Residency Diaries Series #3: thoughts on MICU nights

Below is an entry I wrote while I was on night float as an intern in the medical intensive care unit, or the MICU. Thinking back, it’s crazy that anyone let me be in charge of some of the sickest patients in the hospital- but in reality there were several layers of checks and double checks (senior residents, fellows, attendings) to make sure I didn’t accidentally harm anyone. The scariest thing about being a senior resident and eventually an attending is that every year there is less and less of that layers of checking and protection with every decision I make for my patients.

I recently read about the Libby Zion case and something about it really struck me to my core. If you aren’t familiar with it, this case is basically the reason why there is a 80-hour/week cap on resident work hours. It’s a very sad and fascinating story: a young woman tragically died as a result of being given meperidine while taking phenelzine, an antidepressant she was taking at the time, leading to serotonin syndrome. She was under the care of an intern and a second year resident when she died— both of whom were blamed in a large, public trial. The trial lasted several years, as they usually do, and seems to have been extremely emotional, with grand juries at one point having to decide on charges including murder (ultimately grand jury declined to indict on murder charges).

I feel that if something like this had happened to me as an intern or a second year resident (or maybe even now), it probably would have been enough to make me leave medicine altogether. Being a resident is hard enough— I can’t imagine going to bed knowing that there is a group of people deciding whether your honest mistake should be considered murder in a trial. Apparently multiple experts at that time swore under oath that they were not familiar with the interaction between meperidine and phenelzine and its potential for serotonin syndrome. How could an intern and a second year resident possibly have known that?

I looked up the residents involved in the case and found that they are still practicing medicine. I give them a lot of respect for that. Medicine is a tough career. You make decisions that impact someone’s life and at times, their transition to death. This is especially true in the MICU where patients are often teetering between life and death. I don’t have any more MICU rotations left in the residency, but as a 3rd year resident in the ED, I’m sending patients to the ICU almost every shift. I also lead codes in the ED and am usually the one calling time of death when it becomes clear to me that the patient will not come back (in conjunction with the attending of course). It’s crazy. Who gave me that right and who gave me that power? Am I making the right call? I think a good way to judge is to ask myself: if it were my mom, my dad, my grandma, my husband (depending on the age and comorbidities of the patient in question)… would I do the same thing for them?

2/4/2019 Monday 4:04am

Thoughts on MICU nights:

People die on a pretty frequent basis here in MICU. But I think the worst part of it is actually the anticipation of death rather than death itself. Most patients who die in the MICU have family members who have more or less accepted their loved ones’ death. 

 I recently had a patient who had metastatic cancer, end stage liver failure, severe sepsis with multi-organ failure… Basically the patient was never going to make it. The family couldn’t withdraw care for religious reasons and the patient basically laid in the ICU for days and days with worsening labs and a terrible yellow, ghastly look on his intubated face. The family knew he was dying but couldn’t make any decisions that would actively shorten his life so they had to just sit there and watch. One night he coded and we, as discussed previously, went forward with multiple rounds of CPR. As we were doing our 3rd round of CPR (because of course he got ROSC after 2nd round then went into vfib and received shocks), the wife went up to the nurse quietly and said “how much longer are they going to do this? You know I can’t tell them to stop.”

We eventually stopped and the family was sad of course but I can’t help but feel that there was some level of relief in his death as well. Later one of the residents brought up that in Israel there has been proposals of putting a timer on ventilators so that the family is able to make an active decision to continue care rather than having to make a decision regarding withdrawing care, which they are forbidden to do.  

 [We are often told that the family is against withdrawal of care, but often agree to stop escalating care. Whether that means not adding on any more pressors than what already exists, choosing not to do dialysis when kidneys inevitably fail, or not checking labs… it seems to mean something different for everyone.]

 Something I’ve noted in these deaths following prolonged ICU stay is the family’s presence during the code. In the ED we often make family members step outside as we run the code. I suppose this is because ED codes are often unexpected and shocking. In the ICU, the families seem to be slightly better prepared mentally (as much as possible when it comes to a loved one’s death anyway). The two codes I’ve been involved in so far in the short 2 weeks I’ve been in the ICU, family members have stayed in the room while active CPR goes on. It’s a pretty violent, chaotic scene and initially it was hard to understand why family members would choose to stay in the room and more importantly why no one was trying to kick them out. After talking to family members after one of the codes, I learned that they actually really appreciated seeing everything done for their loved ones. Everything-- including the rib-cracking chest compressions, hurried intubations, yelling of times for the various meds given/pulse checks, sometimes electric shocks that literally lift the lifeless body off the bed… I guess it gives families some peace of mind that everything that could possibly be done has been done.