White sheets

Only forty seven and she lays there with shaved head, puffy ecchymotic, closed eyes, yellow, pale skin, and agonal respirations.  Her family sits around and over her, some crying, some eager, some silent; they know its coming, but their disbelief is evident.  I stare at her as well, my own disbelief also surfacing.  Maybe its selfishness, or a basic human instinct to survive, but I subconsciously wish life on her.  Survive.  Fight.  She looks like a fighter.  She looks like she gave that cancer thief a run for his money.  But now she lays there dying.  Inevitable.  And I painfully break the silence as best as I could.  I speak softly and say little.

She will likely pass soon.  Let us know if she looks uncomfortable and we will give her more medications.

And soon thereafter I find myself beside her again, now with family and extended family waiting outside.  I pull back the sheets and find the PICC line in her right, swollen, edematous arm. It is not sutured in and I quickly remove the tape and pull it out.  I find the peripheral IV in the left arm and do the same.  Her arms are still limp, and the sensation of their weight and lifelessness as I pull at them is unsettling.  I pull back the sheets more and find her gastric tube still embedded in her stomach that is now tense and rigid.  I tug at the tube and it slowly complies.  Out comes the G-tube covered in fetid, fecal, decomposing matter.  The smell is pungent and sharp, instantly bringing a new alertness and disconcert.  I quickly dispose of the tubes and lines and cover her back up.  

The confusion and nauseating contrast sets in for a few brief moments as the live, breathing human and lifeless, odorous cadaver blur violently before me.  But I don't linger there.  I walk out and tell the waiting that I am done, that they can go back and continue saying their goodbyes.  I continue working, moving onto other patients.  But I realize soon thereafter, subconsciously, that this moment will burn itself permanently within me, like many other things, and that I would now carry this moment with me.  

Spirit Blanket.

Eyes stare eagerly, anxiously, expectantly, tearfully, hopefully, woefully, angrily, frustratingly, unknowingly as I walk into the room.  Many are holding hands, some are praying, one is weeping within the embrace of two others, and a few are singing spirit songs in one voice, stirring thick waves from an unknown chasm of saints and angels and God, waves that penetrate and drop a thick, heavy blanket in the room.  The patient is dying.  He is young, he is fighting, but he is dying.  I wade through the stares, clear my voice, take my place in the center of the crowd, and present the likelihoods from the gathered evidence: at any moment this young man’s heart will stop beating.  Everyone remains still.  I wonder, do they see me as a blasphemer?  A heretic?  I continue on.  There is a giant clot that has traveled from his veins, through his heart, and into his lungs.  Treatment has failed, and he will die.  I cringe inside, allowing my words to form daggers to cut deeply into the spirit blanket.  I cringe inside, assuming the spirit blanket will fall at any moment, exposing the rawness and reality of the situation.  I finish and expect a violent reaction to the heresy.  Another moment of stillness.  And as though nothing happened at all, all continue holding hands.  All continue praying.  All continue singing spirit songs in one voice.  And unknowingly, I am swept away into that same, warm chasm.  

grinds my gears.

The jibberers and the jabberers, the chitterers and the chatterers, the complainerers and the malingerers, the "I-think-I'm-going-to-die" when its "you-should-see-a-psychiatrist"-ers. The tremulers and the mentally unstablers, the hypochondriacs and the panickers, the loose-screw-in-the-head-ers, the I-will-describe-something-with-1000-words-when-it-could-be-described-in-5, when "its-all-in-your-head"-ers. The healthcare-funds-sucking, pill-seeking, pill-popping panicking pricks; patience testing, patience stretching, patience ripping, empathy draining, subhuman hordes of subsocietal healthcare whores; those personality disordered, electrically miswired, chemically disequilibriumed, mentally unstable, self-determined-unable, physically capable but lazy-and-looking-for-a-short-cut, workman's comp'ed, the "it-hurts-soooo-much" when "its-only-a-papercut", "you dumbass", sob-story-selling pieces-of-shit. Go crawl back into your mother's womb because both you and your mother should've never come to existence.

Takotsubo in a good way.

After a month spent listening to rattling hearts and lungs, shoving tubes down mouths and noses, coaxing sundowners back into bed, trembling through peripheral line insertions, poking blindly for radial arteries, hiding my afternoon coffee or redbull from infection control, and checking, rechecking, and rerechecking to see that the patient sign-out is updated, my month in the ICU is finally over.

On my way out of the ICU, after an excruciatingly long last day, I stopped by Mr. R's room to say goodbye. I had taken care of this 82 yo man with a dysfunction in almost every major organ system in his body, including his GU system secondary to a traumatic foley insertion which led to almost a liter of bloody urine to erupt out of his meatus after removing the first foley. Thankfully, the urology resident on-call was a close friend, so he graciously accepted the 6pm consult, and even more graciously took care of the bloody mess.

I didn't expect much of a response from Mr. R. Actually, I didn't expect any response at all. See, Mr. R was on a bipap for most of his stay in the ICU. While his initial admission diagnosis was a "left globe rupture secondary to a fall", he was being treated for COPD exacerbation. So with the bipap mask squashing the skin around his nose, his left eye protruded farther out of its socket each day, which caused oozing and pus buildup. He was always in pain, agitated, de-sating secondary to mask removal despite soft restraints. There wasn't much exchange-of-conversation in our relationship. I would trend his numbers each day, making sure he was not trending towards disaster. If he was thirsty, I gave him water. If he was sliding off his bed, I propped him up. If the morphine wore-off and he was due for another dose, I gave it to him.

"Goodbye Mr. R. I know that mask is bothering you, but try to relax. Its helping you breathe."

And as I turned to leave, Mr. R muffled through his bipap mask,

"...Where are you going?"

"My month here in the ICU is over, so I'll be starting a new rotation next week."

"Well I want to thank you for taking care of me. Its been a real honor to have you as my doctor. Best of luck with everything and I know you'll do well."

just like me. just like you.

55 year old male with a history of alcohol dependence/withdrawal presents to the ED after his partner finds him lying on the floor, lethargic, tremulous, with a pool of blood around his head. patient's alcohol dependence dates back to his early teens, or maybe much earlier, as his mother is reported to have been a heavy drinker.

during his mid 30s, the patient is involved in a major motor vehicle accident and nearly loses his life. he was the driver, and he was intoxicated at the time. patient vows never to drink again.

sobriety ends after 5-6 years when patient begins drinking again, heavily: on average, 1-2 bottles of wine per day.

during his early 40s, the patient is involved in a second major motor vehicle accident and nearly loses his life again. he walked into oncoming traffic; he was intoxicated at the time. patient vows never to drink again.

sobriety ends after 1 year when patient begins drinking again, heavily: on average, 1 bottle of vodka per day.

during his late 40s patient is involved in a third major motor vehicle accident and nearly loses his life. he was the driver and drove straight into the side of a liquor store; he was intoxicated at the time. patient vows never to drink again.

sobriety ends after 1 month.

during his early 50s patient experiences his first withdrawal seizure; this event occurs because patient is unable to sustain infusion of alcohol while asleep. patient seizes in the morning, is brought to the hospital, successfully detoxed, and discharged. patient vows never to drink again.

sobriety ends after 1 month.

patient experiences his second withdrawal seizure; he is brought to the hospital, successfully detoxed, and discharged. patient again vows never to drink again.

sobriety ends after 3 weeks.

patient experiences third withdrawal seizure and presents to the hospital today.

in a few days, he will vow never to drink again.

sobriety will end after __ weeks.

goodbye.

she died today. agonal respirations, hypotension despite fluids wide open, extremities edematous. skin cool, yellow-green. pupils fixed, residual bowel sounds present. heart sounds absent, lung sounds absent. 9:22am.

her body is quickly cleaned, top to bottom, front to back. limbs flop around and slap against surfaces; an eerie slapping sound. tag is placed around big toe, and body is wrapped in clean white linen. you'll never forget her face.

did she feel any of this? did she slip away before her body started failing? and you wonder where she went.

no one will know she died.

a young patient in the icu is irrevocably, rapidly dying. she's from another country and all of her family is there; she has no family or friends here. despite our best, best efforts, we've been unable to reach her family or friends in her country. now, no one will know she died.