The unit

I’m now three quarters of the way through my ICU rotation. As I expected, I’ve liked this month quite a lot – interesting pathology, great colleagues, free lunch. Also – unexpectedly – decent hours. My strong preference is to work early-to-early: I like to arrive at work early and leave early enough to spend meaningful time with my kid and husband in the afternoon and evening. These days I tend to get in around 6:30 and I’m usually out the door by 4. Miraculously, medical students in the ICU have weekends off. So, I’m happy: between the ICU and mothering Sam, life is good.

But here’s an ICU tidbit for you: at Stanford – to be fair: Stanford is not known for Wal-Mart prices – ICU beds cost in the range of $30,000 a day. And that’s just the bed! $30K a day before the patient gets a single CT scan, dialysis treatment, liver transplant, subspeciality consult or – as a patient of mine received yesterday – 150 grams of donor derived albumin. ICU stays easily and frequently run to the seven figures and as much as no one wants to think about it, let alone talk about it, the cost of intensive care is a real problem.

There’s a patient on our team, insured by the state’s Medi-Cal program, who has been in our medical ICU for weeks. When she was admitted, the cause of her severe and refractory respiratory distress was somewhat mysterious. In her late 50s, she’s a cancer survivor who received radiation treatment to her chest earlier this year. (Radiation pneumonitis?) Then, midway through her ICU stay, she was found to have a significant burden of blood clots in her lungs. (Pulmonary emboli.) Now, she has a ventilator acquired pneumonia. So she’s been treated for this range of maladies (steroids! Anti-coagulation! Antibiotics!) over the course of the past three weeks and the effect has been … nil. She’s still desperately dependent on the mechanical ventilator to breathe. Worse, her pain and agitation have been exceedingly difficult to control; she vacillates between significant sedation and sedation “holidays” that aren’t fun for anyone, especially the patient and her (equally agitated) nurses. My attending has expressed near certainty that she will never again breathe on her own. Her lungs are too stiff and too scarred. Despite our range of treatments, her morning chest radiograph looks just as bad now as it did when she was admitted. (To wit: it’s hard to see her lungs at all. “White out”, the radiologist calls it.) In fact, there is unanimous consensus among our ICU team that the time has come to withdraw ICU support and to help this patient die comfortably and with dignity. And yet – understandably, I acknowledge – her family continues to drag their feet in a frustrating cycle of missed family meetings and refusal among her adult children to make a decision regarding their mother’s care unless the entire family quorum is present. So we continue to prolong the slow and tortured death of this woman who alternates between sedation and frantic agitation, breathing at a rate that’s more than twice normal. And we continue to spend money at an equally alarming pace: $30,000 or more a day from the California state coffers at a time when our fair state is running a $40 billion deficit.

It’s frustrating to say the least. No one seems to know what to do.