Intensive Daring

This month I'm working in the Intensive Care Unit, the ward in our hospital with five beds for the five sickest patients.  Over the last year we've been admitting more and more children there, so that our adult/kid ratio now is about even. The adults get a real live board-certified academic intensivist (part time) and a dedicated medical officer.  The kids get me, and thankfully my colleagues.

Intense:  "1) existing in a high degree; forceful or extreme; 2) highly concentrated, strong or deep; 3) feeling strong emotion; extremely ernest or serious."

The ICU has the highest degree of medical care possible in our hospital, and pretty much on our continent.  Monitors that read the electrical waveforms of a heart rhythm, and oscillate with breaths, and even sense critical oxygen levels.  Machines, which I grant you are outdated in 2012 but would have been state of the art twenty years ago, with dozens of knobs and tubes and cords, that mechanically ventilate a patient's lungs.  Pumps that calibrate fluid rates to the tenth of a cc per hour.  A nurse for every patient, or at most two.  Good lighting, phones and a desk, space, supplies, physical therapy.

And ICU care is strong, deep, and concentrated.  Most of my medical practice up to now has been more of the inch deep/mile wide variety.  Overwhelming numbers, do what you can for as many as possible.  I'm finding that I like the focus on only one, two, or three patients (for a brief moment we had all five beds once, but generally only a couple).  There is no student, intern, or resident between me and the child, so I'm the one examining, measuring, pondering, head to toe.  Every drop of fluid in and out, every medicine, every change.  Intensive investment.

But I am also finding ICU medicine to be a seriously risky business.  This is the spot of last resort on this earth.  The likely-to-be-fine types don't come here.  The happily curables don't need it.  So it is a service on which one faces death, over and over.  Strong feeling and emotion, yes.

Friday was a 1 for 3 sort of day, where the strongest emotion was sickening grief.

My first patient, baby F, came through the day saved.  He was born with mengingomyelocele and developed a dangerous form of hydrocephalus.  It was my job to recognize that and advocate and keep him alive until our neurosurgeons could operate; to advise his mother to consent to the risky procedure; to get his body ready and manage every detail afterwards.  He is emerging from nearly-dead to potentially-saved. Very satisfying.

But the other two children I was called for the same morning, and tried to revive enough to admit, both died.  The first was a 2-week old infant whose mother had come for her own routine post-partum check.  She didn't even realize that her baby was dehydrated, starving, septic, unable to feed for a day or two but probably sick much longer.  When she asked a nurse to just take a look the infant was not even breathing, and her heart had slowed down.  The nurse rushed the baby to nursery, the nursery team sprang to action, but when I arrived they were doing full CPR with no response.  After ten minutes we knew we would not get this mottled, dusky, limp baby back to life.  Her name was Princess.  First and only child.  I spent a good while just patting the wailing devastated mother, praying for her.  Wrenching.

A couple of hours later, another call, this one from the ward, where a 4 month old with malnutrition and anemia and dehydration whom I had seen that morning crying and with normal vital signs, was now not breathing at all.  She was unresponsive to pain, her pupils did not react to light, but she still had a reasonably strong heartbeat.  As we gathered emergency equipment and waited for the ICU to be ready, we knew it was unlikely that her brain would survive this.  Still it seemed worth a try, and I decided it would be safer to go ahead and intubate her, which I did.  But as I adjusted the position of the tube and a colleague connected a bag for pushing in breaths, there was a catastrophic event.  Our attempt to breath for her ended in a horrible pop, her entire body inexplicably filling with air, and blood suffusing her face and head.  I've gone over the whole thing with everyone involved, and can't really explain how the small pediatric-sized bag breath could result in such an immediate, irreversible demise.  I've cried.  Nothing compared to how her mom cried, holding on to me, undone.  It was awful.

Part of me knows that these deaths, whether from a disease process that has reached a point of no return, or a final complication of trying to help, are part of the territory of intensive care.  That a successful intubation or line or diagnosis or comfort does not mean I'm a good doctor or good person any more than a bad outcome means I'm finally revealed as useless.  But a larger part of me feels deeply the devastation of failure.   I read a good blog (http://www.alifeoverseas.com/pianos-arent-in-the-bible/) where failure is equated with innovation and learning.  Sounds great until the learning experience of trying and failing comes at the expense of an innocent life.  Some days, like today, the idea of stepping back in to a weekend of call after the Friday of Failure makes me want to quit, or wonder if I should find something safer to do.

But I went back this morning, habit or hope I'm not sure.  Perhaps because insulation from death is not a luxury easily obtained in Kenya.  Perhaps because someone is praying and I'm reminded that it is good to be humbled and reminded of my mistakes and limits, even when death is involved, because death is not the final reality.  Perhaps because I resonate with this famous quote used in the intro to a book I'd like to read (http://www.brenebrown.com/books/2012/5/15/daring-greatly.html), that life is not fully lived in the unmarred safety of the spectator seats, but calls for intensive daring:

"It is not the critic who counts; not the man who points out how the strong man stumbles, or where the doer of deeds could have done them better.  The credit belongs to the man who is actually in the arena, whose face is marred by dust and sweat and blood; who strives valiantly;  . . . who at best knows in the end the triumph of high achievement, and who at worst, if he fails, at least fails while daring greatly."  --Theodore Roosevelt