Intensive Care


(This column was first published in the April 5, 2001 ArtVoice of Buffalo.)


John F. Murray is the kind of doctor we all hope to have care for us in an emergency. I am certain, thank goodness, that there are many doctors who enjoy his medical skills and his ability to act quickly and competently to address emergencies. But I am equally certain that there are far fewer who can equal the common sense and compassion he displays in his book Intensive Care: A Doctor's Journal (Berkeley, University of California Press, 2000). That he writes so well is a bonus.


Consider in this regard this long passage from the beginning of his book. Scary stuff:


"An unseen hand flings open the door to the intensive care unit. Then appears the back of a woman wearing a green scrub suit. She has a stethoscope draped around her neck -- probably a medical resident. At her side is another woman in green, who helps her pull a bed in from the corridor by wrenching one end through the ICU door, which a nurse runs over to hold open. The other end of the bed is simultaneously pushed and guided by a young man who is shouting directions. He is flanked by a respiratory therapist doing his best to help push by leaning on the headboard, while both his hands are occupied with the repetitive squeezing of a melon-sized elastic bag, which fills automatically with oxygen from the green cylinder attached to the front of the bed.


"From under a sheet and rumpled blanket extend the head and naked upper torso of a nearly bald man, perhaps in his forties or fifties, with a grizzled face, twisted nose, and cauliflower ears. Instead of a neck, huge muscles flare out from just below his ears to the tips of powerfully broad shoulders. He must once have been tremendously strong, maybe a professional football player or wrestler. But now his skin is sallow and his lips are ominously dusky. He seems lifeless except for the slow, deep rise and fall of his chest under the bedclothes as the therapist compresses the bag to force oxygen into the man's lungs through a clear plastic tube that protrudes from his mouth. A chrome yellow box -- a portable unit for monitoring the heart and shocking it back to life if it stops -- lies on the bed. The wires that attach the instrument to the patient's chest are out of sight, but each heartbeat is announced by a high-pitched ping. The accompanying electrocardiographic wave form is traced on a small screen for his guardians to observe.


"While this improvised cortege negotiates its way through the door, the head nurse calls, "Room Three," and hurries ahead to clear the cor­ridor of chairs, computers on pedestals, and other equipment. Inside Room Three another respiratory therapist waits with a ventilator, a life-preserving breathing machine that will automatically stuff oxygen into the patient's lungs. While he was in the emergency department, two slender plastic tubes, 'cannulas,' were inserted into the patient's veins, one in each arm, and a larger rubber catheter was implanted in his bladder. Once in the unit, a third and fourth cannula are added, one, in a vein, to provide extra access to the patient's bloodstream for medications and one, in an artery, to monitor his blood pressure. The patient appears tethered by the cat's cradle of tubes emerging from plastic bags that hang from stainless steel poles surrounding his bedside; appended pumps control the flow of fluids and medications into his body. A calibrated plastic bag, hanging empty, will collect urine once his beleaguered kidneys recover enough to produce some. Wires sprout from his chest, where small patches of hair have been shaved for electrodes to be securely glued, and they all converge at a large television monitor mounted on the wall. A clothespin-like device, an oximeter, is clamped on his index finger to measure the level of oxygen circulating in his blood; its electrical connection also leads to the television set.


"The screen displays numbers that register the patient's moment-to-moment heart rate, blood pressure, and level of oxygenation, as well as continuous tracings of his electrocardiogram, arterial pressure, and oximeter waveforms. Alarms are set to emit a particular identifying squeak, beep, or ring should a vital physiologic function deteriorate further. Apart from the flashing signals that his heart is beating and his blood pressure exists, propped up by powerful drugs, there are no signs of life. The rhythmic movements of his chest are an illusion created by the breathing machine that pumps in oxygen-enriched fresh air -- no matter what.


"So far so good. Everything is proceeding according to the formula of the medical dramas on television. But here, clinical reality and not television fiction determines the outcome. Whether the as yet unnamed patient, barely clinging to life, will leave the unit alive in the bed he now occupies, escorted by one of his cheerful nurses to a medical ward for further treatment, or whether his enshrouded corpse, perhaps still-unidentified, will leave on a gurney pushed by a dour morgue attendant, depends on how fast and accurately his physicians can diagnose and treat the cause of this catastrophe, and on how well his nurses anticipate and respond to the perilous events that will almost surely complicate the next few hours and days. This is what intensive care units (ICUs) are for, and it is what this book is about: how doctors and nurses make decisions concerning such urgent medical problems."


Yet Murray always adds perspective to his commentaries. Here is how he continues this one:


"Lives are indeed saved in the ICU; that is always the goal, and those of us who work there are good at achieving it. But the other side of the coin is that sometimes even highly sophisticated expert care doesn't work out as planned -- patients die. One of the lessons of this book is that death is an ever-present part of the ICU story. Despite our mastery of medical science and technology, JCU doctors do not always succeed. Another lesson is that death is not a correctable biological condition -- it is everyone's ultimate destiny. Finding that elusive boundary between extending life when there is a chance for more and allowing death when hope has truly gone is seldom easy, yet we undertake that search nearly every day. The reader will learn from actual medical histories that in the ICU we have the power either to delay or to accelerate the course of dying. My own view is -- and you will see why as you read further -- that the current decision-making process can and should be improved."


I have spent enough time in ICUs to appreciate this story as one of those whose lives such doctors have spared. I also have a mother-in-law whose current condition results in part from errors in judgment and care by both family and physicians, mistakes that play an important role in this book.


Consider some of Murray's dead-on-the-mark insights:


About surgeons and internists: "Specialists in internal medicine interact with their colleagues in surgery all the time; we have a necessary and highly beneficial partnership. Each time we meet, though, internists tend to become a little edgy. Surgeons routinely perform technical feats no internist would ever conceive of undertaking, and they bring these brilliant skills with them when they consult on a patient. But they often bring their giant egos and short fuses as well. A surgeon friend of mine has characterized his confreres as 'Often wrong, but never in doubt.' By contrast, the call to arms for internists is 'Don't just do something, stand there.' It is undoubtedly good for the profession that it includes men and women of instant action as well as those of prolonged reflection; but when these polar temperaments meet at the bedside of a sick person, things can heat up."


What surgeon has ever hesitated to flail away at the human body?


About smoking: He tells about a woman whose lung cancer has now metastacized to her brain. He continues,"Her husband, a small dark man with huge bushy eyebrows, who was with her all day yesterday and is here again this morning, keeps saying, 'I told her to stop smoking; I told her over and over.'


"Three hundred eighty-nine years ago, King James I of England condemned smoking as a 'custome lothsome to the eye, hatefull to the Nose, harmefull to the braine, dangerous to the Lungs,' and compared it to 'the horrible Stigian smoke of the pit that is bottomlesse.' He was right."


And drinking: "Every day so far this month, at least one of our patients has been in the ICU for treatment of a disorder related to too much alcohol: acute intoxication or one of its hazards (injury from falls, hypothermia, pneumonia) or alcohol-induced cirrhosis of the liver or one of its complications (bleeding, spontaneous bacterial peritonitis, coma). Other serious problems from excessive alcohol that haven't turned up yet are delirium tremens, pancreatitis, and poisoning of the heart muscle. Overindulgence also causes accidents on the road, at work, and at home as well as several kinds of cancer, and increases blood pressure and the likelihood of having a stroke. Too much alcohol is a gigantic public health problem.


"Against this disastrous medical and social backdrop is the mounting awareness and documentation that just a little alcohol is beneficial. It reduces the risk of developing hardening of the coronary arteries and associated heart attacks, which are the most common cause of death in the United States. It's at least as good at preventing heart attacks as one aspirin a day. Even the conservative American Heart Association supports the belief that consumption of one or two drinks per day is associated with a reduction in risk of coronary heart disease of approximately thirty to fifty percent. It doesn't seem to matter what beverage the alcohol is contained in, although according to some (especially the French) red wine has additional health benefits."


That quotation I will share with my teetotaling wife.


Murray is a great storyteller. Here is part of his exchange with a lawyer. It too is finally instructive:


"We notice that Cesar Fonseca-Santos's two brothers are in his room.... We go over to greet them. Jim, who had met and talked to them last night, introduces everyone. I say, 'I'm sorry I missed you yesterday. I had to leave in the afternoon.'


"'Yes, we heard you were off playing tennis,' they reply hostilely, almost in unison. I am tempted to respond that they arrived several hours later than expected, but I let it go.


"Then I review Mr. Fonseca-Santos's case from the very beginning.... Despite the speed and precision of his diagnosis and treatment, he is doing very poorly. His chest x-ray this morning is a shade improved, but all the other clinical touchstones -- blood pressure, oxygenation, mental status, urine production -- are ominously bad. I finish by saying, 'There's a good chance he won't survive.


"The two brothers just glare. Finally the older one, the lawyer, says, 'We're taxpayers. Don't let him die, doctor, don't let him die. We'll be watching you."


The next day: "I pass on all this dire news to one of his two brothers, who seem to be taking shifts, so that one is with Mr. Fonseca-Santos most of the time. Again, no questions are asked, but the lawyer-brother says in his court­room voice, 'Don't pull the plug on him, Doc. Don't you dare.' He must sense that I have given up hope."


And finally, "Cesar Fonseca-Santos died that afternoon from the overwhelming blitzkrieg of the powerful toxins elaborated by Group A Streptococcus pyogenes.... There is no doubt that we dragged out Mr. Fonseca-Santos's death, hoping to avert it, with all the human science we had. But we failed. In retrospect it is hard to define precisely when his disease crossed the invisible threshold from potentially curable, as it was at the beginning, to hopeless, as it was at the end....


"I went in with Paul Dudley, the youthful medical student, to speak with his two brothers and daughter. I told them I was very sorry it ended this way, but we had done everything possible to save Mr. Fonseca-Santos's life. 'Nothing was spared, right to the end.'


"'We know you did, Doctor,' the lawyer replied, 'and we're immensely grateful. God bless you both.' Then they left, having astounded me with their gracious approval.


"'Whew, I'm glad that's over,' said Paul after they walked out. 'I wonder whether poor old Cesar would have wanted to die like that. It took forever. Pressors right to the end.'


"'I wonder too,' I replied. 'The brothers were certainly clear about what they wanted, but I always had the feeling they weren't speaking for Mr. Fonseca-Santos. They admitted they had never talked about it together.'


"We agreed it was too bad he didn't leave an advance directive. There are two kinds of advance directives, both with legal force: the more common one is called a durable power of attorney for health care, in which someone is designated to carry out a person's declarations about the kind of care he or she wishes to receive -- should a situation arise in which the person is unable to make his or her own decisions. There is also a living will that specifies the extent of medical support desired by a victim of a terminal illness -- when potentially fatal complications supervene. 'Then we could have been sure we were following his own wishes,' Paul suggested.


"I am a great believer in advance directives and promote them whenever I can, but I had to add, 'Yes and no, Paul. Implementing an advance directive, which usually means withholding or withdrawing life-support when someone is dying and unable to make a decision, is not always easy. Mr. Fonseca-Santos provides a perfect example. At the beginning, he had what should have been a curable illness, and there was absolutely no way of knowing that he was going to die. After a few days, especially in patients with such a fast-moving disease, the prognosis, favorable or hopeless, usually becomes clearer. But it certainly wasn't obvious early on in Mr. Fonseca-Santos's case. Imagine what it's like when the illness is insidious and lingering, with clinical ups and downs, as in chronic heart failure, spreading cancer, progressive dementia, or chronic obstructive pulmonary disease. Then it's even harder to decide when the condition crosses the boundary between reversible and fatal. But you're right. Our job would be considerably easier if everyone had an advance directive. Don't expect to find many in this hospital, though; they have been signed by fewer than fifteen percent of Americans, chiefly by those who are affluent and middle class, though many more would like to have them.'


"'Do you have one?' Paul asked.


"'My wife and I took care of that years ago,' I responded, 'and our views haven't changed, only been reinforced.'"


I add one final commentary that was very personal to me:


"Intubation is a common and crucial ICU maneuver. But in people who are awake, intubation is extremely disagreeable and must be performed using local anesthetics to block the triggered by the procedure. Imagine having a one-foot-long plastic tube thicker than your index finger scrape along the back of your throat, force its way between your vocal cords, and finally be fixed within your windpipe by a balloon inflated near the tip. Painful sensations inevitably return when the anesthesia wears off and the reflexes wake up. When patients cannot breathe by themselves or cough to prevent food and liquids from entering their windpipes, intubation must be done to save their lives; but just as soon as it is safe, we take the tube out because most patients fear and hate it. Many of the decisions we have to make are dictated by this dreaded but often necessary tube."


This passage reminded me of the time many years ago my parents arrived to visit me in a Connecticut hospital having driven down all the way from Rochester. I had already returned to my room from recovery after stomach surgery, but just as they entered my room I gagged on the tube that ran through the side of my mouth down my throat. Fortunately a nurse was nearby and she was able to remove the offending tube to let me recover my breath, but my distressed parents were left almost in shock.


I finished reading this book with still greater respect for our medical community. This should be required reading for anyone with aging, addicted or diseased relatives.-- Gerry Rising