And the rain falls...

One of the more difficult tasks in being a resident on the front lines is managing the expectations of patients and their families in the face of death and debility. Just when you think you have a grasp on how patients should do... how they're expected to do... life still manages to upset the odds. Granted you always mention the caveats, as we often throw in the cliche that we don't have a magic crystal ball that can tell us the future. But even so, we minimize the unlikely, and in the eyes of a patient or family member who can only hear one answer, inadvertently tell them that they'll either going to live or die.

I had a patient come in after falling and hitting his head the other day on call. He was pretty old, but all things considered looked like he would walk out of the hospital in one piece. His CT showed diffuse subarachnoid blood around his left temporal lobe, but it wasn't causing any mass effect or obvious compression of the neural tissue. From what I had seen before, the prognosis for this amount of blood wasn't bad. I reassured the family, encouraged them that the first couple days were the most important in determining outcome, but that he was looking good now. No, they didn't have to call in the whole family from across the states. No, they didn't have to have his grand-daughter take the first flight in to be there. He went from talking and following commands to not talking and being extremely agitated. He's just sun-downing, I thought, (disorientation that elderly people may experience when in an unfamiliar place at night while experiencing any physical illness), he'll pull through this. I left post call confident he'd be ok.

The next day I was in the OR till 7PM, but he was still listed as being in the ICU so I didn't bother to check in on him. But the following morning on rounds I noticed that we had skipped him. I asked later what had happened, only to find out that the family had chosen to place him on comfort care, and with a little morphine to ease his pain he slipped quietly into the night.

I was furious.

Murderers, I thought. He was doing well. Why did they have to withdraw care? He was going to make it. I TOLD them he was going to make it. But apparently he didn't do too well the ensuing hours after I had left. I had fought so hard to get him through that night. Seeing my efforts undone by my own unrealistic expectations, by the decisions of family members behind the scenes... I can see why people in this line of work can become cold. How many times does your hopeful encouragement need be proven wrong before it becomes empty words and pleasantries to prevent despair rather than inspire hope? People die. And they'll continue to every day in our ICU. But we need to believe we're making a difference in their outcome. We need to believe that all our fancy intracranial pressure monitoring, lactate pyruvate ratios, transcranial dopplers and jugular venous bulb recordings are leading them towards recovery. Don't get me wrong, we definitely see our fair share of miracles. But in spite of our pontificating and intellectualizing, some people improve while others don't. Some recover from the cold lifeless barbiturate comas on life support while others suddenly pass from the world of the living. We fight against the closing curtain with all our might, but in the end, people die, the sun grows cold and the rain still falls.