ITU

This post is a slight departure in tone from what I’ve written before; I feel the urge to write about some quite affecting and upsetting events from recent weeks, to make an attempt to record their significance and impact before I become hardened to the harsh realities of modern medicine. For confidentiality and out of respect for the privacy of those involved I’ve changed most of the details about what follows but remain honest in my attempt to convey how I felt. It’s difficult to communicate what I mean: writing it down helps a little, but I don’t expect what follows to be of much interest to anyone else.

Hospitals are an altogether unpleasant place to be. Unless a person is paid to be there (or , like me, is learning how to eventually be paid to be there), that person’s  visit to hospital is inevitably associated with an adverse event, it is either a trip necessitated by their own sub-optimum health, or a visit to someone close who is unwell. During my most recent attachment I spent some time on the hospital’s intensive care unit (ICU, confusingly aka ITU or CCU), that quiet part of the hospital reserved for the care of the hospital’s most unwell patients,  the patients who require close monitoring and often multiple organ support.  The patients are often sedated and ventilated, supported by a network of drains and lines connecting to various machines. Their existence is simplified to some matrix of data regularly reporting their oxygen levels and blood chemistry and other important values. A patient must be really quite unwell for admission to ICU, and so unfortunately many of them do not recover – about a third will die on the unit. There were ten patients on the unit at the beginning of my week’s attachment, of which a good outcome (eventual discharge home without serious disability) was only a realistic possibility for one or two. Patients with hypoxic brain injury and no chance of regaining meaningful function are depressingly common.

The consultant explained that the job is like spinning plates, supporting several patients at once by bolstering their failing organs until they either make some recovery of function, or they don’t. The doctor must also communicate with anxious relatives often, calmly and kindly explaining the situation and inevitably breaking bad news several times a day.

I found it odd then, how a doctor could be so professional, understanding and compassionate with the relatives but seemingly so ruthlessly frank, flippant, and perhaps even brutal when discussing the patient in private, within seconds the patient becomes anonymous and insignificant. Given the type of patient on the unit, and their bleak average outcome, it is understandable that the staff may become desensitised to the individual tragedy of every case and the devastation that such conditions wreak on patients’ families. Patients on ICU can become dehumanised. They can quickly come to be regarded as non-responsive fleshy masses in union with tubes and wires and bleeping machines, large and awkward Tamagotchis that inconveniently occupy hospital beds (an expensive hotel at around £2000 per night).

This is probably not at all as I’ve described it; I don’t doubt the competence, concern or sense of responsibility of the medical staff. They work tirelessly and do an excellent job. It would be impossible to become deeply emotionally involved with every patient and perhaps if one were to this may impair the ability to function as a good doctor. But I can’t help but be disappointed in the apparent absence of compassion; I don’t ever want to reach the stage where I regard a dying patient as just another occupied bedspace on the ward.

I verified my first death on ICU, with one of the junior doctors. A woman in her 50s had had a completely unexpected and catastrophic bleed in her brain and only survived for a few hours on the unit. The verification of death is a mundane responsibility for doctors in hospital, it is supremely common and necessary but I found it surreal and was a little shaken in taking part. There is no formal legal definition of death in the UK and so verification simply requires clear documentation that several normal signs of life are absent. This lady was completely and indefinably different in death compared to the appearance of living patients but paradoxically one could still regard her as simply sleeping comfortably. She was still warm when I checked her pupils, felt for her pulse and listened for heart and breath sounds. I tried to illicit a response to pain by pressing firmly on the bone between her eyes, and then mechanically and self-consciously uttered “time of death 09.25”, as if I were transported to a medical TV drama.

A short while later I accompanied the ITU registrar to an emergency call in A+E. As we hurried to the resuscitation room he explained that usually these alerts turn out not to be too serious, but since he’d had a long run of simple cases recently he thought this one might turn out to be significant, and his premonition sadly rang true. We arrived moments after the ambulance to a manic scene. A tiny toddler lay on a startlingly over-sized bed in the bay dwarfed by medical staff in a flurry of activity around him. He had no heartbeat and one of the junior doctors was performing chest compressions. 

Almost immediately the registrar took over the ventilation of the child with a bag and mask and I was ordered to ring for the ITU consultant. After what seemed like ages I got through to him and I quickly mumbled my panicky message: paediatric cardiac arrest in resuscitation, please come ASAP.  Soon there were 12 people around the bedspace, taking turns to perform chest compressions on his miniature torso. A nurse barked timings over the ordered chaos, cues to administer adrenaline and assess whether any signal could be picked up by the heart tracing. At one point the A+E consultant optimistically shouted “stop CPR! There’s activity on the monitor!” only to immediately concede “no activity, resume CPR.”  

By this point a small audience of medical students had gathered, awkward morbid voyeurs feeling helpless and hopeless and in the way but a grim curiosity rendered us mostly unable to tear our eyes from the terrible scene unfolding. I will remember the next 15 or so minutes as some of the worst of my life.  The boy’s inconsolable mother watched impotently as the boys whole body was jerked up and down by the compressions. The simultaneous assertive voices of the team strained to compete with the suffocating sound of drilling intraosseus access points into his tiny shin bones, because it was impossible to get access to his veins to administer fluids. Eventually there was a slow realisation of the inevitable which surpassed the atmosphere of panic. I couldn’t stay in the room.

After 40minutes without a heartbeat the team closed the curtains. Alfie was two years old when he died, from a cardiac arrest following a seemingly standard tonsillitis. He had been seen by his GP and prescribed the correct antibiotics, but tragically he had become septic, his heart starved of oxygen stopped, and he died. His father arrived at hospital moments later.

I spent the rest of the day thinking about this event. Whilst the parents howled and embraced each other I watched the medical team slowly file out of the room, each to return to their jobs, and their lives. Alfie was two years old. No amount of thinking makes the outcome okay, nothing about this story is fair.