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Hell on Earth: The Medical Intensive Care Unit

December 12th, 2009 Leave a comment Go to comments

I have recently finished up my 6th week in the MICU and I am safely say that it has been among the hardest things I have ever done.  The MICU is a simply soul-sucking place where become come to die. This is  due to the fact that the clientele of a medical intensive care unit are people who can no longer breath on their own or their heart can no longer pump without aggressive intervention.  In the MICU death is omnipresent and simply part of your daily life.

No physician welcomes death; we spent a disproportionate amount of our time trying to stave of death another day, hour,  even minutes.  However, it is recognized that death is part of the profession and often a blessing for the patient and family.   However in the MICU, death is a part of your life,… just like brushing your teeth.   When you go in the morning, the first thing that you see is families crying in a waiting room that is tastelessly furnished with glass walls.  If you are lucky, you do not recognize the people and can assume your patients made it through the night.  You then check the board and see who has died, and follow up by talking with on of the few nurses you trust to find out who your sickest patient is.  The majority of the day is then devoted to trying your best to prolong the life of a patient.

However, when all of your patients are this sick it is usually just a matter of time before they pass.  Often the hardest part if telling families that their loved one has already passed, but we are mechanically keeping them “alive” with ventilators, constant dialysis, and pressors.  They see us doing so much that they cannot understand it is futile and the horrifying reality is that anything that can feel has to be agony.  It is gut wrenching to see a rare moment of lucidly in a patient’s face and the expression of pure pain, sorrow, and longing to die.  And yet I am there only to keep them a live hours longer.  And it is only 7 am and knowing if I am lucky I will leave in only 12 hours.  The worst is when your on call and knowing it will be a minimum of 30 hours before leaving these harrowing wards.

On a long call after everyone else has left, three things inevitably happen. 1) A patient codes/seizes/becomes hypotensive or maybe all three 2) The ED calls you with a patient they have intubated (and therefore cannot talk) for a reason you cannot quiet discern, no one has a history/contact info 3) Some other service calls you wanting to transfer a patient that they have has for 4 months and no longer want to talk care of.  Usually all the above happen at once.  You spend your night talking with families on patients you barely know, making life and decisions on these patients, nursing calling you every 15-20 minutes with a critical lab, admitting new patients, training patients on other services, and after 24 hours you cannot think, physically drained, emotionally drained/liable, the opportunity to sleep has never crossed your mind, and yet you still have 6-10 hours before hoping to go home.

Now rinse and repeat for weeks on end.  Night/day cycles completely erratic, never rested, no time to visit family/go out.  And this is only the pressures of work, what about a home life, the economy, etc?  By the end of the third week you notice that no one has shaved in a week.  What quality of physician do you think is taking care of you?  I have no qualms admitting that I failed to live up to my own expectations.

Excluding the patients that you know will die the moment you lay eyes on them there are three other types
– The first are patients that should have never come to the ICU.  Patients who had to come due to some silly hospital rule about administering a medication, a patient forced into the unit by an important physician wanting good care for a special patient, or a similar circumstance.
– The persistent patient: The person who the ED did that “one extra round of CPR” and brought back someone how has been without a pulse for >30 minutes.  I’m not saying they shouldn’t try, but there is a 90% mortality rate for CPR >10 minutes and horrible long-term morbidity for those very few who leave.  More often then not these patients only have cranial reflex, meaning they can gag/blink, but nothing else.  These patients can live on the ventalotor for years (like Terri Schiavo).  An MRI can confirm that their brain matter was atrophied away and they are not locked-in.  These patients often have been in the same room for 6 months or even a year.  Most of these patients do not have health insurance, so they stay in the MICU and we watch them gradually die over the years.  They persistently occupy a room that should be used to save another,  . . .
-The final type of patients are the few rays of hope.  These are people how by all accounts should have died, but recover.  There are  a few every month.  Diffuse alveolar hemorrhage, drug ODs, hypothermia.  Sadly, these saving graces, often mean more to the physicians than the families and the patients themselves.  These very few patients do not make life any easier, but they make the struggle worthwhile.

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