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Medical Humanities

ICU, a Shared House of Rituals

Matthew Ettleson

The physician floats through the morning ritual on his way to his new job site: the intensive care
unit. The crescendo of a local radio station breaks the silence of night. With a jet of warm
water, condensation on glass obscures a tired reflection not quite ready for the day. Flakes of
cereal scatter in a bowl, and a splash of milk makes a quick morning meal. A key turns and an
engine rumbles to life. Next is a cruise through a quiet downtown, still mostly in slumber. Even
the street lights, flashing yellow, are half asleep. A lonely parking lot awaits its earliest visitors.
A quick scan of a badge, and the side door of the hospital slowly acquiesces. Down a short
stairwell and up via elevator, the physician finds himself at the doorstep of the ICU, home to
the sickest patients. Just before entering, as if to savor the very last moments before being
swept away in the current of patient care, the physician steps to his left into the nearby lobby.
The open space of the lobby is bordered by tall glass windows. Curious as always to what the
day will bring, the sun peaks over the tree-lined arboretum, bathing the lobby in sunlight. Light
stretches to a doorway, which links the family waiting area to the general lobby. The door to
the physician team room stands within the waiting area, causing the physician to awkwardly
enter this space. Early in the morning, the only protest to the incursion is the low din of the
national news cycle on a small television fixed to the corner of the waiting room. As the shift
ends, the physician again crosses into the waiting area to return to the team room to collect his
belongings prior to the journey home. The ritual repeats.

In many ways, the ICU is a house of rituals. Every physician, nurse, and patient engages in his or her own pattern of behaviors, set against the background of the perpetual rainbow of tracings
and chorus of bells produced by the telemetry monitors and ventilators. As patients teeter on
the edge of stability requiring frequent attention from all parties, the ICU has a gravity that can
be difficult to escape. After the first few days, the physician adopts the ICU as his home,
spending more hours in the unit than he does in his own home.

Then, without warning, the cycle breaks. Waking from sleep, the physician begins the morning
ritual. With a certain automaticity, he is back in the sunlit lobby, peering into the family waiting
area. Interestingly, there is a perturbation in the morning ritual. Normally open, the door to the
family waiting area is shut, blocking the rays from creating their usual yellow pathway to the
team room. The physician, with caution, opens the door slowly to find a counterpart, not much
younger than he, asleep on two chairs configured into a makeshift bed. Suddenly, the physician
is an intruder in a private residence. He makes a quick dash for the team room door and closes
it quietly behind him. Having placed his bag in its usual resting place, the physician ventures
back out into the family waiting area. His glance lingers on the sleeping stranger a bit longer,
and he suddenly recognizes the stranger as the grandson of the patient he admitted the night
prior. He spent the night at the hospital, not far from his grandfather’s side.

Over the course of the following week, the physician and grandson form an alliance in patient
care, interpreting subtle grimaces and gestures in the hopes of communicating with the patient
and loosening the grip of delirium. Slowly, with certain trepidation, the patient inches stepwise to his former self. The plastic connecting patient and machine is removed. Feet that have been
elevated and cushioned for days now embrace the floor in uncertainty, as the first steps are
attempted with assistance from physical therapy. Patches, wires, and catheters are discarded.
In his final act, the patient takes his seat in a wheelchair, with grandson at the helm, as he
passes through the double doors exiting the ICU. As the patient slips out of sight, the grandson
turns back and meets the distant gaze of the physician. A quick nod is exchanged, and the
alliance is dissolved. But captured in that moment is the memory of the new morning ritual. The
physician, quietly entering the grandson’s temporary home, did his best not to disturb the
precious sleep few are afforded in the ICU. The grandson provided updates on the patient when
the physician was busy with other tasks. The physician and grandson were destined to split
eventually, but for that brief time together, they navigated the patient through the ICU’s
controlled chaos.

The ritual restarts. The physician lumbers through the sleepy downtown once again. He takes
the elevator to the ICU lobby, which is dimmed from overcast skies. The waiting room door is
open and the path to the team room is clear. Yet, there is a brief moment of loss. No longer a
home, the family waiting room is quiet, abandoned. What was once a bed is now just
misaligned chairs and a used blanket. Picking up his head, the physician walks back through the
double doors into the house of rituals, ready to forge a new alliance.

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Matt Ettleson is a third year internal medicine resident at the University of Michigan. He studied chemistry as an undergraduate at Northwestern University and received his medical degree from the Feinberg School of Medicine. He is interested in medical education and patient-physician communication. He is from Chicago and currently resides in Ann Arbor, Michigan.