CSICU
Namath S. Hussain

Walking down the main corridor of the cardiac surgical intensive care unit (CSICU) was definitely a different experience for me. Although I had been on the wards for several months now, I had never seen patients this sick before. Patients on multiple drips, each with at least 4 to 5 lines running into them, with invasive monitoring, arterial blood gas lines, Swan-Ganz catheters, and intra-aortic balloon pumps. Observing medicine from this vantage point was certainly different. I had never seen such intensive and detail-oriented management of patients and minute to minute changing of drugs and orders. It was much more fast-paced, and I felt like doctors were using their academic medical school knowledge more than in other ward settings. The whole process seemed more academic, rather than merely vocational. We were looking at PV loops, blood pressures, and heart rates and playing with the variables. Basically, if you give one drug, you increase this. If you give another drug, you decrease the rate of that. It was very surreal. My first night on call was even more surreal.

It was 10:00pm. The dimmed hallway looked ominous. Patients hidden away in dimly-lit rooms, just as if they were waiting for death to overtake them. Monitors beeped periodically, and nurses ran over to check on patients and silence the beeping, which was probably the result of a loose lead or something, not a real medical problem for the patient. However, there was one beeping sound that night that wasn't merely a computer glitch or a misplaced or fallen-off lead. Something serious happened that night.

Mr. G was an ill-appearing male in his 70s who had cardiac surgery several weeks ago, but was in the CSICU for post-op care like most of the other patients. What made his situation different from other patients that stay in the CSICU for a few days before going home is that he had a severe infection of the sternum and mediastinum where the surgeon made the thoracotomy incision. This infection progressed over several weeks leading to septic symptoms. Multiple surgical debridements were of little use in his case. Surgeons kept on cutting away infected tissue to find more infected tissue beneath it. So now, Mr. G was in the CSICU, trying to make it through the night.

Dr. M was the attending that night. I had met her before, actually, because she interviewed me when I applied to medical school and was also my faculty advisor. During evening rounds, we talked about the different cases as we passed by each bed. When we came to Mr. G's bed, Dr. M had a drawn expression on her face. She told us that she suspected something bad was going to happen tonight. I was confused about why she chose him out specifically, because all of the patients in that unit seemed to be in the same horrible condition.

Later on in the night, our team congregated near the front desk area, which was near Mr. G's room. We talked about plans for the night and then dispersed. Dr. M and I drifted towards Mr. G's room just to check up on him. He was sound asleep, with the same vacant look on his face, this time with a slight frown. Dr. M sat down, and I asked her a question about one of the other cases. I stood facing her. As she was sitting, she answered my question while looking at the monitor above Mr. G's bed. However, this look turned from the usual old glance to the bedside monitor into a frank stare. I was confused why she was staring and not adequately answering my question. When I turned around to look at Mr. G's bed, a monitor started beeping. We both saw a nurse crouching down near Mr. G's bedside picking up some looped IV line off the ground. I breathed a sigh of relief. A lead probably came loose while the nurse was fumbling around near the patient's bed and IV pole. But she got up and stepped away from the monitoring lines. She wasn't touching anything. Nothing was disconnected. No leads were off or loose. No computer was being cranky. This beep was for real. Mr. G was coding.

Dr. M told the nurse to get out of the way and ran over to Mr. G and called everyone in. She quickly checked the leads and setup near the patient and found nothing wrong with the hookups. The crash cart came tumbling down the corridor. Nurses were ripping out endotracheal tubes quickly at first, but then advanced to a more nervous and frantic pace after Dr. M shouted "Come on!" in a brusk tone. Dr. M got the right tube and gave it to the surgery intern who was holding a Macintosh blade, ready to intubate. Her tremulous hands tried to pry open Mr. G's mouth. Secretions came flooding out of his mouth. Dr. M used a Yankauer tube to suction while the intern tried again. The intern quickly gave up, complaining of too many secretions. Dr. M took over and opened the mouth and stuck in the blade. She inserted the tube, and then a nurse checked for breath sounds. We were in! I was sort of just standing there watching, and Dr. M asked if I knew how to do CPR. I vaguely recalled the 15:2 rule from CPR class back during my second year of medical school. I started compressing.

Softly at first, until one of the nurses said "Harder!" So, harder I did. The intern was at the head of the table bagging the patient while a nurse brought out and charged the defibrillator. "Clear!" We all moved back, and he placed the steel paddles on Mr. G's chest. A tone…and then Mr. G jumped. Then again…and again…and again. No response. Dr. M got gowned up and was ready to crack the chest. The cardiac surgery fellow got to the scene by this time and gowned up. The fellow made the midline incision with a scalpel in one clean pass. Dr. M and the fellow then got a hold of the tough steel sutures and proceeded to unwind them. I sat there in awe. They were going to expose Mr. G's heart right there at the bedside. Until now, I had never seen even a minor procedure outside of the OR. As Dr. M was struggling with the thick steel blades, her thin arms trying to the strip the knots out, she slowly but surely made progress, and we were about to get into the chest and attempt to save a life. But then a nurse from outside the room jumped in with a telephone receiver on her shoulder. She said that the patient's surgeon was on the line. The surgeon said that we should not enter the chest under any circumstances. What?!? We're already there. Stop now? Fine. We stopped.

I could see the life leaving Mr. G's face. I could really see it. A few minutes before, his face looked alive. Not well, but still alive. But now his face really looked dead. There was no color in his cheeks, and the expression was just one of death. It wasn't vacant or expressionless. I've seen those before several times. But just dead. Things slowed. Everyone felt the big let down. It was time to clean up. Get the stuff back into the crash cart and clean up the room. Wow, we really did make a ridiculous mess in there really quickly. As we took off our gowns and gloves, Dr. M explained to us that the surgeon thought that if there was a situation that necessitated us going into the patient's chest, then his chances for survival were so minimal that whatever intervention we would apply, it would be pointless.

At that moment, I realized something. Opening up Mr. G's chest and taking heroic measures to save his life had not been balanced with a practical point of view of whether or not it was likely that he would survive. You must be practical for the patient's own sake in order to prevent subjecting him or her to undue pain and suffering, rather than taking heroic measures designed in large part at times to fulfill your own ego and take away that feeling of guilt.

Before coming to medical school, I never understood why surgeons would refuse to do procedures. I assumed that, in such cases, surgeons were just giving up on their patients. That is something I swore to never do. However, I can now see the wisdom behind a doctor stopping therapy or stopping a surgery. There comes a time, when doing more isn't doing better. I assumed that the more you do, the more the patient will benefit. I thought that there was a direct, linear relationship between the two. But, I guess, that's too simple of a model to analyze the complexities of human healthcare.

Patient consent and listening to what the patient wants and not being paternalistic is big in the medical news these days; however, I think that we can't just let patients and families do whatever they want. Physicians know medicine. That is their expertise. They should not always defer decisions to patients or their families. Physicians must provide input and, at times, must make decisions that are contradictory to what the patient or family wants. That probably is paternalistic, but that type of paternalism is needed if we are to protect our patients from fruitless interventions.

Being on the wards has taught me a lot about medical practice and physician decision-making. Experiencing medicine rather than just learning about it has really made the difference for me, and I have come to learn to cherish these special interactions between physicians and patients. Halting care for a patient may seem cold-hearted at first. But, often, when you analyze the situation more closely, you'll find wisdom and courage in that physician's decision. The wisdom to have a vision for the patient's future and the courage to stand up to patients, their families, or other healthcare providers to tell them that an intervention must stop.

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