I am so proud of him.
"I love you too"
I can hear these words in the back of mind as I look around the room I am about to leave. The words are soft as if whispered by a lover, but they hold no intimacy in their context. By complete chance, I heard these words spoken and saw the look that accompanied them in this very room 2 days earlier. The phrase was spoken by a man for whom it would be his last, the look of sincerity that joined them given to a son whose face would be the last he would see. I knew almost nothing about this man or his family, yet the significance of what I accidentally witnessed as we prepared to intubate him was not lost on me.
The man had come into the hospital due to increasing dyspnea. He was diagnosed with acute respiratory failure. We attempted to ventilate him with BiPAP and when it did not work we were forced to intubate him. He developed ARDS and as his oxygenation status worsened the family decided it was best not to fight the inevitable and stopped the treatments.
A noise down the hall distracts me from the almost cinematic replay in my head. The ICU area I am in isn't huge; the area I have been living in for the past three days consists of basically a "U" shape, 19 rooms, 19 people, 19 families, 19 stories.
A subtle movement draws my eye to room 3. I remember when I first met the pt in that room. A man with severe neuro defeceit after multiple CVAs. When I first looked at him on that first day, he was so obviously compromised that I never even felt a human connection with him. He wasn't there, he was a vent to me at that point, numbers on a complicated machine. His sister was there regularly, and I had always chatted briefly and warmly with her, it was obvious that she was remaining strong but struggling with it at the same time.
It was decided that he was to get a trach and on my second day we were called upon to transport him down to surgery. My preceptor and I arrived at the room a little early, my preceptor stepped out to take care of something else while we waited and soon after the nurse stepped out as well. This left the pt, his sister and me in the room alone. It wasn't uncomfortable, we made small talk, it was polite and without tension. There was music playing in the background and I commented on it as it was the first time any music was playing in the room. His sister smiled broadly and said "Oh yes, he absolutely loves music. He is a musician. He plays the mandolin".
Have you ever looked at those paintings that have the image hidden in them? I think they were called magic eyes or something similar. You stare at it for the longest time and finally something clicks and bam you see it. There is a microsecond disorientation that always happens when I finally see that image, a nano-dizziness. That same thing happened at that moment. He "is" a musician. He "plays" the mandolin. There was no past tense in her description.
In a flurry the surgical team and entourage sweeps into the room and in a flash I am handed the ambu bag and off we go down to surgery. When we arrive there is the usual delay and wait in the hallway while the surgeons and anesthesiologists get ready to take the patient over from us. I am left alone with the patient, my preceptor a couple of steps away on the phone. I look down at the patient and I can see for the first time that he is not a vent or a set of numbers but instead a man. A man with a concerned wife a few feet away from me nervously talking with the doctors. A man who was a musician, and who used to play the mandolin. It is obvious that he will never again create music from a brain that has just been ravaged by a rogue blood clot.
This man was a child once. He played with little toys, cried for no reason and felt fear from such things as the dark and the boogie man. He went to grammar school, probably played some parts in school plays that were not strong candidates for Broadway yet most likely received standing ovations a Broadway actor waits their whole career for. He went to high school, he had a first love, he met the girl of his dreams and shared a first kiss with his wife in front of family and friends. Now I am connected to this man, quite literally as I am squeezing a two dollar plastic bag so that he can continue to live, and I realize that I am playing a small part in this long production that is his life.
"Excuse me bud, " I hear from behind me, snapping me out of my recent playback. It is the cleaning team and they are trying to get into the room I was blocking the doorway to. I hastily step back with muttered apologies and watch as they quite quickly start resetting the room for the next patient.
"Are you ready?" asks John. John is the ICU nurse who was quite intimidating to me for some reason. "To extubate?"" I reply, really more of a rhetorical delay tactic than a true question. I had known that eventually I would have to do this, but I was caught alone in the hallway, my preceptor four the day two rooms down. "Do you need Jane or can you handle this?" he asks, and I can tell his expression is a little softer than normal. My doubts must have been a blazing neon sign on my forehead. "No, it's fine, I can do it." And with that, the nurse, myself, the attending Dr. Young and a resident walk into the room. I suction him one last time as family is waiting to come back and be with him in his final moments and we do not want him to be choking on secretions when they do,
I had been lucky enough to work quite a bit with Dr. Young during the past three days. He is quite an amazing man, more because of the way he balances his confidence and ego with how he treats nurses and RTs. You are never in doubt that he is in charge but you are never hesitant to voice your opinion either. We had done a few bronchus together and he had even called upon me directly to answer some questions in front of the entire medical team over my preceptor twice.
So it was with a little surprise that I watched him take a deep breath and lean with both hands on the end of the man's bed as I began to extubate. It was obvious that he was genuinely sad about the outcome of this pt. and while this makes complete sense, I still did not expect to see that vulnerability, that emotion. The extubation completed, we left the room, the family was ushered back in and we stood in the hallway watching his little piece of digital real estate on the monitors. We watched as his heart rate and respirations got slower and slower, until they were finally zero.
I started to wheel the vent back to the storage room where I would clean it and get it ready for the next patient, the next fight for life. I glanced one last time at that hall monitor that showed everyone in the unit's vitals. The room I just left was, of course, blank, but the other rooms all had numbers and graphics. 18 rooms, 18 stories. The noise level seemed to gradually increase for some unknown reason and I could see families walking in and out of rooms, I noticed a couple of people laughing and hugging. Nurses and RTs and housekeeping, X-ray techs...they all seemed to come out of nowhere yet were filling the hallways with activity as I watched, going about their days. A small smile seeps across my lips.
This was a sad day to be sure, but it was infinitely more sad for the family that was most recently in the room I just left. I realize that the time I spend in the ICU isn't about me. It is about these 18 remaining stories. 18 remaining outcomes that have yet to be decided. It is about recognizing that each room contains a person, not just a patient, and that the care given and the words spoken need to be done in consideration of this. I am just a microscopic player in this gigantic story, but it is an honor to have a part nonetheless.