|Life in the ICU is like a game of Snakes and Ladders. Illustration by Dr. Tirthankar Dutta|
“Can you tell me where you are, Mr. Pemberton?” I would ask the middle-aged man every morning as he was recovering from abdominal surgery. “Oh, I’m in New York,” he would answer with unwavering conviction from within the depths of his crumpled bed sheets. “Just sitting here drinking my coffee, until my wife comes back from her shopping trip.” Two weeks earlier the surgeons had excised a melon-sized tumor from his bowel and found his abdominal wall peppered with several other smaller tumors, signifying a slim chance of cure. He had some baseline dementia before the procedure, and the anesthetic and the ordeal of the surgery seemed to have further impaired his cognitive function. I knew there was little chance of improvement, yet I liked knowing every day where he thought he was. Some days he would be by the Thames in London, on others just exiting a bookstore in Paris. “I’m having such a good vacation!” he exclaimed one afternoon to the nurse who was documenting his bowel motions at his bedside.
“Oh we’re so glad you feel that way, Francis!” she replied.
“But where’s the nearest pub?” he asked.
Going on an annual overseas trip had been one of the major highlights of his marriage. Now every day after lunch his wife, a retired librarian, would sit with him and they would attempt to complete the day’s Sydney Morning Herald crossword puzzle together (another long-standing ritual). Some days he would fire off the answers, on others he would simply doze off or barely respond to her repeated prompts. When the crossword proved too much, they would shift to playing Snakes and Ladders. He would punctuate his moves with the sound effects a child would make, “Clip clop, clip clop, uppp the ladder. Whooosh . . . down the snake. Uh-oh!” She took the variations in his cognitive status in stride but diffidently asked us from time to time if there was any hope of getting him back the way she had known him. Our answers were always non-committal and guarded.
The impression an intensive care unit (ICU) often projects with its shiny machines and screens and meticulous documentation is that we have medicine down to a perfect science. That we can predict a patient’s prognosis with mathematical precision. What is closer to the truth however is that life in an ICU is like a game of Snakes and Ladders.
Mr. Antonopoulos was a case in point. A sturdy former miner, he was rushed to ICU after suffering a sudden cardiac arrest while undergoing rehabilitation for a knee replacement. An angiogram found three large blockages in the blood supply to his heart. He returned to ICU following the insertion of three coronary stents, intubated, requiring mechanical ventilation and heavy sedation. Over the next few weeks his family, who were by his bedside every day, read an ocean of hope into each ripple of movement—the flicker of an eyelid, the twitch of a hand. After ten long days we finally removed the tube from his throat. Two days later he began breathing on his own without support. When I came around to examine him on my night shift, he was more interested in discussing the latest cricket scores than whether or not he had any chest pain. The relief on the faces of his wife and adult children was tangible. His wife brought in baklava for the staff to thank us all for taking such good care of him. Our nurse unit manager put in a request for a bed on the ward; he was ready to be “stepped down.” (Only in ICU does a step down actually mean a step up in terms of your health).
And then one night I heard a slight wheeze in his chest. Despite re-starting him on stronger antibiotics, having the physiotherapist undertake “aggressive chest physio”—literally thumping his chest to make him cough up and dislodge sputum—the wheeze became louder. Eventually he was unable to get enough oxygen into his lungs and even the act of breathing became too tiring for him. From one night to the next, after being so close to exiting our unit, Mr. Antonopoulos slithered down the snake and ended up intubated yet again, with a machine supporting his respiration. Yet again his family resumed their heartbreaking daily vigil by his bed watching, waiting, and hoping. He eventually succumbed to his intractable pneumonia.
Still there were others who somehow defied the odds. Brother and sister Mark and Clare Johnson found themselves in ICU at the same time, he because of acute kidney and respiratory failure, and she with cellulitis in her legs that got out of hand. Mark had to stay in an isolated room because of certain antibiotic-resistant pathogens in his blood, but Clare would monitor his progress from a nearby bed via the nursing and medical staff and relay messages to him. For most of his time in the unit Mark was intubated and unresponsive, his blood circulating through a dialysis machine whirring next to him. Meanwhile Clare’s wounds seemed relentless, burrowing into her soft tissue and making her daily dressing changes absolute torture. Even with painkillers prior to the nurses taking her bandages off, she screamed in agony. We wondered if Mark could hear her above the erratic jazz of beeps, clicks, and whirs of all his attendant machinery. Miraculously, Mark began to breathe on his own on Australia Day, which also happened to be Clare’s birthday. We wheeled her over to his room in a wheelchair so that he could wish her a happy birthday. After that, both siblings began to recover, as if they had conspired together to formulate a coordinated exit plan from ICU. Clare’s wounds healed without needing surgical intervention and Mark’s kidneys came out of hibernation and sprung into action. Within days of each other they both managed to leave for the wards.
And Mr. Pemberton? He too ended his stay in ICU and went to a regular ward. I later heard he had been well enough to make it back home with his wife. I visualize them fondly, as I used to see them in ICU, their heads close together, huddled over the day’s crossword puzzle, sunlight streaming in through the venetian blinds, him still regarding life as an ongoing vacation.
The personal narrative is based on my experiences as a resident medical officer in the intensive care unit. Patient names and other identifiers have been altered in order to de-identify the individuals mentioned.
SHAMPAS SINHA, MBBS, is a former Australian diplomat and World Bank public health specialist, currently working as a medical registrar in Sydney, Australia. She has published poetry, travelogues, and fiction in a variety of publications in the US, Australia and India. As a medical student, she was selected as one of five students internationally to blog for The Lancet. She has a keen interest in indigenous and global health issues and palliative medicine. This personal narrative is based on her experiences as a medical resident in ICU.