The very phrasing of a doctor’s rounds implies repetition, the physician rotating around the hospital as if running laps. But in truth these circuits are never the same twice, our visits less rote than improvisational. You must budget time for patients whose answers are elasticized through analgesia, the narcotics slurring and slowing their responses; you must defend against the ambush of an out-of-state relative, appearing at the eleventh hour to ask pointedly why you’re “not doing everything” for a moribund patient about to be detached from the ventilator; you must explain to said accuser about the two hellish weeks in the ICU that they circumvented from afar, parsing out mechanically inflicted agonies from the agonal breathing that signals the swansong of a merciful finitude. If our rounds are like Stations of the Cross, this interrogation is like being forced to narrate the crucifixion, blow by blow, nail by nail.


But most of all you must be prepared to handle absences. Sometimes your daily visit coincides with the patient having been taken elsewhere in the hospital for testing, whisked away in a wheelchair to the radiology department for X-rays, for instance. You have to make a mental note to circle back in the evening to check on them and their results, adding another loop to your daily programming. But other absences are more foreboding than mismatched schedules. Occasionally the empty room speaks of a permanent vacancy.


Such is the case this morning in the intensive care unit. While calm environments can be conducive to healing, there is such a thing as excessively quiet. Even when the patients are unable to talk, the machines that sustain them are audible, the low hiss of air compressors sitting shiva by the barely breathing. Heartbeats can be heard too, broadcast as the hopefully-regular beeping of pulse monitors. And so there are auditory cues upon approach to an ICU room as to the status of its occupant.


Silence fills me with dread, and I can hear too well the clacking echo of my footsteps hurrying towards the noiselessness.  There’s a visual hint as to the room’s contents too. The sliding door, usually pulled shut to keep the patient semi-hermetic in their suspended animation, is conspicuously open. And finally, an olfactory clue before the revelation: the sharp note of ammonia, wafting not from an unclean bloodstream but from a liberal application of bleach.


Finally at the entrance to the room all this sensory input coalesces into proper context: he is gone. It is at the judgment of higher forces as to whether he has risen but there is no doubt of his departure, somewhere. Most tangibly his body has been relocated to the morgue, awaiting its final resting place in the earth or sky depending on the decedent’s wishes. The housekeeping staff has moved quickly to scour away the vestiges of his gory final days, stripping the bed of soiled linens. I have no doubt that the last sheet laid over him would have looked like a macabre shroud of Turin, stained in cold blood. Elsewhere his skin would have wept from IV insertion sites and decubitus ulcers, the stigmata of the bedbound in multi-system failure.


And so this visit renders me less like a healer than Mary Magdalene, reconstructing the scene after the fact.


I ask why I wasn’t notified of his passing in the night. I receive only a shrug in return, and I know the tacit answer of a foregone conclusion. I too have participated culpably in the futile exercise of the half-code. It is a dirty little secret of medicine that sometimes we try longer and harder to bring one patient back than another. The football player who collapses mid-play will get more sustained and vigorous attempts at resuscitation than the cancer-addled nonagenarian.


Some of this is pure physiology. Not all cardiac arrests are created equal. The ventricular arrhythmias tend to be shockable, capable of being coerced back into normalcy with a sufficient and well-timed jolt. But others are beyond rescue even with a substation’s worth of voltage. Pulseless electric activity, for example, is a disorganized jumble of spikes unable to synchronize the muscles, a heart’s final fury signifying nothing.


More of it, though, is learned helplessness of who you can’t bring back, mingled with the guilt of past spasms of violence aimed at the nearly departed. The patient may decide not to go gentle into that good night, but we should not dispatch them with uselessly fractured ribs. Successful cardiopulmonary resuscitation is life-saving; unsuccessful CPR is abusing the dead. Often we can tell the difference before the very first chest compression.


My pager was silent overnight, and I can only hope that my patient slept just as peacefully.

Mark LewisComment