Shrodinger's ICU

Every second was an eternity, but ten minutes passed in the blink of an eye. As Ella waited for the phone to ring, trying to decide what she would say when the moment came, she felt acutely how terrible it was to be caught, trapped, between the world of knowing and not knowing. The impending collision of these two worlds was imminent- the next ringing of the phone would be the warning shot- and not knowing exactly when that would be was its own type of torment. 

There was so much work to do: an admission note, an event note, a discharge note, check the midnight labs for the patient in 475, check to see if the patient in 360 needed to have his furosemide re-dosed. She was so tired. What she should be doing, needed to be doing, was focusing on the tasks at hand, but instead her mind kept wandering between half-formed explanations and wordless apprehension. 

She had practiced for this. In standardized encounters in medical school and patient simulations during residency orientation, Ella had learned all sorts of tips and tricks for this situation. Find a quiet place with no distractions. Use simple language and be direct. Don’t be afraid of silence.  Those practice sessions had felt real and useful at the time, but now she realized how woefully inadequate they were. She realized how woefully inadequate she was.

The opening lines of her admission note swam and blurred in front of her. The patient is a 68 year old male with metastatic gastric cancer, initially admitted with bright red blood in his stool. She rubbed her eyes to clear them, then repositioned her fingers over the keyboard, pausing as she tried to gather the right words.

It had taken less than two hours from start to finish for the whole thing to happen. One minute she was in the call room not sleeping. Staring at the ceiling. Wired from the 8pm cup of coffee and also the terror of being on call for the first time overnight in the ICU. She had practically levitated at the sound of her pager going off, and her heart rate, already clipping along in the 90s, rose to the 110s as she read the page from Simi, the critical care fellow. Meet me on 5 south for a new consult.   

Am I supposed to run? she wondered. No, it’s not a code. Simi would have said if it was a code. Right?

She settled for a brisk walk to the elevator. As she walked, she concentrated on breathing, focused on putting one foot in front of the other on legs that suddenly felt like overcooked spaghetti. While waiting for the elevator, she ran through her inventory, hands lightly touching each object as she thought of it. Stethoscope? Around her neck. Code cards? In her back pocket. Phone and pager? Pen and paper? Shirt pocket, waistband, back pocket. She was ready.

The patient was pale and the front of his hospital gown was covered with blood. He looked terrified. 

“He developed large volume hematemesis a few minutes ago,” Simi told her as she entered the room. “I’m concerned for a gastric perf, but he’s too unstable to get a CT scan.” She eyed the patient. “We should call surgery for an eval, but with metastatic cancer…”. She shook her head.

“No surgery,” the patient said, his eyes wide. “I just want to say good bye to my wife.”

The fellow nodded. “We can transfer you to the intensive care unit for supportive care until your wife arrives.”

“Anything, anything, I’ll do anything,” the patient said frantically, as Simi described placing a central line IV in his neck, starting intravenous fluids and medications to support his dipping blood pressure. “Please, call my wife. I just want to see my wife.”  

They wheeled him down to the ICU with them, an emesis basin at the ready in case he started vomiting blood again. Once in the ICU, he seemed even more frightened. He refused the central line and refused pressers, instead insisting over and over that he wanted to see his wife.

While Simi continued to discuss the risks of refusing further therapy with the patient, Ella stepped out to call the patient’s wife. The woman answered after many rings, in a voice that was thick with sleep. 

“This is Dr. Christakis from the hospital,” she started.

“Oh my God,” the woman exclaimed before she could finish the sentence. “What has happened? Is Jean alright?”

“He’s very sick,” Ella responded carefully. “We think you should come to the hospital to see him. He started vomiting a large amount of blood and -“ she paused, the words feeling heavy in her mouth as she said aloud for the first time what she had been thinking ever since she saw the patient, “we are concerned that he might not live through the night.”

“Oh my God, oh my God.” There was silence, then the sound of a few ragged breaths being drawn in. “I have to call my son to pick me up. He lives an hour away. How much time do we have?”

Ella turned to look at the patient, who now vehemently shaking his head to whatever the fellow was suggesting. He looked paler than he had before, and the monitor above him blinked a red 124 next to heart rate. “I’m not sure, but I think you should try to get to the hospital as quickly as possible,” Ella replied.

“Oh God, oh my God,” the woman said again, her voice barely a whisper. “I’m a diabetic, I can’t drive at night, I have to call my son to drive me, I-I-I can’t drive at night. I have my own health problems.” She was sobbing now. 

“It’s ok, it’s ok, I understand,” Ella said soothingly. Internally she felt like crying, too. “We want you to be safe. I’ll tell your husband that you’re coming. You should call your son.” The sobs slowly grew quieter. “I’ll tell your husband that you are on your way.” 

She was hanging up the phone when Simi walked by. “He’s refusing everything,” she said. “I’ll be in my call room.”

Ella nodded, still thinking about the patient’s wife, her naked fear, her anguish, the sense of guilt simmering below her words. It would be at least 90 minutes before she and her son arrived, and the patient was fading quickly, but there was no alternative. Her heart ached for the family, each of them separated but working towards a common goal, racing against time and distance to be with their loved one. She hoped that they would make it in time. At least she could tell the patient that his family was coming to see him as quickly as they could drive.

“Uh, Doc?” the nurse called. 

Ella turned. Blood was pouring out of the patient’s mouth. 

“Shit! Shit! Call the fellow!” She shouted, hastily throwing on a pair of gloves and running into the room.

The monitor showed a heart rate climbing to the 140s as she scrambled to find a pulse on the patient’s wrist. It was there, strong and rapid at first, but growing fainter and more intermittent by the second. Finally, it petered out, replaced by single, random beats many seconds apart.

She stared at the monitor with its beeping red numbers, then back at the patient, as pale as alabaster, lying with eyes rolled back. “What should we do? What can we do?” She asked the fellow wildly. 

Simi shook her head. “He’s DNR,” she said. “We don’t anything.” She eyed the body balefully. “We can tell his wife when she arrives. I’m going back to bed.” She left.

Mutely, Ella started at the man, at his still body, at the blood that continued to dribble out of his mouth even as the last erratic heart beats underneath her fingers faded to nothing. She had never seen so much blood. And the smell. It had an almost fetid odor that threatened to overwhelm her.

The room was silent, the heart rate tracker on the monitor now resting at zero. She stepped back. Peeled off her bloody gloves. Stared in shellshocked silence at the nurse. 

“This was a bad one,” he said, head indicating the mess between them. “I’ll call EVS to clean the floor, and we’ll try to get him cleaned up before his family arrives. The death paperwork is behind the front desk.” He started to remove the patient’s soiled hospital gown as she tossed her gloves in the trash and backed out of the room. 

And now the waiting. One half of her psyche rebelled and screamed at the unfairness of life, at the seeming callousness of the fellow and the nurse. She had just witnessed a horrific death scene, stood helpless as a man bled to death in front of her. Nothing had prepared her for that, or for the guilt and rage she felt as she realized that four years of medical training left her with no tools to alleviate this patient's suffering. The other half of her psyche was running in terrified circles around the thought of her new responsibility. She felt as if she was stuck in a strange limbo, in a universe parallel to that of the man’s family. In their reality, he was alive and waiting for them, as they raced toward the hospital to say their last goodbyes. In hers, he was dead. It was her job to merge the two realities, and she did not know how she was going to do it.

The phone rang. “That guy’s wife is here,” the unit secretary called across the desk to her. “What do you want me to tell her?”

“Tell her to wait outside. I’ll bring her to one of the family rooms to talk,” Ella said. She drew a deep breath, squared her shoulders, and walked through the ICU doors and into the new reality.