First Day in the ICU

As I write this I am sitting in an ICU family waiting room.  I have often sat in rooms like this, comforting families and explaining to them what is happening to their loved one or discussing treatment options. Today, it is my family I am sitting with, and my family member in neurosurgery.  The ten of us are sitting in a circle.  The comfort of being together is inexpressible.  We sit and talk alternately of trivialities and of life and death.  One knits, another is on the laptop posting updates to Facebook, I am writing a blog entry.  The surgeon figured it would take three hours.  That was over four hours ago.

This was in none of our plans for the weekend.

***

The surgeon finally came out.  It was worse than he anticipated.  He was trying to be positive, but let slip words like “heroic measures” and “if she makes it.”

It is all very surreal.  Someone says, “I feel like I’m watching a movie.”  The whole gamut of emotions pours out, opposites juxtaposed incongruously:  shocked looks, tears, laughter at a suddenly resurrected old joke.  We pray.

***

The surgeon just came back out, a few minutes later.  A terse, hurried report this time:  the post-op CT scan shows swelling, and they need to do emergency surgery now to relieve it.  Silence, everybody together but alone with their own thoughts.  Someone passes out snacks.

***

I hate being a doctor and knowing what’s going on.  Or maybe I just hate what’s going on.  Is it more terrifying to hear cryptic references to “dilated pupils” and “midline shift” and have no idea what they mean, or to know exactly what they mean, and their implications, and get a queasy feeling of impending doom?

***

Some of us eat snacks.  Some read waiting room magazines.  Every once in a while an attempt at small talk, an attempt at normalcy.  Mostly quiet.  I’m glad we’re all together.

***

It’s been another hour, and no word.  That can’t be a good sign.

***

Hurry up and wait.  Another half hour has passed.  We’re a little more lively group now, laughing and kidding each other.  It’s hard to maintain that serious aspect through the long, anxious watch.

***

 

At last — the surgeon has come back.  He is guardedly optimistic.  He looks weary.  I walk out with him for a doctor-to-doctor talk out of everybody else’s earshot.  He is more frank about how he feels;  in some way, we can understand each other.  When I return to the group, the atmosphere is much more relaxed.  Not that the news is that great, but at least the uncertain waiting is over.  One round of waiting, that is;  everything depends now on how she will wake up, and how she does over the next couple of weeks.

***

 

The next moment of truth;  the nurse has just come out, and told us that in about ten minutes the family can come in to see her, two at a time.  Deep breaths:  we’re about to dive in, and God only knows what the water will feel like.

***

Psalm 121.   I lift up my eyes to the hills — where does my help come from?   My help comes from the LORD, the Maker of heaven and earth.   He will not let your foot slip — he who watches over you will not slumber;   indeed, he who watches over Israel will neither slumber nor sleep.   The LORD watches over you — the LORD is your shade at your right hand;   the sun will not harm you by day, nor the moon by night.   The LORD will keep you from all harm — he will watch over your life;   the LORD will watch over your coming and going both now and forevermore. (NIV)

***

Just back from visiting her room.  The ICU smell!  Intubated, sedated, tubes everywhere, the Darth-Vader hiss of the ventilator, monitors, drips, her head wrapped with a little blood seeping through the right side of the bandage . . . I talk to her as if she can hear, I kiss her on the side where she still has cranium.  I come back to the waiting room and I am trembling.

***

Exhaustion.  I was tired before this started;  I am almost numb and staring now.  If this were a novel, I would have to fight turning to the last page to find out how it ends.  It is a little like a novel, or a movie.  Sometimes I want life to have a plot.  Well, it does today:  suspense, unexpected turns, hope and despair and snatches from the jaws of death, heroic actions, a beautiful damsel in mortal peril.  God knew what he was doing when he made life full of more routine than plot.  I don’t think we could take too much of plot.

***

***

It is too easy as a busy physician to forget in the rush that all patients have stories, have families.  It is all too easy to objectify people, to think of them as their disease, to fall into thinking of “the asthmatic in room 39” instead of “Mr. Brown, who is a forester with a wife and three children and who has just been laid off and is here because his asthma is worse.”  Or to say, “The drunk is back” instead of “Mrs. Smith, who desperately wants to stop drinking but her daughter came over with a bottle and she couldn’t resist so she is back here looking for help and does she ever feel awful.”  It is a good reminder, this being on the other side of medical care.  I have cried (and laughed) a little bit more readily with my patients this last week.  I don’t think that’s a bad thing.

Physicians, Technicians, Clinicians, and Providers

A few weeks ago I had lunch with two doctors who are currently in a residency training program.  In a moment of candor, both of them remarked, “I feel like I’m being trained as a technician.”

This comment struck me as tremendously important (and not just because I am heavily involved in their training and their words highlight my failure as a teacher!).  Because if their perception is correct — if we are indeed instilling in future physicians the ethos of the technician — then we had best be prepared for the inevitable results.  “To a man with a hammer, everything looks like a nail;”  to a technician, every problem looks like a technical problem, one which needs to be solved by a technique or technology.  The dizzying upward spiral of health care costs is driven largely by the increasing use of increasingly expensive technologies;  training a technician workforce can only exacerbate the problem.  The technical bias towards the automatic, unreflective use of technology simply because it exists will lead to more of the inappropriate use of technological interventions that are the bread-and-butter of hospital ethics consultations.

But more importantly, not all problems in medicine are technical problems;  some are singularly resistant to simplistic, technical solutions.  For some conditions, the doctor is the best drug:  his or her human, caring, and compassionate presence, just being with the patient.  Yet to the technical mindset, this simply attending to the patient (from which we get the expression “Attending Physician”) is discounted in favor of doing things to patients;  and while both the being and the doing are necessary for the practice of good medicine, the standardization, mechanization, and industrialization of medicine in our day has heavily favored the latter at the expense of the former.  More often than our technical mindset acknowledges, it is better not to do something to the patient;  but this option is not in the purview of the technical mindset.  We always feel we must do something, and medical caring  often suffers as a result.  The central economy of medicine, the physician-patient relationship, is lost in the technical mindset.

The ongoing industrialization of medicine is reflected in and driven by the terms we use to describe doctors.  In the May 25th JAMA, the authors of an essay entitled “Dear Provider” wrote of the replacement of the title “clinician” with “provider.”  The authors believe that this semantic change could be subliminally altering professional self-concept and behavior, “shifting the clinical encounter from patient-centered to task-oriented.  Nowadays, patients are quickly ‘plugged in’ to templated workups;  progress notes have become computerized inventories of completed tasks;  and when we ask residents on teaching rounds ‘What do you think?’ we often hear ‘I think I want to get an MRI.’  It appears that the time and effort spent by providers packaging patients through the system is displacing most other clinical activities.”

Packaging patients through the system. Sounds like a technician’s handiwork to me.  How did we get to this?  Do we turn back or go on?

 

Contemplating “The Scandal”

CBHD Scandal of Bioethics Conference Graphic

CBHD Scandal of Bioethics Conference Graphic

This coming July, the Center for Bioethics & Human Dignity will host its 18th annual conference. This year’s theme is “The Scandal of Bioethics: Reclaiming Christian Influence in Technology, Science & Medicine.” The conference theme poses a number of interesting questions that, I believe, would be worth considering in advance of the meeting.

First, do you believe Christian moral reflection has been marginalized in bioethical discourse and public policy decision-making, and if so, in what ways?

Second, what may we cite as the evidence of a contemporary bioethics bereft of Christian influence? How might the bioethical terrain differ from its present state if the Christian voice had enjoyed a more sustained presence in public policy discourse?

Third, to what may one attribute this marginalization of Christian moral reflection in bioethics? Is the problem external to the Christian community, or do we share in the blame? If the latter, in what way?

We’ll save the question of a way forward for another post, but perhaps you have other questions pertaining to the diagnosis of a diminished Christian influence in contemporary bioethics and its underlying cause(s).

Your comments?