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In the ICU, and thinking about Huckleberry

I'm in the ICU this month. It's a great place (the only place?) to learn what I need to be a competent ER physician -- but it's no less draining for knowing that.

The medical ICU is a joyless place. It's a place where very sick people stay, usually at the end of their lives, to absorb all the high-tech medicine that we can possibly throw at them, in order to live a few more weeks than they would have otherwise. Yes, there are important exceptions, where we save a patient's life in the ICU and he or she leaves to spend time with their families and go for walks on sunny days in their favorite park -- but this is still an exception.

Add to this the horrendous hours, which makes it impossible or at least very difficult for residents to get to know each other as anything other than tired, overworked, cogs in a machine. Throw in the intern's inevitable lack of knowledge and gross inefficiency, and it shouldn't be surprising that there's not much joy for them in the ICU. Speaking for myself at least, there isn't.

My brother just lost his cat, Huckleberry. He was the greatest cat. Friendly, intelligent, and always hungry! He had some klnd of cancer that deformed his jaw, and he had to have it taken off. For a cat who loved to eat, that must have been a particularly large loss. My brother, because he loved this cat, did the best thing for him in the end, and had him "put down" by the vet. Huck, RIP.

If Huckleberry had been a person, he would almost surely have been laid up in the ICU for the last few weeks of his life. He'd have been unconscious, with a feeding tube down his throat to substitute for the eating he'd loved before the cancer. The people "caring" for him would have been overworked and unfamiliar with him as anything other than a reason for more chores. They'd have been more concerned with writing down all the numbers that the machines hooked to his body were spewing out 24 hours a day than with "caring" for him in any sense that could have mattered.

I'm not saying that we should euthanize people. I'm saying that the end of Huckleberry's long life was probably better, being my brother's cat, than it would have been as a human being.

***

Here's a poem I've posted before that means more to me now that I'm spending so many hours in the ICU.

Three Elegaic Poems
Wendell Berry

I
Let him escape hospital and doctor
the manners and odors of strange places
the dispassionate skill of experts

Let him go free of tubes and needles
public corridors, the surgical white
of life dwindled to poor pain

Foreseeing the possibility of life without
possibility of joy, let him give it up.

Let him die in one of the old rooms
of his living, no stranger near him.

Let him go in peace out of the bodies
of his life --
flesh and marriage and household.

From the wide vision of his own windows
Let him go out of sight; and the final

time and light of his life's place be
last seen before his eyes' slow
opening in the earth.

Let him go like one familiar with the way
into the wooded and tracked and
furrowed hill, his body.

II
I stand at the cistern in front of the old barn
in the darkness, in the dead of winter,
the night strangely warm, the wind blowing,
rattling an unlatched door.
I draw the cold water up out of the ground, and drink.

At the house the light is still waiting.
An old man I've loved all my life is dying
In his bed there. He is going
slowly down from himself.
In final obedience to his life, he follows
his body out of our knowing.
Only his hands, quiet on the sheet, keep
a painful resemblance to what they no longer are.

III
He goes free of the earth.
The sun of his last day sets
clear in the sweetness of his liberty.

The earth recovers from his dying,
the hallow of his life remaining
in all his death leaves.

Radiances know him. Grown lighter
than breath, he is set free
in our remembering. Grown brighter

than vision, he grows dark
into the life of the hill
that holds his peace.

He's hidden among all that is,
and cannot be lost.

Comments

I lost a cat to feline leukemia once, and it was heart-wrenching. Poor Huck.

What lovely,moving and touching poems. Perhaps because I am now approaching that era of my life, I can relate so well to them.
Yes, one should be able to see the faces of loved one as death nears. Thanks for the good ear.

Nice post, I enjoyed reading as always. I will be in Chicago this week for a health law conference. As I am sure the ICU is occupying your time we will have to grab lunch or something another time. Good luck on the remainder of your rotation!

What a thoughtful post, Glorfindal. Keep it up. We need a lot more dedicated people like you!

This was incredibly thought provoking on many levels. First, I'm sorry to hear about Huckleberry - it's hard to lose a much loved pet. Secondly, the beautiful poem brought back a flood of memories of my father's death 6 years ago at home through Hospice - it was a sacred event (and I don't say that lightly or tritely). Thirdly, many ICU patients (more than just a few exceptions)go on to have good quality lives after going through Physical Medicine and Rehabilitation (can you tell I work at a rehab hospital). That's where some joy comes when they discover that one can accomplish great things in a wheelchair or with only one limb or after being shot in the head or falling off a sixth floor balcony or being hit by a car. There is joy after intense suffering. I've often thought about the Emergency Medicine doctors who probably never know what happens to some of the horrors they help put back together and whether or not it was worth it for the patient. A couple of our PM&R doctors (one an attending and one a resident) are confined to wheelchairs - one paraplegic and one quadraplegic after being hit by a car in a parking lot. I can't begin to tell you the encouragement they bring to all the patients, especially the SCIs. One of them spent a lot of time in the ICU. Fourthly, you sounded so tired and weary in your post and sometimes it's hard to see the whole picture when one is sleep deprived. Fifthly, thank you for going through all this so some of your patients can experience the joy after the suffering.

I stumbled upon your blog via Pharyngula.

I don't know what it is, if it's because I just watched the first season of Scrubs again in like 2 days, but your thoughtful treatment of this subject really got to me. I am especially fond of the poem you included at the end there.

I had a pet ferret named Guinevire who was diagnosed with an insulin-secreting pancreatic tumor. She was hypoglycemic, and she lived a fine life for about a year taking daily medicine much like a diabetic would. However, at the end of that year she started having seizures every day or so, with little or no improvement inbetween. I took her to the vet and decided to have her euthanized, because (surprise surprise) she seemed to not be enjoying the constant seizures. There's no doubt in my mind that I did the right thing.

This experience made me think a lot about human illness and the way we treat it, even when it's clear that the patient will never recover. I don't know whether that extra week, month or year is worth it to the patient or their family...but I do think that people should have the right to choose euthanasia for themselves.

Anyway, your post provoked some thoughts and there they are. I will continue to read in the future. Good luck with your stint in the ICU.

Nice post. From my residency training, I found the ICU time to be the most challenging, but also fun because it was intellectually engaging and a bit complex from a mathematical perspective.

This morning I had my 19 year old Packy, old faithful cat put down. I've had to get use to the idea of taking her in for almost a year but I decided I was being selfish. I've known for a while she no longer feels very well. I knew this morning when she didn't want to get off the bed and she just couldn't eat breakfast that it was her time. We spent a quiet early morning on the couch so I could pet her a say my goodbyes.
The thing I wasn't prepared with was the flood of memories that have come to me, all the associations that Packy was part of like when my daughter Marissa found her as a starving kitten and bicycled with her in her backpack for 2 miles to bring her home. The death of my parents who I lost 3 years ago. My God, I'm utterly in mourning.
That you for sharing your beautiful poem. The responsibility of taking a life is enormous. I feel happy that Packy is in a better place now.

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