[Album: Unapologetic]
"round and a round and a round we go."
Finished Week 3 out of 4 on Neurology -- this one spent on the Neuro ICU floor.
Edit: I started this post at the end of Week 3. I now finish this after the final week and immediately after the Neurology Shelf Exam. Entry shall be adjusted accordingly. sho nuff.
The Intensive Care Unit is as Medicine as Medicine can get.
Although the unit I was in this past week had a Neuro focus it allowed me a quick glimpse at what a general Medical ICU might entail. Despite the Neurological emphasis, every single organ system was still reviewed and examined. Cardiovascular. Respiratory. Renal. Gastrointestinal. Genitourinary. Younameit. The Medicine I saw this week was so thorough and all-inclusive -- at times I forgot I was in my Neurology Rotation. Conversations concerning other body systems, more often than not, took center-stage as the Residents and Attendings scrutinized every detail to ensure the most fragile of Patients did not deteriorate any further.
"I threw my hands in the air, said, 'show me something.'"
I've often wondered what Intensive or Critical Care Medicine would be like. I braced myself at the beginning of the week because I wasn't sure what to expect. It turns out, possibly, that this past week is the most I've ever learned within a one week span as a 3rd year medical student.
In my head, and in general, hospital specialties tend to be roughly divided between the Medical Specialties and the Surgical Specialties. If nothing else, this past week has me convinced that the kind of thinking and consideration that go on in the ICU warrants a third designation...or perhaps a hybrid of both.
In Medicine one talks and forms differentials for hours.
In Surgery one stands and manipulates instruments for hours.
In the ICU one does both. At the same time.
It's Inspirational and Intimidating and Intriguing. All at the same time.
Maybe the "I" stands for all of those instead of 'Intensive'?
crate --
--I.C.U.
If Medicine is analyzing every symptom, every Crate, to diagnose what's wrong...then ICU Medicine is analyzing every last splinter of each Crate AND all the nails that hold it together...just to keep Patients alive.
The first couple of days my brain was pretty much swimming. Most of the words spoken between the Residents and Attendings went right over my drowning head. I feel that we have been trained and conditioned so well to look at the body just one system at a time, with limited thought as to how complex the interplay can potentially be within the human body as a whole. That's not a surprise, however, since as aspiring Physicians we know we have to put all the different Crates we are learning together like puzzle pieces into a final mosaic -- a final diagnosis that we can act upon. The surprise, instead, is that ICU Patients have multiple body systems failing. Too often, every single organ system is failing. As a result, there is no single Medication or Procedure that can fix ICU Patients. That kind of luxury does not exist.
"It's not just something you Take...it's Given."
And here is where I left off before embarking on a frantic week-long study binge for the Neurology Shelf Exam earlier this morning. Admittedly, the Neuro ICU experience is not as fresh as the day I originally started this entry. Regardless, it's still an experience that is hard to forget. And you know what? That is one thing that, in particular, sticks and hits home harder than Miguel Cabrera of the Detroit Tigers (holla). Nothing about the Patient can be forgotten in the ICU, lest you overlook or counteract a vital fact or exam finding. Allergies? Recent anticoagulation medications? Renal excretion and toxicity? Increased PEEP ventilator pressure leading to decreased venous return?
It's a veritable rodeo in there.
"Oh now, tell me now, tell me now, tell me now, you know."
Micromanagement in its most excruciatingly pure form. That is the Crate that is the ICU. Every microliter or microgram of anything that enters or leaves the body is recorded and accounted for. Every organ system is monitored as intensively as NASA in Houston does for every spacewalk (possibly a slight exaggeration here, but you get the picture). As a result the Attendings on this service are like hawks, with oversight that would put the visual acuity of eagles to shame. I was very impressed with the decisiveness and breadth of knowledge that the Attendings, Fellows, and Residents had while caring for the sickest of Patients. In a way, you see...or try to see everything in the ICU. I was blown away.
"It takes me all the way."
hippo --
--I. See. You.
So many labs. So many disease processes. So many medications, procedures, and intertwining differentials to carefully and methodically tease apart. It's a wonder there is any room left for Hippos with all these Crates.
But they always persevere in Medicine. Duh.
I technically experienced a death during my week at the ICU. I regret not having the privilege of meeting the Patient while they were lucid and conscious, but perhaps its for the best -- as the personal connection may have just destroyed me.
I learned, initially, about the Patient's story from medical histories and Physician's notes. I did my best to learn everything I could about him because I secretly and fervently hoped that, even with the slimmest of chances, I might find something that the busy Physicians had overlooked and could use to reverse the Patient's, then, comatose state. I found nothing.
"All along it was a fever."
It started with the mildest of symptoms... a low-grade fever and a throbbing headache that persisted and could not be attenuated by over the counter medications. The Patient was found to have a Subarachnoid Hemorrhage that prompted an immediate trip to an ER and then an OR. I found nothing.
"A cold sweat, hot-headed believer."
I still kept on looking. Believing. Digging through years old medical records and CT scans. Even though I found nothing I thought it for the best that I knew this Patient inside and out, so that I could relate his story and predicament with every new Attending and Resident I came across. I wanted to know him because that's what you do in the ICU -- you look at everything and you don't forget.
None of us believed he had any family. No visits. No contacts. I found nothing.
The day he passed away, however, was probably the day I got to know him best. His wife came. Yes, he had a wife -- and one that without a doubt loved him dearly. She allowed us to remove his endotracheal tube and free him of the necessary monstrosity that is the mechanical ventilator. His sister came. His aunts and uncles came. Two of his daughters came. His grandchildren came and almost unleashed the safety valve on my tear glands when they saw their grandfather like they had never seen him before.
No medical records, lab value, or diagnostic image could have allowed me to see him as a person more clearly than the day he passed away -- when family member after family member filed through to say their goodbyes and have their final conversations.
ICU. I See You.
I get it now.
"He said, 'if you dare...come a little closer.'"
--Shelf Exam. Self Exam.
I thought about him today. I had a question that matched, pretty closely, my Patient's initial presentation to the hospital. I'd like to think I got that question correct -- because I saw it in the ICU. Because I saw him.
3rd year clinical clerkships are a unique experience. In many ways it's the same rinse and repeat story we, as medical students, are all too familiar with. Another month? Another rotation -- punctuated at the end by another Shelf Exam. Been there. Done that.
But I am seeing it all around me. A slow transformation. Yes, it is extremely repetitive. Sometimes it can be, admittedly, extremely boring. At all times it is most definitely tiring and taxing in more ways than one. But I am seeing hints, here and there, of what I looked up to in my Pediatrician and in other clinical mentors I've encountered in my short life.
The way my colleagues carry themselves. The style and content of the conversations we now have. They are almost entirely different from the ones we had two years ago. And although we are far, far from being full-fledged Physicians...the only way I can describe this new style and culture...it's all very 'Doctor-ly'.
"Funny you're the broken one, but I'm the only one that needed saving."
My ICU Patient was sick. And although he never opened his eyes or said a word he inadvertently showed and told me more than I could have ever imagined. He may have been physically ill but he was the one that helped me feel better and more rejuvenated.
There's probably a reason Medical Education is the way it is...and has been for well over 100 years. It is tiring, and boring, and frustrating, and on the surface it can be a waste of time. But experiences like this are hard to come by and are too valuable to miss.
How else can we gain this insight?
How else can we become Physicians?
"'Cause when you never see the light, it's hard to know which one of us is caving."
And for all the Practical individuals out there...all these intangibles...this anecdote and this 3rd year experience. Well, again, I'd like to think I got at least one more question correct on today's Shelf Exam. So yes, there is a technical gain in all of this. A little surprise Crate if you will.
If you ask me, however, every Shelf Exam deserves a Self Exam.
I saw a lot in the ICU.
Ultimately, I saw myself in the ICU.
No doubt I called my Mother and Father that day after being "busy" for the past 2 weeks.
"Makes me feel like I can't live without you."
I only wish I could have had a conversation with him.
I want you to Stay.
