thought it would be better for her family to be with her rather than absorbed in macabre glowing numbers and waveforms on a screen high up on the wall to one side. Even if you don’t know how to interpret what you see up there, the gradual trend of everything to lower numbers and flatter curves has got to be pretty unambiguous.
I leaned back in my chair and took a deep breath. “I’m pronouncing her,” I told the nurse. “O3.46. I’ll go tell ’em.”
I leaned gently through the curtain. “She’s gone,” I said quietly. “I’m very sorry.” Mr. Horst looked up at me blankly. The son slowly levered himself out of his chair, shaking his head as if in a fog. The daughter came around from the other side of the bed.
“Come on, Dad,” the son said. “Let’s get you home, okay?”
Six hours later, on rounds with the team, I was babbling about horsewhips and the difference between a flog and a flail. “The flail,” I announced in a grey haze of caffeine and fatigue poisons, “is when we run around like idiots trying to figure out what to do. You know, when someone’s crashing in gouts of oily flame.” Graham, one of the chiefs, looked at me like I’d just blown a fuse. I dunno, maybe he actually heard it pop or something. “The flog, on the other hand, is different,” I announced gaily, warming to my subject. “That’s when we mercilessly horsewhip some poor fucker so they’ll stick it out another couple of hours or days. Swiiiish Crack!” I tried to make a horsewhip noise. “Yah there! Move along li’l doggie,” I drawled. “No dignity in death for you, no sir. Reckon ah’m gonna whip you to the very end. Let’s go! On your feet. Move ’em out!”
Graham was staring at me as one might regard a dog on a chain, wondering if it was about to leap for your throat or roll on it’s back and wag for you. “The flog and the flail. I like it,” he said cautiously. “You might have something there.”
“Do you think administration would get pissed if I bought a horsewhip and stuck it on a nail over the patient name-board, all coiled up and ready to go?” I asked. “I coulda used it last night.”
“I don’t think that would fly, man,”
“Damn. Those no-good sons of bitches.” I stared morosely at the board, thinking that a carefully oiled whip on a heavy nail or maybe even a kinda rusty railroad spike would look really neat. “They never let me do anything, you know. They just don’t think I’m as funny as I think I am. I know - they’re jealous.”
“You’re right,” he said, still looking at me strangely. “They’re jealous . . . you know dude, you are definitely a very sick unit.”
“Two weeks and you’re just now figuring that out? Gosh, your powers of observations do you credit, Graham.”
“I want to tell you a little rhyme, okay? You like poetry and all that artsy crap. I heard about you reciting Keats or someone on rounds the other day.”
“It was Hopkins, dickhead.”
“Birdie with the yellow bill,” he
said smiling sweetly, “Sitting
on my window sill.”
“I draw him near with crumbs of bread . . .”
“Yeah, so what?” I interrupted. He continued to smile, the very picture of innocence.
“And then I smash his fucking head.”
I just looked at him for a few seconds, while he beamed at me beatifically, then I started to giggle. I ended up in such dire straights, sipping for air, that I had to lean on his shoulder to keep from falling over. After a few seconds he shrugged me off.
“Touch me again, dude, and I’ll kill you.”
“Yeah, yeah - I know. Just make it a clean shot, okay?” I said, still struggling for air through the giggles.
11 May
I recall that much later that afternoon I was sitting in my folks’ kitchen, getting my mom to tell me about a tour she had led. It had focused on architectural flourishes on various facades in Downtown Pittsburgh; griffons, gargoyles and the like. “So, tell me about your day,” she said. “How was call?”
I grunted, reached for a cigarette, and told her Graham’s rhyme.