A Tour of the Intensive Care Unit (ICU)

I have a rendezvous with Death
At some disputed barricade,
When Spring comes back with rustling shade
And apple-blossoms fill the air—
I have a rendezvous with Death
When Spring brings back blue days and fair.

It may be he shall take my hand
And lead me into his dark land
And close my eyes and quench my breath—
It may be I shall pass him still.
I have a rendezvous with Death
On some scarred slope of battered hill,
When Spring comes round again this year
And the first meadow-flowers appear.

God knows ’twere better to be deep
Pillowed in silk and scented down,
Where Love throbs out in blissful sleep,
Pulse nigh to pulse, and breath to breath,
Where hushed awakenings are dear …
But I’ve a rendezvous with Death
At midnight in some flaming town,
When Spring trips north again this year,
And I to my pledged word am true,
I shall not fail that rendezvous.

—Alan Seeger, I Have a Rendezvous with Death

The Intensive Care Unit is an uncomfortable place. It is where the sickest patients in
the hospital reside. Because many of the patients require emergency medical interventions or close monitoring, the layout resembles that of the emergency department (ED). Patient rooms encircle a nurse’s station where computers sit on a long table. As in the ED, each room is filled with machines
projecting vital signs, EKG tracings, IV fluid rates, and other information towards the physicians and nurses. And the nurses in “the unit” (as it’s
commonly referred to) are always active, checking in on patients throughout the day and night.

There are many different types of intensive care units: some for patients with heart issues (cardiac ICU), others for patients with neurological issues
(neuro ICU), pulmonary or general medical issues (medical ICU), surgical issues (surgical ICU) and cancers (oncology ICU). What we see in each unit,
however, is equally disturbing. And what follows are the some of the things one might see (and which I have seen) in different ICUs over the course of a
day.

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In the neuro critical care unit, one patient lies unconscious with a massive and deadly brain bleed. In another bed across the room, a patient with a rapidly expanding
brain tumor cries out in searing pain from a headache. In the cardiac intensive care unit, a patient, hours after receiving a ventricular assist device (VAD), a device which helps the heart’s ventricles pump out
blood after being weakened by disease, receives chest compressions from a nurse as he goes into cardiac arrest. Another unconscious patient in the far
corner of the room is on ECMO, or extracorporeal membrane oxygenation, after
having massive heart and lung failure. ECMO takes blood out of the venous system, oxygenates it in a machine and then pumps it back into the arterial
system, thus bypassing the heart and the lungs. In the normal circulatory system, blood goes from the veins into the right side of the heart and
subsequently to the lungs where it is oxygenated, flows to the left side of the heart and is pumped into circulation to nourish the body’s tissues. ECMO
temporarily maintains circulation until the patient’s heart and lungs can function on their own.

In the oncology unit, a middle-aged cachetic patient lies face-up in the bed, staring at the ceiling while fungal and bacterial infections cause his blood
pressure to drop and heart rate to increase. Despite the medications used to prevent these infections in cancer patients with very low white blood cell
counts, sometimes the microbes sneak by. And because chemotherapy used to treat cancer destroys white blood cells, the cancer patient has nothing left with
which to fight off the infection. Even the most minor bacterial invasion can be fatal for these patients, as it eventually was for him. Meanwhile, in the next room, another
patient had just passed away and her family crowded around her bed sobbing and mourning their loss while holding the expired patient’s
hand, hoping for the return of warmth.

Unusual sounds percolate from room to room in these dank areas of the hospital. Most noticeably, IV poles beep
constantly as they run out of their fluids or medications. Cardiac monitors sound alarms as patient heart rates dip too low, rise above a normal level, or register abnormal
rhythms. Some patients moan and scream, losing all sense of time and of themselves. Or, perhaps they curse and threaten nurses while withdrawing from
alcohol. Others vomit and pass gas. Some patients demand the impossible: “get me out of here!” or “leave me alone!” Sometimes patients need to be strapped
down to the bed because they pull out their IVs as they wail and moan and thrash about. During the day, minimal light shines into the unit and it is
tainted by the sickness and suffering which pollute the air and tint the windows. Foul smells, which I wrote about here, are most potent in the ICU. Many ICU patients,
though washed by nurses, have not bathed in weeks. The stench of sweat, stool, and blood permeates the unit when nurses change patients’ diapers,
suck accumulating mucous out of patients’ mouths, and clean up blood-stained sheets.

And if you think it’s bad for providers, imagine what patients experience. The ICU must feel like a kind of hell on earth. Sleep is rare when your
neighbors expectorate, choke, vomit, and shout, and nurses and physicians constantly wake you up, draw blood from your veins, and examine you to ensure your
mind still functions correctly. Some patients can’t eat or drink because they need surgery (it is safer to put patients under anesthesia for surgery when
they have not eaten because food will not come up from the stomach and choke the patient or travel into the lungs while they are unconscious) and so they go to bed hungry and
thirsty. A patient may even go to sleep not knowing whether he or she will wake in the morning. You may be one of those who
has a rendezvous with death tomorrow; you may be one of those who survives; you may hang on by a thread for weeks. Who would ever want to end up in an
ICU?

And yet, it is in the ICU that patients receive the most fastidious care. Nurses watch over only one or two patients and thus can keep a close eye on them.
Physicians trained in the art of emergency procedures, like intubation, are always around
and watchful. Nobody will be more attentive to your medical needs than an ICU team, which monitors every sign of life you emit: breaths, heartbeats,
skin color, blood pressure, electrolyte levels, blood counts, infectious disease cultures from your urine to your spinal fluid. The advantage of being in
the ICU is that you receive the care that you need even if it is in a frightening environment. I hope I never have to be there, but if I am severely ill at
some point in my life, the ICU is the place I would choose to be.

Labor and Delivery

The obstetrics nurses rushed the stretcher through the triage station as the resident tore out of her chair and followed them. I jumped up and ran with
her. It was the second night of my obstetrics rotation and there was no time for triaging this patient, who was on the verge of giving birth. And because
she spoke almost no English we could not get a history from her. If we had been able to, we would ask all about her gynecologic and obstetric history. Most
importantly, we would ask if she had been screened for sexually transmitted diseases (STDs) which can be spread to the baby
leading to horrific consequences including severe developmental disorders and death. The baby, though, came too fast for any kind of serious conversation,
even with a translator. In women who have given birth before, like this particular mother, the birthing process goes much faster. Therefore, when a multigravid woman comes in and claims that the baby is about to come out, obstetricians immediately
rush her into the delivery room.

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We transferred the patient onto a bed, pulled out stirrups for her patient’s legs and detached the bottom part of the bed such that half of the patient’s
derriere hung off its edge. As she opened her legs I saw the tip of the emerging child’s head, mostly covered in dried amniotic fluid, blood, and other
bodily secretions. The resident, attending, and I quickly put on sterile gowns, gloves, and masks and, encroaching on the woman’s privacy (though she didn’t
mind just then as she began to howl in pain with each uterine contraction),
stood in between her open legs at the entrance to the vagina, our hands ready to catch the baby.

With each muscular contraction of the uterus, the baby inched further and further out into the world. The resident coached the mother, imploring her to
push as she continued to scream. In a not-so-surreptitious manner, the father pulled out his iPhone as he stood by his wife’s head and hit “record” to
document the birth of the couple’s third child. He wore an enormous childlike grin as he did so, aware both of his
slight irreverence and of the imminent addition to his family.

After a few contractions, the baby’s full head emerged and the resident and attending supervised as I delivered the baby. My heart rate skyrocketed; I
sweated, trembled, and attempted desperately to remember the childbirth simulation I had been through one week earlier.

The delivery of a baby is not all that complicated when it’s first explained (here’s a proper

YouTube video of it
 — ignore the very corny soundtrack and beware the graphic nature of the video) but try doing it when the time comes and you freeze up very fast. In an
ideal world, as the baby’s head appears, one puts pressure on it so that it does not pop out and tear vaginal tissue. Make sure the head rotates so
that the baby faces the inner thigh of the mother (also known as external rotation). This rotation also allows one of the baby’s shoulders to emerge. Once
that shoulder is out, tip the baby towards the exited shoulder to allow the other emergent shoulder to exit as well. If you try to get both shoulders out
at once there is a danger of shoulder dystocia in the newborn — the shoulder of the infant
sticks behind the maternal pubic bones leading to anything from transient nerve paralysis in the baby’s arm to compression of the umbilical cord cutting
off oxygen supply to the child.

With the resident’s and attending’s hands near mine, I performed the delivery. As I angled the baby’s shoulders and allowed its body to exit the vagina, a
huge amount of fluid gushed out — a combination of amniotic fluid, some blood, liquid mucus, and vaginal discharge — and soaked my shoes and gown. Ignoring
this, I clutched the child to my stomach to prevent her from slipping out of my arms (not very smooth). You’re supposed to hold the baby in the left arm
with the head in the palm and the body resting on your forearm, not clutch the baby to your chest. When babies are born they are frighteningly slippery though.
And, fearful of dropping the baby, I used both arms and my abdomen to cradle the child, praying I would not drop her.

I held the neonate below the level of the vagina to allow the umbilical cord, which has vessels
that carry oxygenated blood to the baby in utero, to drain all the rest of the blood into the child before cutting it. The resident clamped the
umbilical cord on two ends, waited a bit, and then cut it. This prevents the two ends of the cord from bleeding. Simultaneously, the attending suctioned
out the baby’s nose and dried off the baby with a towel. Newborns are prone to temperature changes so we dry them off and then wrap them in a blanket to
keep them warm. The resident took the child from me and handed her over to her mother while the father continued to use his iPhone to record this remarkable moment. The mother bawled and even the father cried as his smile enlarged to one of complete and unreserved joy. Their perfectly healthy, new daughter held their rapt attention
and despite the commotion around them, nothing distracted the parents from this life.

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The pediatricians arrived in the room, examined the baby for any malformations (none were found, thankfully) and placed her in a hospital crib. We continued to deliver the placenta, tissue which attaches to the uterus
and allows for the umbilical vessels to exchange deoxygenated blood from the baby for oxygenated blood from the mother. It is semi-flat and looks very much like an alien organism
nonetheless it is crucial to the survival of the fetus. After the baby is born, if the placenta remains inside the uterus, there is a greater risk of
infection in the mother. I gently tugged on the umbilical cord while I massaged the lower abdomen with my other hand. This helps coax the placenta out of
the uterus and also helps to stem the bleeding from the uterus (uterine contraction is integral to cessation of bleeding postpartum). The placenta slowly
plopped into my hands; warm, squishy, and bloody. I placed it in a plastic tub and began to clean up all the tools, gowns, and gloves when the resident got a
call on her phone: another woman about to give birth two doors down. We rushed out.