the end of ICU

I came into my ICU rotation feeling like critical care is the opposite of primary care and what I want to do, but open to enjoying the experience. I knew I’d enjoy parts of it and learning the medicine and challenging myself with things that scare me. But I was surprised by how much I loved it. Intensive really is the most appropriate word for it, and I feel really lucky to have had such a uniquely intense experience.

There are so many things that make the ICU very different from everything else in medicine.

First, I’m struck by how close you become to people who you often never get to know. If people get better, and are able to interact more, we quickly transfer them out of the unit to make room for sicker patients and reserve our energy and space for the acutely ill. But you get to know the idiosyncrasies of their bodies—how they respond to changes in their respirations, how different medications improve their blood pressure, how their delirium develops in response to their environments. As we poured long days and weeks into thinking about how to care for people’s bodies minute to minute, our team grew close to people whose voices we never heard.

Second, there is more death, obviously. I’ve never had so many breaking bad news conversations. I won’t forget what it’s like to explain the unlikely recovery of a thirty year old man to a room full of his family, or to call a woman in the middle of the night to tell her what she already suspects when someone calls you at one in the morning. It was deeply rewarding to learn more deeply how to speak to people about such extreme illness and to understand their responses, which can often be harsh, and almost always heartbreaking. This was the first time I’d been a part of terminal extubations, something I never gave thought to when entering medicine. And that’s thing about this career. People talk a lot about how we idealize this field, and it’s true that a lot of the day to day work is not what most people would imagine. But there is an incredible amount that is so much more powerful than I ever anticipated.

The medicine is extremely complex, and interesting. I find acute respiratory distress syndrome (ARDS), where your lungs are flooded with inflammation, really interesting-- in that an illness in one part of your body can then trigger such a dramatic and life-threatening response from your lungs, even when your initial illness had nothing to do with your lungs. In medical school I struggled most with understanding the physiology of the lungs; it never came very intuitively and I had a lot of trouble visualizing the organ. Now I have a much better sense of how they work, how amazing and resilient and sensitive they are, and I really value having better understanding of what it is that enables us to breathe.

Another thing I loved about the medicine was trying to piece together stories of each person’s sickness. Very often, our patients came to us unresponsive and unable to tell us anything about how they’d been feeling up to that point, and very often we’d unearth things about them that they themselves didn’t know. A woman with unexplained low blood pressure, in whom we discovered widely metastatic cancer, we guessed from images of her heart, her need for oxygen, and her newly diagnosed cancer that she was suffering from large clots in her lung even though we weren’t able to see them. In another young man whose heart stopped inexplicably, we used his medical history, laboratory findings, and an exam of his stomach to learn that he likely used pain medications to treat the pain of an inflamed pancreas, causing his breathing to slow, aspirate contents into his lungs, causing less oxygen to reach his heart and a cardiac arrest. With the sudden collapse of a very young woman, I learned from toxicology that this was a common presentation of GHB overdose—a drug used for highs and also for date rape because it causes unresponsiveness without a change in your heart rate or blood pressure. I learned so much medicine as a result of trying to make diagnoses, as well as trying to manage the diseases: how severe an illness pancreatitis can be and how important early aggressive hydration is, how to use measurements of blood pressure to determine whether giving a person fluid will help them, how to evaluate whether an intubated patient has developed a pneumonia when they can’t tell you anything about their symptoms, how to predict whether an intubated person will be able to breathe on their own without the tube. I also loved how quickly we could gather information and learn in the ICU, because tests happen quickly, blood can be drawn at any time, vitals are monitored constantly.

One very concrete thing in the ICU that was different from other rotations is the fear it instilled in me, mainly fear of 1) procedures, and 2) emergency situations like codes. I’m happy to say that I’m not that scared of either of these anymore, which I really didn’t think would be the case. I’m not the best at either of these, but I feel at the very least competent. I did a lot of lumbar punctures, arterial lines, and central lines. I’m confident that I can place a central line (a catheter into the internal jugular vein, or femoral vein as I had the opportunity to do once), by myself, and because of that I’m not as worried about being on call overnight alone anymore. And as someone who isn’t very procedure oriented, I’m surprised by how much I enjoy having this skill. Likewise, I was surprised by how much I appreciated codes—situations where a patient has lost a pulse, or having unstable blood pressure/heart rate. I was part of one, and had to be the leader for another. The one that I mostly observed was a classic case (ventricular fibrillation, a deadly heart rhythm) with a defined algorithm, but complicated by its length and the difficulty in when to stop trying to resuscitate the patient. Amazingly, at the very moment when the decision was made to stop after another round of CPR and we stopped that round of CPR to check the patient’s pulse, it had returned. It amazes me on so many levels: 1) that after half an hour of being essentially dead, that a person could return to life; 2) we have the power to do that; 3) how tenuous and arbitrary the boundary is between living and dying, such that it comes down to an individual person’s evaluation of when to stop trying to resuscitate, and how if we’d given up (very reasonably) one minute earlier, things would be so different.

The other code, which I had to lead, was not as straightforward and I was so fazed by the suddenness of everything that it was hard to remember and think of everything I needed to. But I learned so much from just a few minutes of events, and now will likely never forget how to evaluate for causes of asystole (flatline, when your heart basically stops) and how to quickly manage it. I had a lot of help and played a small role in this, but nonetheless it feels good to be part of reviving a person. I still know that emergencies aren’t my style, but I also realized that often we think we dislike something that is inherently enjoyable because we’re scared of it, or aren’t naturally good at it. In this case, I think most people could enjoy the quick critical thinking and immediate cause-and-effect nature of codes.

And so that’s how a month whose beginning I dreaded became an experience whose end is bittersweet.

in the middle of ICU

It’s hard to know where to begin writing about experiences in the ICU, and it’s easy to not try because it’s so hard. It’s difficult to describe what it feels like, and so I thought I could just describe concretely what happens, but that’s also difficult. But I think it’s important to try. In the mornings we go from room to room, learning the details and mechanics of each person’s breathing and blood flow through their vessels. There is a ton of science and linking of every organ system. I like that breadth a lot, and I also like the detail more than I expected.

Then we enter the rooms and a lot of the time there is still a lot of science, but many times it becomes human. Yesterday, we spoke to a family who decided to withdraw care from their mother, a woman that before her illness had been a feisty, vibrant woman who traveled to Vegas and smiled gently at us when she was awake. When we first met her we thought she might be improving, even leave the ICU. Then things progressively worsened to the point that we weren’t sure she would recover, and if she did, surely not to her baseline. As the decision was made to make her comfortable and remove her breathing tube, I thought, I can’t remember the last time an entire team of interns, residents, fellow and attending cried with a patient.

Then we saw another patient’s family in tears. This patient had also been healthy and active, and had collapsed suddenly the day before, and found to have had a large heart attack. The family told us that their husband, their father, had woken up, could show them two fingers when asked to. And we cried a little again, this time not for letting go but for remaining connected.

Then we visited a young patient whose medical course has been up and down since he’s been in the ICU. He will seem like he’s getting better, staying stable, and then he’ll crash. His partner, a naturally sweet woman who is always so grateful and kind, asks if he is likely to get better or worse, and none of us know. In him I can feel the entire spectrum of upswing s and downturns that embodies the ICU.

starting ICU

On the day before starting my ICU rotation, which inspires a unique kind of fear, we received information about the current patients in the ICU. It's pretty amazing how sick these patients are. Even though I have no interest in doing critical care in the future, it's definitely a good experience to see how much people can go through and survive. Reading about one person with a urine that contained heroin, cocaine, benzos, and opiates, I think about all the toxins we accumulate in our lives, concrete and otherwise. It's both our absorption of these, and our resilience against them, that gives so much value in caring for critical illness.

Now on day three, I think back on what's happened:

Day one: Death A patient who collapsed in the morning was brought to the emergency room. She had one event after another in rapid succession throughout the day. In one day, her years of functioning came to an end. Piecing together what happened to her medically, imagining how she existed before this, communicating with her family--being in the ICU where things can evolve quickly means having entire narratives ravel and unravel over one day.

Day two: Achievement I don't have much experience with ICU-related procedures, in part because I haven't had much ICU experience and also because I'm known as what they call a white cloud, where I find myself just not having as many patients and many emergency situations as a lot of other residents, which can be a good thing but also means that I'm less prepared coming into this than everyone else. So our ICU fellow was very nice and approached me to do a procedure to get practice. Which I promptly failed twice. But when later that night I was by myself and had to do it again, I was able to do it on my own. I was proud of myself for braving it alone instead of immediately accepting that I wouldn't be able to.

Day three: Failure I made some poor decisions about a sick patient overnight that became much more evident in the morning to everyone else. There were several points where I could have done things differently, and I know that other people in my position would have done things differently. But I'm trying hard not to compare myself to others, and to remember that there are different strengths with different visibilities.

transgender

Our program started a curriculum on LGBTQ and transgender health these past couple of months. We've received lectures on the whole spectrum of definitions of gender identity, and yesterday we had an in-depth lecture on primary care for transgender patients. I was struck by how this obscure area of health (we don't receive much teaching or exposure to this in medical school and this is the first year it's been taught in our residency program) embodies so much of what I love in medicine. In particular, there is a huge amount of individual variability, both in physical and psychological health, such that it really emphasizes how important it is to get to know your patient. There is also a lot of personal evaluation and patient-centered decision-making because there is not as much research based evidence to guide clinical care. For example, a transgender woman may not need a mammogram as she doesn't have native breast tissue, but what about the fact that she may be receiving female hormones? Or what if she would like to receive the same routine care as another woman? How do you balance this with the high false-positive rates of mammograms for even cis women (women who are born as females)? How do you approach doing pap smears on a transgender man who may physiologically need one for cervical cancer screening, but who no longer identifies with that component of himself?

This is an area of healthcare I honestly haven't given much thought but now having been exposed to its complexities, I find it really interesting. I feel lucky to be in a program that considers the value of care for different populations of people. I also thought it was fascinating to learn about hormone therapy and reconstructive therapy, and how surgeries like hysterectomies (removing the uterus) and vaginoplasties (constructing the vaginal structures) can affect physical and psychological well-being. I think this area of medicine has so much depth, and shows how lucky we are to have opportunities to draw upon multiple components of who we are. This is something that requires skill in human relationships and learning about things that may be foreign to us, continued diligence in observing biological mechanisms in the face of a lot of uncertainty about what we know, and adapting as we go along. We have been having conversations lately about different kinds of intelligence, and I think things like this rely on the most admirable (to me) intelligence of synthesizing our knowledge of human experience and being open to what we haven't experienced and may never will.

January

This month's update on my resolutions:

1. Blogging: Despite having intermittently blogged since college, I haven’t really figured out what makes it sustainable, or what exactly the focus of my blogging should be. But I’m not trying to have high aspirations at this point in my life (eg, finishing residency), and right now I just want to get back into writing when I feel like something is worth recording. Whether those somethings are connected, is irrelevant to me right now. So in that respect, four entries in the past month is on mark with my goal to write one post weekly.

2. Recipes: This past month, I discovered polenta. I wasn’t really sure what to do with it at first. Reading about it, it seems that people use it often as a base for toppings. So I used it as a base for eggs (yolk in tact) and roasted sweet potatoes spiced with oregano and cayenne for breakfast, which was delicious. Especially if you cook the polenta in a little bit of butter. Another time, because I’d read that it goes well with pasta sauce, I used it as a base for the tofu tomato soy sauce scramble I make often when I need something easy and savory. My second recipe was an effort to vary how I eat tofu, and found a baked peanut tofu recipe that was perfect and that M liked a lot too: http://minimalistbaker.com/crispy-peanut-tofu-cauliflower-rice-stir-fry. I scaled back on all the times in the recipe so that it only took half an hour to make and it was still delicious.

3. Albums: This was my favorite resolution this month. I’ve been away from music for so long. During residency when I’ve tried to venture back, my finds have been lackluster. I’d forgotten how much continual listening it takes to discover the narratives that really move you. This month I had the luxury of listening enough to find three albums that I absolutely loved; in the future I suspect that I might settle for just listening to three new albums in general, but at present I feel lucky. After listening to Alt J, both An Awesome Wave and This is All Yours, I felt again the desire to listen to music not as a backdrop but as a sole experience. I also loved Angel Olsen’s Burn Your Fire For No Witness. Her vocals are both extremely bare and complex, a dichotomy that I think we’re drawn to by nature, maybe because there is constant conflict between our simple, fierce feelings and all the layers on top that we’ve cultivated and absorbed.

4. News: M predicted this would be hard for me, and it was at first. I haven’t been u p to date with current events since the beginning of medical school, so I really do fairly or unfairly attribute my ignorance to medicine. Which, like many things in the process of medical training, is ironic. Anyway, this resolution was a little difficult at first, but after getting into the flow of it, I’m finding it hard to not spend all my free time reading. I’ve gotten a subscription to the Economist, which I like for its big picture focus and ability to give equal weight to a lot of different topics, including ones that other sources wouldn’t find headline-worthy.

5. Exercise: I did pretty well with this one except for the swimming, which is hard logistically because I have to get to my brother’s gym to do this. Overall I am happy with January’s fitness, especially being able to go to yoga most weekdays. This does mean that my body will feel at a deficit when I start in the ICU next month, but I’ve started doing more yoga at home so this will still be feasible when my hours get awful. Climbing-wise, I would really like to pick up momentum at some point because I feel a strong plateau that likely won’t move without a lot more practice. I also feel a strong fatigue and burnout with running, which I think has to do with too little variation in my routine so I’d like to run more outside and on different routes. But these are all general thoughts, and my concrete goal to keep me grounded is that I just want to do each activity (yoga, run, climb, bike, and swim) once a week, so that I’m doing something active almost every day and that there’s enough variety to keep myself feeling buoyant.

three day weekend

Saturday: Took the winding, foggy drive to Big Basin in the Santa Cruz Mountains. In parts the fog hugged the coast and drifted onto the ocean; in others, it blanketed our entire view. Hiked eight miles with towering redwoods shaping the sky ceiling, and ate lunch by a waterfall. We noticed the varying positions and states of the trees--how some had fallen, some had blackened from fire, some were hollowed out ("what do you think lives in there?" M asked). Over the years, we have come across the same beauties--the fog over the hills on Skyline Drive and coasting onto 280, the redwood forests, the integration of dirt, water and foliage. So a lot of feels familiar, tickling the pores of my skin as we pass through it. At the same time, the power of escaping the compactness of the city always feels fresh. And there is always the sense that there are new things; we've been to Muir Woods and Redwood National and State Parks, but not to Big Basin, and there are so many more trails to explore.

Sunday: Drove down the coast to Santa Cruz, where we have been many times before. Even though Santa Cruz isn't far, the roads leading there are rough to navigate, and maybe because of that path, despite being familiar with the city, I don't feel quite connected to it. And maybe because of that I'm always newly struck by how beautiful the ocean is there. Having watched waves so often with M, I'm better able to recognize differences between waves, and have new appreciation for the uniqueness of the breaks there, how long and high the waves ride. The water there is always glassy, and the sunsets always bring the kind of light that makes photographers swoon. We saw arches of stone form over the beach, wondered how they are made, and laughed at the dozens of dogs running free on the sand.

Monday: Woke up to one of our cars not starting, decided to leave dealing with it for later and drove to Sonoma for wine-tasting. It was a little harder to decide on which wineries to visit, as the wineries are a little more spread out than in Napa. We went to Benziger first based on an internet recommendation, and it was the perfect choice. We really liked each wine in the tasting, with four really amazing reds in a row, and the grounds were gorgeous. Wine country really brings out natural feelings of leisure, and the comfortably sunny weather complemented this internal warmth. At Benzinger we were given a two-for-one tasting coupon to another place, which turned out to be a cozy microwinery where a big golden retriever nuzzled up to the customers. We We met a woman who had grown up in Sonoma and who recommended VJB Vineyards up the street. By this time I was a little too buzzed to have much more (we'd had seven wines at the previous place), but I loved this Italian-inspired vineyard. It was a little plaza of a winery, deli and outdoor pizzeria, outlining an open courtyard. We had Italian champagne (Prosecco) which was delicious, and more delicious reds. We also had a flatbread pizza with the freshest ingredients, including housemade mozzarella, basil, avocado and tomato. Dessert was salted caramel gelato. Driving home didn't do much to work off the food, but was a perfect way to end the indulgent day, with views of rolling hills, a marsh whose water kept changing degrees of reflection as dusk settled, and my favorite: long fields of yellow wildflowers that stayed bright in the night, both from their natural vibrant color and from the waning sun that cast its light from far off in one corner across the entire span of the fields.

When weeks begin and life becomes more confined to rooms and buildings, it's nice to remember that these weekends are really where the full spectrum of life starts.

resolutions by number

1. Write at least ONE blog post a week, which can include an update on these resolutions (this is one of those every-year resolutions but I believe in repeated attempts, if only for intention)

2. Make TWO new meals a month (including inpatient months!)

3. Listen to THREE new albums a month (music, which used to be half my life, has evaporated and I'd like to make it solid again)

4. Read FOUR news articles daily from different sources (this is actually really hard for me as I prefer fiction to real life)

5. Do each of the FIVE following kinds of exercise each week: yoga, climb, run, swim, and bike (my most important one).