D-E-A-D

Overnight call in the surgical intensive care unit. Arguably one of the scariest places in the hospital, the SICU consists of 30-something rooms with sliding glass doors lining the perimeter of a huge cluster of desks and monitors and collections of tubes and people and chaos. Most of the patients within each glass cubicle are hooked up to 2-10 different foreign bodies: central and peripheral IV lines, arterial lines, Swann-Ganz catheters, nasogastric tubes, drains, chest tubes, endotracheal tubes attached to ventilators, a dozen different kinds of ports of which I still don't know the names. Most of them are so heavily sedated that they do not even grunt when you poke and prod them, lifting their gowns to inspect their oozing wounds and measure the output of their bodily fluids. They're kept alive with positive pressure ventilation and potent vasoconstrictors to support their blood pressure. They're monitored more closely than anyone else in the hospital - besides the doctors (who actually do check on them repeatedly), they are cared for by ICU nurses, who are exceptionally smart and demonstrate more dedication and compassion than anyone around.

Still, I hate it here. I am so viscerally uncomfortable, the minute I punch the combination code to enter the SICU fortress. Every time I hear something beeping, my stomach curdles and I want to go home. This is why I requested to do a 27 hour shift here: to own my discomfort, immerse myself in the overwhelming chaos. And maybe, just maybe, learn a little bit about how to take care of the sickest patients I'll ever meet.

I've spent most of the day being just as useless as on my other surgical rotations - tagging along and lurking behind hardworking residents. But I'm actually learning a ton. I'm already far less overwhelmed by the mysterious collections of "things" to which people are attached, and things that beep. It's been a relatively smooth day...

... until tonight.

I accompanied my resident to see an 86 year old woman whom we intubated earlier this afternoon, who was now coming off of her sedation and beginning to appreciate the circumstances of her world. She was not pleased. Pulling at her breathing tube, moaning, gesturing to us to take it out. My resident explained that she needed it to breathe for now.

Out of the corner of my eye, I saw her tapping her bed - waving, almost. I asked her if she were trying to tell us something. She nodded.

I offered her paper and a pen. She began to scribble, slowly. I translated aloud, spelling the letters as she wrote.

D ...a....e...d....d...p...u...d...e...d...

This went on for five minutes. She kept tapping the pen in frustration every time I misread a letter.

D...a...e...a...d.

My heart sunk. I knew exactly what she was trying to write now. Should I continue? What if I were right? Or worse - what if I were wrong? I ignored my predictions. I dared not suggest it, just in case -- how scary and rude and horrific for her to hear this if it had not already been on her mind.

"Dead."

I read it, silently. Now there was no mistake. I couldn't ignore it -- now it was in plain sight. She was truly communicating to us that she wished us to withdraw support, right here on my little scrap of paper. My eyes glossed over. Chills down my spine, down my left leg.

"I can't read what you're saying -- maybe we can talk later?" said my resident.
I wasn't sure if he was dodging the issue, or truly couldn't see what I saw.
"I think she just spelled out d-e-a-d..." I said, softly.

Our patient began to tap fervently and nodding her head. We both stood there, frozen. I didn't know what my role was supposed to be at that moment. I hadn't even introduced myself as I tagged along with my resident into the room. I didn't know her, I didn't know her family. I didn't belong here. But here she was, telling us that neither was she. We had something in common.

I don't know anything about ventilators and central venous catheters and fixing people who are dying. But I knew a little bit about being scared in a hospital.

"I know you're scared. The breathing tube is just temporary. It comes out soon, as soon as your blood tests come back normal to make sure you're safe."
Blank stare.
"Is that what this is about? The tube?"
She shook her head no. I had no idea where to go from here.
"In the hospital, it's very common and normal to feel depressed and scared and hopeless. It goes away, it gets better..."
Blank stare.
"Your family -- do you remember them coming today?"
Shook yes.
"How about we wait for them to return tomorrow so you can talk with them?"
Shook no.
"Have you spoken with them before about your wishes?"
Shook yes.
"Are you close with your family?"
Shook yes.
"So how about we wait til tomorrow - maybe the tube will be out and you can speak freely..."
Shook no. She pointed again to her tortured letters on my notepad.

I hurt for her. She was so hypovolemic that her eyes were tearless. Mine made up for hers, I guess. I was at a loss. I understood her. I understood her loud and clear.

And I didn't know what on earth to do about it.