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Tuesday, July 22, 2014
ONLINE FIRST: BOOKS: ‘ON THE EDGE OF LIFE: Diary of a Medical Intensive Care Unit,’ edited by Mikkael Sekeres, MD, MS, and Theodore Stern, MD; Reviewed by Robert C. Young, MD

                                                              ROBERT C. YOUNG, MD

 

There seems to be an intense public fascination with emergency room medicine. Television shows like Scrubs, and ER presented humorous or sanitized versions of the subject. A documentary series on Vancouver General Hospital on the Knowledge Network (Emergency Room: Life and Death at VGH) won several awards this year. Books abound: Emergency! True Stories from the Nation's ERs by Mark Brown, MD; Angels in the ER: Inspiring True Stories from an Emergency Room Doctor by Robert Lesslie, MD; and Something for the Pain: Compassion and Burnout in the ER by Paul Austin, MD, all present a more distilled and abridged version of the reality experienced in the trenches.

 

This is not so with On the Edge of Life. Mikkael Sekeres, MD, MS, rotated through the ER of Mass General where a journal had been started by Theodore Stern, MD, allowing house staff to jot down their thoughts about the experience. Now, 20 years later, the journal has grown to seven volumes of unabridged observations recorded in real time. The editors have used these thoughts and distilled them into separate chapters on humor, life and death, patients and families, and doctors.

 

The result is a candid, realistic, no-holds-barred, even at times harsh, collection, which will unfortunately ring true to all who have rotated through an MICU. It must be said that the information is also disturbing and in many ways disheartening. As one house officer said, “I’m scared, sad, incompetent, weak, pressured, lonely, isolated, bitter, dumb, inefficient, and nobody else could feel as I do.”

 

House staff are plunged into this fray and have to act immediately to care for the sickest of the sick. One house officer captured the feeling of inadequacy perfectly: “I wrote my first order as a physician (to give the patient potassium). Actually the nurse told me the patient needed potassium, taught me how to write the order, what to give, where and when. But I was able to write my name without any help!”

 

Humor somewhat paradoxically is a common part of the MICU experience. Dr. Stern emphasizes that “Humor bonds staff. Sleep, food, and shared laughter are powerful medicines and great pacifiers. Displays of humor insulate staff from the misery around them. To outsiders, the gallows humor may seem inappropriate, sophomoric, and ill timed. It probably is. Humor can facilitate coping but it comes at a price. Doctors use humor because at times it is easier to laugh than to cry.”

 

Female physicians struggle with career building and child-bearing during training years. This makes for some unique physician-related humorous circumstances. Consider this interaction: “JAR [junior assistant resident] on the road to matrimony plans for the future. Let’s see, if I get pregnant right now, I wouldn’t have the baby until August.” SAR [senior assistant resident]: “It would make rounds a little uncomfortable for the rest of us.”

 

Humor often comes from patients who misunderstand our “medspeak.” Here is an example: "Patient who had an inferior wall MI while walking his pit bull. SAR: He needs bypass surgery. Patient: Can’t I just get rid of the dog and take it easy?"

 

One of the grimmest messages in the book is the struggle doctors have to come to grips with the realities of desperately ill patients. Twenty-five percent of patients will not leave the MICU alive, and even fewer will leave the hospital and return to functional lives. The ideal candidate for the MICU is a patient with a short-term serious curable illness. Yet the editors point out that “most [MICU patients] are frail, elderly, and destined to die of chronic disease but are kept alive by the use of advanced technology.” As one house officer explains, "Plenty of people have come through the MICU this month. Yet it strikes me that in the saves column, after 59 admissions and only 12 deaths, we have only two.” As another house officer wrote; “just because we have the capacity to prolong life in elderly people doesn’t mean we have to, but we do; everyday in this place we prolong suffering at little benefit.”

 

The editors explain; “We manage to learn a great deal about the mechanics of medical care for desperately sick patients, but caring for patients in the ICU raises issues about aggressive and expensive health care; it is often ambivalent and disturbing. A lack of definitive answers, guidance, and policies contributes to the distress experienced by house officers.”

 

Because these unvarnished thoughts from these young physicians are all too familiar to most doctors, it’s hard to know whether re-reading these first-hand experiences will be of sufficient interest to a broad spectrum of doctors or oncologists. It certainly left me with the view that many of the serious and stressful issues of complex care of the chronically ill in MICU’s have not been addressed since I was a house officer.

 

Unfortunately, patients and lay readers will likely be confused by the medical jargon and probably frightened by the candid expressions of ambivalence toward end-stage medical care expressed in such blunt fashion.

 

However, progress in making the MICU a more inviting and compassionate place is being made. In the June 26 issue of the New England Journal of Medicine (NEJM 2014;370:2506-2514), a review article, “Dying with Dignity in the Intensive Care Unit” by Deborah Cook, MD, and Graeme Rocker, MD, explores in detail the coexistence of palliative care and critical care in the MICU. They discuss the need for palliative care, the importance of eliciting the values of patients, the critical need for communication about patients’ perceptions about what matters most for high-quality end-of-life care. They call for providing clear prognostic information, recommendations to forgo the use of life- support technology, and the need to provide holistic care. They advocate for patient and family-centered decision making, communication, continuity of care; emotional, spiritual, and practical support; symptom management; and importantly, organizational support for ICU clinicians. The article is a comprehensive and encouraging blueprint for improving MICU care. However, it will be a challenge to accomplish in this era of restricted health care budgets, manpower shortages, and clinicians’ time constraints.

 

In the same issue of the journal, a Perspective article, “Where We Die” by David Rothman, MD (2014;370:2457-2470), notes that throughout history until the mid-20th century, the appropriate place to die was at home surrounded by family and friends. Now in the 21st, we are returning to more deaths at home and fewer in hospitals, but greater ICU use.

 

The test for the future will be to create an ICU culture that utilizes increasingly complex treatments but also helps patients and their families make wise decisions about managing the end of life.    

 

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