If you are among the thousands of doctors who make their living as intensive care physicians, there is no normal work day with predefined hours or routine. Interruptions are the norm. Your day starts early in the morning, meeting with the ICU nursing staff and respiratory therapists long before morning rounds. Difficult clinical issues are reviewed as you and your team apply critical thinking on the challenging problems of the day.
Patient rounds begin, and you collectively go over each individual’s active problem list — respiratory failure, septic shock, acute renal failure, delirium, metabolic disarray, adverse medication reactions, labs, x-rays, EKGs, physical exams, sedation protocol, ventilator weaning, nutrition, central lines, Foley catheters, family questions, resuscitation status, and on and on. The concerns are seemingly endless. In each case, for every ICU patient, there is both a professional side and a personal side, all differing as you change and adjust them to meet individual needs.
Now the phone rings and it’s the emergency department calling you for an immediate consultation. The patient is a 60-year-old white male, brought to the ED by his family. His symptoms include malaise, fever, nausea, and difficulty breathing. Ultimately, given the results of your subsequent workup, the decision is clinically easy: intubate. But this must first be discussed with the patient and his wife. They are opposed to placing a breathing tube in his lungs, yet you know that without this support, he will most likely not survive. Proper explanation is critical, and after a long conversation, the decision is made to place the patient on a ventilator. The wife is crying uncontrollably. She is taken aside and spoken to softly, as all of her husband’s details are again reviewed. She understands now, but still the potential fear of death colors her view. You hope that this can shift to hope for a better life, but time will tell.
Soon after, your cell phone rings. It’s the ICU calling to relay a husband’s concerns about the condition of his 42-year-old wife. She has widely metastatic breast cancer and septic shock. For a week, she has been on mechanical ventilation, requiring full hemodynamic support. Her entire body is swollen from aggressive fluid resuscitation. By her bed is a lovely photograph, which no longer resembles the woman lying before you. The husband’s tears of love and sorrow pour from his face. He knows his wife’s decision for her end of life care, but he is stalled by her family’s desire not to let her go. His own personal anguish, his love for his spouse, and his concerns for her immediate family members all make acting on her wishes all the more difficult. It’s a struggle you see daily here; and the best support you can offer is to gently demonstrate that end-of-life care is not the termination of care, but an appropriate change in the “goals of care” for an individual patient.
Around the corner, a 95-year-old white male with a history of progressive Alzheimer’s dementia has been staying in the ICU due to syncope and head trauma resulting in a small subarachnoid hemorrhage. Earlier today, he was sitting in bed, speaking about times gone by, but with no sense of the present. He was happy. He was smiling. Now, you have been called to his bedside because his rhythm strip has demonstrated no electrical tracing. His eyes are closed. His rambling conversations have ceased and he is no longer moving. You turn to the nurse and ask, “Resuscitation status?” An official DNR is verified. No further aggressive medical interventions are necessary. He is now able to go home forever.
An ICU physician’s work is never done. The need for critical thinking and compassionate patient care is the delicate balance that we must face everyday. We care for the sickest patients. We inform and support family members through very difficult times. Our successes are wonderful. Our failures are emotionally and physically wearing.
Research shows that, due in part to our aging population and the increase in life-sustaining medical innovation, the need for critical care continues to rise. This means that by 2020, the shortage gap between supply and demand (measured in hours) will reach 35%. It is important to highly value your critical care staff and resources, for they are a vanishing breed.
Harlan R. Weinberg is an intensive care physician. He blogs at The Doctor Blog and can be reached on Twitter @iknowmedicine.
