Bardos

Buddhism has this concept of transitions, or bardos, transitions between one state and the next. When a practitioner is prepared, they can be opportunities for enlightenment; for the unprepared, they can be terrifying. Buddhism captures the same fears and opportunities many religions do about death, just in a different framework. The picture is the 'big buddha' on Lantau island off of Hong Kong, which I saw in college--although my favorite was the tiny stone buddha in an alleyway in Kathmandu.

When I saw those buddhas and read about bardos I had never seen people die. From my perspective they really do withdraw; wikipedia above describes all these stages of the bardo of death--final breath, lucidity after the final breath, then the space until the next life. I feel as though my whole service right now is in that state--some stage on their way out. Three brain-dead patients between yesterday and today, two donating organs, preserved for now. I joked I was the angel of death. Now, I think not so much. That's too stereotyped, co-opted by the halloween crowd. Bardos are more my style. They're more real, too. Death can be terrifying, but maybe, if we prepare ourselves, it might be a transition to something else? I hope?

Old School

When my hands ache from four central lines and an arterial line, and I laugh inappropriately at the MRSA swab on the brain dead 20-year old overdose admission because I'm too tired to care about hiding my derision...

When my boss tells me to go upstairs and talk to the overdose girl's family and it's just me and two parents who have lost a daughter and the nurse...

When it gets to be one in the morning and I haven't even started my documentation for the three afternoon transfers...

When these shifts come along, they make us doctors.

End of Life Care

I morbidly joke, usually on my ICU months, that when my time has come, I'm taking my morphine and going on a long hike.

The way we treat end of life care in this country bespeaks a discomfort with death that is bad for the dying. My jokes aside, ICU patients are often there for unexpected catastrophes: muggings, subarachnoid hemorrhages like time bombs in people's skulls, car accidents. That these people are alive is a medical achievement of high order.

However, as Buckeye Surgeon notes, the return on our investment is somewhat less than miraculous. After these catastrophes, despite our ability to image the smallest blood vessels in the brain, and measure a gazillion-and-one physiologic parameters, we rarely are able to restore full or even almost full function. As a pediatrician I was shadowing once said to a patient, 'we can fix some things, but if you fall on your head or neck, we can't always fix it'.

For families, this presents a problem. Some don't care; they bring the social security benefits form in for their comatose relative to 'sign' with an X so they can collect a check. Others are in the ICU room for days and days, monitoring tiny changes in progress. My wife blinked. My mom moved her toe when the doctor yelled in her ear.

I think we need a frank discussion in our society that makes it OK to transition to comfort cares. Hospice docs have long held that allowing a failing body to expire on its own is more comfortable than prolonging life. Gradually failing lungs raise CO2 levels and essentially sedate the dying patient. Procedures to monitor ICU patients, on the other hand, are often painful--bladder catheters, arterial catheters, needles, ventilators.

Don't get me wrong--these are life-saving advances. But when it becomes clear that the prognosis is poor, it should be easier to say, 'enough'. We need to face death and accept it, not hide it behind sliding glass doors and curtains.

Damn it all

Just had to intubate the Marlboro man, in room 3. Stubborn bastard wouldn't keep his sats up. Second time in a week.

This tube didn't feel like saving a life, it felt like ending it. He'll never come off the vent.

Scary

Room 1 is an 84-year old stroke, clotted off her whole left carotid. We had to place a central line. Her BP is supposed to be like, 220.

Room 2 is a forty-something with c-spine surgery that lead to fulminant meningitis on the ventilator.

Room 3 is a COPD-er who is breathing 30-40 and dropping his saturations to the low nineties on BiPAP who we are giving one last shot at breathing because if we tube him he will never breathe without help again.

Room 4 is an intubated subarachnoid hemorrhage who moves her feet, sometimes, and blinks.

Room 5 got tPA today and was bleeding from her IV, her ET tube, her NG tube, and her eyeballs when she arrived. Her blood pressure is supposed to be low. Pray I don't mix room 1 and 5 up.

Room 7 is a poor guy who got mugged for three dollars after his car skidded into a ditch and the person who offered to help him beat him up. He only moves half his body.

Room 8 is bleeding from her tracheostomy, has renal failure, and can't move because she's been here so long. She's having trouble breathing.

I'm the only white coat here.

Only six more hours until the others return.

Only five hours, fifty-nine minutes until the others return.

And so on.