YOLO

Heralded by screaming lights, a man was dropped on our doorstep. Sepsis. Diabetic keto-acidosis. The brink of death.

He was also cachectic from decades of drug abuse and malnutrition, and didn’t have much reserve to fight the illness. He was struggling to breathe. He looked on with hollow eyes. We knew right away he wasn’t going to make it through the night.

Because the foreseeable outcome was so extremely grim, we were upfront in asking this man exactly what he wanted from this hospitalization: How did he want to die? Would he have us pave for him a comfortable end? Or would he have us wring out every last drop of frail existence before throwing in the rag?

To our surprise, he didn’t give us permission to let him go. In previous months, his life had been repeatedly spared in hospitals. But each time, he was restored to lessons unlearned—if he was better, he was better enough to overdose. So said his family, but he didn’t believe it.

So onward we fought.

These are Medicine’s most trying moments. I have sent off many people from this world, now—always when they’re ready, and sometimes when they’re not. It’s humbling and gratifying to be the last friend in a well-lived life, the one to bestow a parting IV and hospital blanket in the final glow of sunset. It’s frantic and dissonant to be the desperate arm over the cliff, the one obliged to hang on until the last futile chest compression. So often I’m assigned the latter role by patients with too many regrets in too little time.

Miracles are doled out too, in small packages of insulin and antibiotics. This man survived to wake up tied to a hospital bed, and—this is the miracle—to think to himself, “This ain’t me.”

The next few days were excruciatingly painful. We gathered everyone—patient, family, and doctors—to have a big heart-to-heart. The man expressed his resolve to come off all narcotics forever. The family had heard it all before. The medical team decided to test his resolve by taking away his pain medications gradually. We had legitimate reason to be skeptical, as he had legitimate reason to be in pain. Every morning, I asked about his pain. The answers went from “Okay” to “It’s 8 out of 10, but I can get used to anything” to “It was more than I could take last night, but I’m bound and determined to do this.” I don’t know how, but every day his smile grew wider and he was able to walk farther. All the while, his severe joint deformities were a constant reminder of his strength in coming face to face with this pain for the first time in so many years.

He later told me of the transformation that came over him. The morning light was breaking through the blinds. He was strapped at his waist. The nurses were eerily quiet in the hallway. He thought of what we had told him, that we expected him to die from the consequences of his habit. “I haven’t been scared since I was in Vietnam crawling through the jungle. But that night, I was ready to put on my street clothes and run!”

I don’t know if all this will last. But thanks to him, I’m willing to give a second chance to many more of my future patients. I wouldn’t have believed that, with either his body or his mind, he would make such a recovery. Now I’m starting to think I’m in Medicine to be proven wrong—and, in the process, to be made better.

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Trauma, Death, and the Big Picture

In reading this eulogy of Steve Jobs written by his sister, I was tickled to learn that on his ICU bed, Steve was inventing hospital gadgets.
One time when Steve had contracted a tenacious pneumonia his doctor forbid everything — even ice. We were in a standard I.C.U. unit. Steve, who generally disliked cutting in line or dropping his own name, confessed that this once, he’d like to be treated a little specially.

I told him: Steve, this is special treatment.

He leaned over to me, and said: “I want it to be a little more special.”

Intubated, when he couldn’t talk, he asked for a notepad. He sketched devices to hold an iPad in a hospital bed. He designed new fluid monitors and x-ray equipment. He redrew that not-quite-special-enough hospital unit.

For the really big, big things, you have to trust me, he wrote on his sketchpad. He looked up. You have to.

By that, he meant that we should disobey the doctors and give him a piece of ice.

I just came off my first overnight call in the Trauma ICU, after working 31 hours straight. This sketch of Steve is just like the patients I’ve met this week: can’t eat, can’t breathe, can’t move, but would like to go back to skydiving ASAP.

I think there are generally two types of ICU patients. There are the vegetables subsisting on life support, and the rest are feisty. The bull-rider with multiple spine fractures insists on bull-riding again the next day, even as he struggles to sit up. The teenager, whose ATV accident required brain surgery, asks me every hour whether we can take out the tube draining the bleed within his skull: “Will it be later today? Not ’til tomorrow? I can’t sleep with this thing coming out the back of my head.” As I write this, a man whose brain is exposed by gaping holes in his head, is trying to pull out every IV and monitor and walk right out of the hospital.

It seems as though these patients have an entirely different set of priorities than their doctors have for them. We want to manage their fluids and electrolytes. We want to make sure they have an airway. We want to save them from dying of pneumonia, of ischemic bowel, of cardiac arrest. But all they want is to continue whatever they were doing that landed them in the hospital in the first place. Don’t they learn from their mistakes, and don’t they realize that they can’t live without these devices and measures we are taking for them?

But as damaging as it can be to a doctor’s ego, I get it. I don’t believe our work is more important than the lives we save. We bring out the defibrillators and ventilators to make people continue living, but that is not what I consider “saving a life.” People don’t live to have normal potassium levels measured in their blood. People live to bull fight, to dirt bike, to invent computers, to be home with their family.

Obviously the basic needs have to be met in the hospital. It can be a cruel process, and patients may not get that ice cube after they’ve already starved for days, but we take great consideration in the treatment plan and believe that what we’re doing is for the best. But after the healing is done, when bodily functions return to baseline, then what? Our story ends with the hospital discharge.

But the hospital discharge is the beginning of a longer road to recovery and life. Lots of changes and arrangements have to be made at home. The patient may be a burden to their family for a long time yet. That is why, beyond getting to leave the hospital bed, my hope is that these patients can survive to the next time they can do what brings them joy, whether it’s strapping on a parachute or bouncing their child on their knee. To me, that’s when their life has truly been saved, not a moment sooner.