The Road through Residency:

And None at All...

The soft glow of the monitor displays a bright red and green light across the patient's face. The slender endotracheal tube juts forth, sideways from the mouth, winding down and then upward into the mechanical ventilator. The chest rises and falls. On the other side of the bed, tubes full of blood run down from the patient and into a machine. The rolling apparatus, moving steadily like a metronome, pushes the blood through the machine and back down into tubes that return it to the patient. For this patient, the lungs no longer pull in air from the room, and the kidneys refuse to strain out natural toxins from the blood. Long ago, these organs were working well, during decades when a president was shot, or when a war raged in Vietnam. Earlier, on a beach somewhere in Europe, the diaphragm was able to contract tightly, drawing in deep breaths of sea air. Going farther back, the kidneys were doing great when this patient first had a beer. But years of life have taken their toll on what was once a pristine chemical machine, leaving it an organic ruin. Now, all that keeps this flask churning and burbling are machines and electricity.

The ICU is a netherworld. It's quiet and almost serene late at night. The nursing staff sit, twisting side to side in their rolling chairs, watching… waiting. Every once in a while the quiet is broken by the annoying, computerized tune of an alarm going off. Apnea alarm, bradycardia, oxygen saturation dropping: ding-dong-ding. Buttons are pressed, the pulse oximeter wrapped around the finger is changed, and the ICU once again falls silent. As I sit there, watching… waiting, it dawns on me that it is perhaps only with expectations that we become disappointed.

A new patient from the emergency room is brought up to the ICU. Old lungs and a worn heart have left little to drive him forward, and years of smoking have further weakened his lungs and given him cancer. This is his tenth admission in the past year. Each time, he is tuned up and sent back out into the world, always a little sicker than when he last came in. His family, hearts full of hope, sit outside while we transfer him. We place him on the monitor and the ventilator and open the bag of saline. I go out to talk to the family about his code status. "Do everything. Anything you need to," they say. I smile, nod, and walk back into the ICU, but deep inside, I know that all we can do will never be enough.

It is five o'clock when the heart first stops. Slowly, it makes its declaration of intent, the pulse coming down, the blood pressure ebbing. Then the pulse ceases. In the movies, this is when heroes and heroines spring into action, desperately grabbing for paddles and needles, and they usually win, beating back the inevitable for one more day. In the real world, very little is in our hands to change. I cannot give the patient a new heart, new lungs, new kidneys. I can't erase 70 or 80 years of life. In some situations, you simply know that you are not there to try to save someone, but just to be his witness at the end.

Multiple times the heart stops, and multiple times we restart it, not knowing how much damage has been done. I speak with the family many times and paint the picture of what is happening 20 feet away, and they eventually decide to stop intervening. The patient passes in the next hour. The tubes are removed, and the family comes to say their goodbyes. The ICU again is quiet and I sit there watching… waiting. To paraphrase Arthur Young, there is a great difference between a good physician and a bad one, but in certain circumstances, often no difference between a good physician and none at all.