picu

It's Sunday night. On Tuesday, a classmate and I are presenting a case report that will soon be published in a journal of hospital consult psychiatry. I just met with her for a final discussion of what we are going to say...and before that, write. We're both exhausted; she's on internal medicine and I'm still in the PICU, and we've been putting this presentation off week by week. Now, I have this evening to write it, or we're going to look pretty bad on Tuesday.

but first, it's time to blog....

I got up a few hours ago, after my 3 hour post-call nap. My call nights on the PICU (pediatric intensive care unit) are 30 hours long. I come in at 6am on my call day and stay until noon the following day. Unlike trauma, my resident usually lets me go and sleep for 1-3 hours, which is very nice of her given that she usually sleeps less than one hour a night. At the same time, the call nights have been much harder to take. Maybe its because I'm burned out; maybe its because I have far less responsibility. Daily ICU patient care is not very exciting unless you actually "own" a patient and get to be involved in the direct decision making. Everytime I've gotten a patient so far, I just manage to interview and examine them and write my note...just before they get transfered onto the floor because they are no longer "critically ill".

...Healing hands, I tell you, healing hands.

Last night was an interesting night. I started out the day tired (my attending asked me if I was post-call...NOT a good comment to receive from someone who will likely evaluate you). I also hadn't slept much on Friday night -- again, not a very good idea. The day and evening was so slow that I eventually snuck off to our new student lounge to watch a movie. Sometime around then, I might have said something about how "slow" it was (a four letter word usually superstitiously banned from places like ERs and ICUs), and it was as if I had just punctured a very small hole in a very unstable dam.

Until that evening, we had had one acutely ill patient in the ICU, a 7 year old boy with severe traumatic brain injury from a rollover car accident. For the past week, as his worried family continues their vigil, we study CT scans that show large areas of hemorrhage and necrosis in nearly half of his brain, and struggle to keep his intracranial pressure low in order to prevent his brain cells from suffocating or his brain from herniating into his spinal cord. Half of his head is shaved, he has swelling and bruising around his eyes that is caused by mulitple skull fractures near his orbit, and neurology has drilled two holes into his brain to further relieve the pressure. His prognosis is unknown, but likely poor, and over the last few days, we have seen dozens of family members, usually two at a time, coming into his room and just standing over his mangled body, maybe trying to make themselves come to term with his condition. His parents don't speak English, and though this has made daily communication with them difficult it may be also isolating and protecting them from the daily drama and stress that surrounds their son's care.

Most of the other kids in the ICU are very ill as well, but many have been there for weeks if not months, and they, their parents and the staff have settled into a somewhat surreal co-habitation.

Last night, we had two unstable and critically ill patients come in, and their management took not only our entire medical team, but also the trauma team, neurosurgery, and half the ICU nursing staff. One was a patient from the floor with several days of leg pain, whose diagnoses throughout the night evolved from compartment syndrome to DVT to pulmonary embolism and necrotizing fascitis. Trauma took her to the OR three times, first to stop compartment syndrome, next to ampute her leg below the knee, and then finally, to ampute above and remove skin, muscle and fascia up to her abdomen because the infection was spreading so quickly. Her family, of course, was devasted, and throughout the night I passed them in the hallways, unable to tell them anything that could help. Her condition remains critical.

Sometime in the middle of the night, sometime after our patient was first returned from the OR and looked so bad that a crash cart was brought in and we prepared bags of ice to put around her head, my friends from trauma called again to tell us that another patient was coming our way. This was a thirteen year old boy who had been shot in the shoulder and back of the head, and had dozens of shotgun pellets embedded in his shoulders, neck, and unfortunately, brain. He appeared somewhat responsive, but paralyzed on one side, and neurosurgery was brought in again to drill a hole in his brain to prevent herniation. His mom, a small, mexican-indian woman, was brought in, appearing uncomfortable and intimidated by the setting, and we tried to go about our work and give her those ICU-patent "supportive, but not too encouraging" smiles, as we waited for a translator to come help us tell her just how critically ill her son was.

The night was intense. Besides being confronted with the tragedy of these kids' (and their faimilies') lives, and also trying to set up a balance between having empathy and isolating myself from the full impact of daily tragedy, I also had a lot of mixed feelings come up regarding whether or not I could -or should- take on such a career. I was obviously thriving in the environment, more than I had on any other day or night at the PICU. I was glad to work with my old trauma people again, and felt that I almost served as an interpreter between them and my less intense PICU team. I also noticed things and thought of good ideas that directly benefited our patient's care, which gave me some encouragement in the fact that I might acutally have the mind for this kind of work. At the same time, the sheer gravity of the situation was terrifying. It was well and fine to be on the sidelines, throwing out ideas and doing literature searches, but I could not even begin to imagine being in my attending's place, having such a huge and urgent responsibility, when the complexity and uncertainty around diagnosis and treatment were so great. Every attending had a different idea, and no one really knew who --if any-- were right. Everyone had to balance their ego, their mind, and their passion in a way that would best serve the patient, and amid the exhaustion and exhiliration, everyone still tried to somehow work together to keep the dam from collapsing anymore. As a career it is exciting and stimulating, but as a daily existance, it continues to frighten me in how all-consuming it can be.