A Biopsy

There are certain patients who never fade from a doctor’s memory — they make
an indelible imprint on one’s training. Thinking back on these patients and their respective hospitalizations is
like gazing through a pristine window pane on a clear, sunny day. Often they
stick in our memories because one becomes emotionally invested in
them or because there is some interesting disease or singular clinical
outcome. The former patients usually affect us more deeply.

Blood cells from a patient with Leukemia
(Prof. Erhabor Osaro via Wikimedia – CC)

I can tell you her name, age, and favorite foods to eat and cook. I recall,
without difficulty, how many children she had, her religion, where she grew
up, traveled and met her husband. I can even recreate her hospital room in
my mind — family pictures across from her bed, a knitting kit on her
nightstand next to her laptop computer, a plastic storage bin with clothing
and candy.

She was in her fifties and had been diagnosed with

, a cancer of the blood. There are different types of leukemia, but in
general, patients with leukemia have bone marrow that overproduces certain
infection-fighting cells, or

white blood cells
. Some of these cells function normally, but many do not. They overcrowd the
marrow, preventing it from making red blood cells and platelets. If there is a high enough number of them, they clog up blood vessels. And
eventually, the cancer kills you.

Treatment of leukemia involves rounds of chemotherapy,
potent drugs that arrest cell growth or division by acting on a specific
stage in a cell’s reproductive cycle. Each of these drugs
targets different aspects of quickly dividing cancer cells. But they also
wreak havoc on the body’s normal cells, causing nausea and vomiting, hair loss,
heart damage, kidney damage, and liver damage. Unavoidably, the therapies for
leukemia have serious, sometimes intolerable side effects.

The goal of prescribing such potent medications is to wipe out all of the
cancer cells. But it is especially important to wipe out the “stem cancer
cell” — that is, the original cell or group of cells causing this tempest. If
you can’t kill those cells, you cannot cure the cancer; they divide and produce more defective, parasitic, and deadly neoplasms. For
certain patients a

bone marrow transplant
 is the best hope for a cure. Chemotherapy wipes out one’s own bone marrow
and cancer cells to make room for the transplant, which does not contain
the same cancer progenitors. The donor’s marrow must match the patient’s
marrow; the cells produced from the transplant must be sufficiently genetically similar to the patient’s or the white blood cells from the donor tissue will attack the patient’s own body.

Our patient had gone through multiple rounds of chemotherapy, all of which
failed. She had found a match for a bone marrow transplant, though, and was
going to try a new combination of chemotherapeutic drugs to wipe out her
bone marrow in preparation for the procedure. This process takes weeks. Thus, she lived
in the hospital, receiving family along with friends from church.
During the afternoons, after rounds, I would come by and chat with her if
she wasn’t too exhausted or sick. Our conversations wandered from religion to food, travel, and family. We talked about history, too. She was a Civil War buff
and had no trouble discussing her favorite historical figures from that era
and her favorite speeches.

She possessed a seemingly infinite amount of patience and kindness given the
circumstances. I never once heard her bemoan her situation. She wanted, I think, to be treated as she had always been
treated, even as the reality of her prognosis set in. If she hadn’t had children, she once mused to me, she would have given up after the last round of chemotherapy failed and opted for palliative care. But her
children were too young to lose their mother, and so she hoped to live on.
So we hoped with her, attempting just once more to extend her life.

At a certain point towards the end of the chemotherapy regimen, we extract
bone marrow from the patient and look at the marrow under the microscope
with a pathologist. A
hematologist aspirates the sample using a large needle and spreads it onto
an approximately three-inch-by-one-inch slide. The oncologist, pathologist,
residents, and students look at the small sample of tissue. Ideally, there are very few cells and almost no cancer cells.
Otherwise, the chemotherapy has failed and the transplant cannot be done.
As the pathologist moved the slide of our patient’s marrow around, large dysmorphic cells popped into view. There weren’t a lot of them, but they
were noticeable and they were cancerous. I heard the pathologist offer up a
disappointing, “Hmmm.” No, as it turns out, the chemotherapy had not killed
enough cancer cells to make the bone marrow transplant worthwhile. Tragically, the patient would soon die.

It is strange, is it not, that this human being’s outcome depended on an
inch-wide sample of bone marrow? We do not think of people as bundles of
organs and cells but as whole, complete beings. We think of people
abstractly or even holistically — character or personality, physical and
mental abilities, age. Who cares about the cells in their marrow? What
bearing does that have on the life to be lived? But it matters much more
than it seems. This small sample ends a life or gives fresh winds to a sick
life. It is counterintuitive to the way we think, but it is how we make
decisions in medicine. We treat the person but we also treat the disease.
If the disease still exists and runs rampant within the body, the person, no
matter how admirable, familiar, and recognizable, will perish.

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

Image via Shutterstock

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

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.