Now I Know

I’ve not blogged much lately because my current job is really hardcore and I haven’t had that much time and I didn’t want to spend the free time I have had blogging because it reminds me of work.

In August, when I started working in Intensive Care the lead consultant, Dr. Cullen, asked me whether or not I wanted to do Intensive Care as a future career. At the time I really had no idea, and told him as much. You see, to us anaesthetists, Intensive Care work is a bit like Marmite in that it we either love it or hate it.

I worked in ICU in my first year of anaesthetic training, but at that time, I felt I didn’t really get a feeling of whether it would be something I’d like to pursue further down the line. I felt that I didn’t know enough stuff to be really useful and I didn’t know enough to actually make a real difference to the patients that I was helping to look after.

I’m now coming to the end of my current attachment in ICU and yesterday Dr. Cullen asked me again if I would consider intensive care as a career. This time I had an answer for him – no.

There are things that I really like about working here, I like it when we’re given a rapidly deteriorating patient, and I can stop their demise and (hopefully) put them on the road towards recovery. I actually like going round the wards and being able to be useful to other doctors who are struggling to look after their ill patients. I like the fact that I can actually do the majority of medical procedures, I’ve done dozens of central lines, arterial lines, intubations, chest drains, difficult venflons etc… etc… and these things no longer hold any mystery or worry for me. I like the fact that the ICU nurses are so switched-on and the fact that there are so many of them means that they can help us doctors out more which means I get to concentrate more on actually trying to get our patients better.

ICU is no land of milk and honey though. There are lots of things I really don’t like. A while ago, I wrote about why doctors get stressed and about some of the ways they cope. I said that simply being around unwell people is uncomfortable for people who have dedicated their lives to trying to make people well. I’m finding this really true of myself. Even when everyone is totally stable and there’s not much happening, I find just being on the intensive care unit stressful. The constant beeps, the almost continual alarms of the infusion pumps, monitors and ventilators, the fact that I know that things can, and often do, go tits up at any moment, all this things conspire to put my blood pressure up.

Our patients are all teetering on the brink of death. Actually, it’s more accurate to say that they’re well past the brink and with our machines we are desperately trying to push them back ONTO the brink so they have a fighting chance of living. This means that one of our patients will frequently drop their oxygen levels or blood pressure to a dangerously low level. They often hallucinate and try to pull out the very tubes that are stopping them dying. While the nurses are very good at sorting these things out, often they’ll need help just to stop the patient from expiring and it’s me that has to go and sort these problems out. Often I feel I’m fighting a pitched battle against the very people I’m meant to be helping. I find it frustrating that I can’t talk to my patients and that they’re often on the ICU for so long with only very tiny improvements to their health each day.

And then there’s the relatives. Seeing your husband/son/mother/grandpa/sister/friend unconscious and hooked up to all our machines must feel horrible. I can’t even imagine how I’d feel if I saw my mother lying their as one of our patients, I shudder at the thought. We try our best to explain what we are doing but I find having these conversations difficult simply because I don’t know what’s going to happen to their loved one. The two commonest questions a relative asks are “Is my loved one getting better?” and “Is my loved one going to die?” And the trouble is, often I simply don’t know if they’re going to live or die and, unlike when I was a physician, often I don’t even have a handle on how likely survival or death is. The uncertainty is often really hard for relatives to understand and deal with. But what I think is even more difficult is the timescale. As I already alluded to, patients stay unconscious with only very slight changes in their condition for days or weeks. We as doctors can see the subtle changes in their inotrope requirement, ventilatory demands etc… but basically, from the outside they look exactly the same. (Actually, as time passes, ICU patients look aesthetically worse as they swell up with fluid and accumulate puncture scars from all the tubes we keep sticking into them.) While we try to explain what’s happening, the seeming lack of progress after such long periods of time is often really distressing because relatives are sort of suspended in a seemingly unending, hellish limbo. Seeing relatives upset in turn upsets me because I too want their loved one to get better quickly, but it’s rarely possible and it leaves me wishing I could do more when I just can’t.

Dealing with other doctors can be wearing as well. There’s a constant trickle of calls for little things like venflons, lumbar punctures, central lines etc…from acopic ward doctors but that stuff doesn’t really bother me. I use my discretion. I help out if the request is reasonable and I’m free and able, if they’re just taking the piss and trying to get me to do their job for them, I have no qualms about telling them where to go. No, there are two things that really get me. Firstly, some doctors seem to have the belief that every unwell person should be looked after by the intensive care team. This really isn’t the case. Sick patients often don’t need Intensive Care, but they need the ward doctors to pay close attention to their condition and give appropriate treatments and sometimes, it’s hard to get ward doctors to understand this. Secondly, there are the group of patients who have been blatantly mismanaged on the wards and then I get a call to see them and am somehow expected to perform miracles. This frustrates me no end too.

And finally, there are the times where it really does all go wrong. There’s the fast bleeps, there’s the trauma calls and there’s the cardiac arrest calls. On average, I go to two or three of these every shift (my record is eleven). These are the situations where people are literally at (or through) death’s door. Sometimes, there’s not much for me to do at these calls, but sometimes there is. Often they’re just a horrible disaster and often the patient dies, sometimes in a more painful and disgusting way than you ever thought was possible.

So all in all, I’m working hard in Intensive Care, but I’d hate to do this forever. There’s too much drama, too much stress, too much politics, and too much frustration. If I had to do this forever, I think I’d end up worrying myself into an early grave, there are far easier ways of earning a living. I don’t think it’s any coincidence that two weeks ago, I found my first grey hair.