Editor's Commentary on Lesson

 , June 21, 2020

One of the necessary growing pains of residency is working in the intensive care unit (ICU). Along with learning how to pronounce a patient, break bad news, and juggle multiple tasks simultaneously, learning to cope with what is seen in the ICU is required learning. As newly minted MDs, we gain acceptance with our long white coat and stethoscope around our necks. But we soon find out that neither of these are protective against the life-and-death drama of the ICU. Zhang reflects on his month in the ICU at a major quaternary hospital in the midwest, describing each patient that he remembers. A young patient with seizures due to a rare metabolic disorder; a lady with severe respiratory failure who ends up with strokes, ischemic limb and subsequent renal failure; and lastly a failed 3 hour code. The barrage of patient information and unavoidable mortality in the first paragraph serves to overwhelm readers, reflecting a similar moment that the author was in. 

Zhang finally describes a middle-aged man he was taking care of in the ICU with pontine glioblastoma. He quickly runs over the facts, listing admission diagnosis, pertinent blood work and imaging, and the medications he orders to reduce intracranial pressure. Afraid to admit to himself that the patient improved, he instead notes that “everyone starts to believe that we had successfully pulled him from the brink of death.” Then the patient suffers a spontaneous head bleed which is deemed non-operable. 

What do we do when there is nothing else to be done? We learn that despite the hard-won years of medical knowledge and training, we may not be able help our patient the way we want to. We cannot reverse glioblastoma nor death, only alleviate suffering and provide comfort. When there is nothing more to be done, we help our patients by being there for them and their families. 

At the end, Zhang watches as family members go in and out of his patient’s room to say goodbye. It’s a poignant moment of quiet realization, and of his resignation of the need to do more. He accepts the finality of death when the patient’s wife thanks him. Connecting with his patient made it more difficult to realize that nothing more can be done. But without the connection, his patient would just be another number, another task. Zhang shares an intimate reflection of his own limitations, illustrating the constant tension between what is, and what ought to be. 

Esther Lee