Avoid peoples' stories

My parents call me every few days and ask to hear stories. Sometimes I'm contrary about it, and just rattle off a list of diagnoses and interventions. But I know that's not what they want. They want a heroic ideal. They want a dramatic arc. They want a story.

To get to the ICU, you have to be unable to either breathe or maintain a blood pressure on your own. Most of our patients are mechanically ventilated and quite heavily sedated, and all require careful attention to the tiniest minutiae of their conditions. We rarely know what our patients were like before getting, as one of my residents says, "shlogged." I suppose this makes it easier to focus on the doings of their protoplasm instead of the drama of their survivals-or of their deaths.

I guess what I'm trying to say is that the ICU is a place where it's easy-and maybe even beneficial-to avoid peoples' stories. Even when a patient's chart suggests good buildup or interesting characters, those things easily get lost in the thicket of tasks surrounding the gathering and management of their medical information. Maybe that's why I don't love the ICU: although my colleagues are quick-witted and entertaining, I only get the faintest outlines of what, other than physiological parameters, defines my patients.

On call nights in the ICU, I'm responsible for covering not only patients in the unit, but also "weaners"-patients elsewhere in the hospital who are slowly coming off mechanical ventilation. At about midnight last night, I was called to see a weaner for "poor toleration of feeds." I did, and then sat down to order some tests and write my note.

Here is how I started: "Called to see patient to evaluate for poor toleration of tube feeds." What I meant was: This man, who breathes with the aid of a machine through a surgically created hole in his neck and eats 70 milliliters an hour of a light brown solution through a different, also surgically created hole in his abdominal wall, just vomited out of the surgically created hole in his neck.

The next sentence: "Patient is an 85-year old man with quadriplegia and global cognitive impairment following a motor vehicle accident one year ago." What really happened: An old man drove his car into a building and nearly killed himself, but someone was able to keep his organs perfused and his lungs inflated. Although he can't move or think or speak or understand, he can blink, and because of that, his wife can't let him die.

And the punchline, my assessment and plan: "Flat plate abdominal film shows evidence for abdominal ileus. Recommend holding tube feeds, continuing insulin coverage as necessary. Reassessment in a.m." Translation: I hereby pretend to subscribe to whatever logic has made it possible for this man's existence to get to this point, and tomorrow morning, you should, too.

It sometimes seems that the sicker patients get, the more their real stories reflect doctors as villains. I'm not sure how much people want to hear about who we really are.


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