A morning in the MICU

Maybe I don't hate medicine, after all.

This morning, I made a visit to the MICU, or the Medical Intensive Care Unit, thanks to the generous offer by one of my professors who is a pulmonary critical care doc.

A typical day at the MICU begins with the rounds at 8AM. A team of doctors, residents, and nurses takes turn presenting each case and checks in with each patient.

The first patient was an old lady with end-stage cancer and dementia. When we walked into her room, the patient was lying on her bed -- alone, unconscious, each of her shallow breath rattling with mucus. 

'That's not how I want to die,' I thought.

The patient's chest x-ray showed signs of pleural effusion, or a build-up of fluid around her chest wall that makes it difficult to breathe. Through a procedure called thoracocentesis (also called pleural tap, although I realized I kept saying pleuracentesis, which isn't a real word -- dammit!), we can remove the fluid in order to make her breathing easier.

A palliative measure, they said. It's not going to cure her, but relieve some of her symptoms and pain.

The physician used ultrasound as his guide to locate the area of fluid build-up. When he pulled the syringe, dark brown, watery fluid drained into the 50ml syringe -- it will be sent to the lab for further analysis. "Keep your eye on her heart rate, and let me know if it changes," said the doctor.

As he drained more fluid out, the patient's heart rate began to fall -- from 90 beats per minute to 80, then to 65. "She's going to code," he said. In a few minutes, the entire team was in the room, trying to resuscitate her. She was not taking in enough oxygen, and her heart slowed down to a dangerous level. The heart rate fell to 40 beats per minute, then into 30s -- I've seen that kind of heart rate once before, moments before my grandfather passed away in a neurosurgery ICU. 

"Push in epi," someone said, referring to the drug that increases cardiac output. A round of epinephrine flowed into her bloodstream. No improvement. A second round of epi went in. Her heart rate and rhythm began to rise again. "That's epi doing the work," said one of the nurses. "We don't know if we can maintain the heart function when the drug wears off."

At the same time, another physician was attempting tracheal intubation -- putting an oxygen tube into her airways. A resident was trying to put in a central line into a vein in the groin area. I don't know, maybe that's before they pushed in the epi, maybe after. It was my first time watching a code happen in front of my eyes -- just like most of you reading this, the only other times I've seen a code were from TV. No defibrillators, though (the electrical shocks, you know?). No panicking, either. The nurse doing the CPR was even cracking a joke. For some reason, that didn't feel inappropriate. It seemed to show they knew what they were doing.

I didn't get to stay long enough to see how the patient turned out. But, "if we did save her from cardiac arrest, we'll let her die from terminal cancer," as the attending physician said. The patient's children, who had the durable power of attorney, had stated that their mother get all the necessary care, regardless of invasiveness. "Respecting their will is part of the doctor's job, regardless of your principle," said the attending.

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If the reason I have to learn how to calculate alveolar-arterial oxygen gradient, determine the anion gap, and memorize the afferent and efferent neural pathways of the parietal pleura is to cure illnesses, alleviate pain, ponder the consequences of well-meaning procedure, and reflect on the meaning of life and death, then I am more than happy to suffer right now. Perhaps I already knew it, but it is too easy to forget why I signed up for this job when all I do is just calculate, memorize, and choose single best answer on the scantron. 

But, hey, you know what I realize -- doctoring can be pretty awesome. I just need to learn, pass exams, and stay alive until I get there. Hopefully we'll get to do more fun stuff in the third year. Hopefully soon.