A Critical Day in Critical Care and Med School.

It is my final clinical rotation as a medical student, and my last few days of it. I have spent this past month doing an elective in Critical Care medicine. But today was truly a critical day -the most intense of all my days on this intensive care unit, revealing a lovely synergy of lessons from my entire experience as a medical student. How appropriate for the metaphorical 'eve' of my becoming a real doctor.

It started off ordinary, unremarkable -dare I say, a "slow" day, in the ICU. I joked with the other med student, "It's the calm before the storm". I was lucky to even have a patient by the end of the morning. Something was amuck with her -we knew that since yesterday. Now, more obviously in Acute Respiratory Distress Syndrome (ARDS) -not ASA toxicity, not as likely an inflammatory / autoimmune process, most likely infectious and not faring too great. We decided it would be best to intubate her. With that small chin and big, thick tongue, we predicted a difficult intubation and had anesthesia present for back-up. The room was loaded: nurses, resp therapists, students, residents, fellows and staff physicians, and the bunch of us watching through the glass, from the outside. One, two, three tries; oxygen saturations plummeting down within moments from 90% to 80, to 70, to 40, to 7. I was strongly reminded of my little NICU baby who had also been difficult to intubate and had so desaturated a year and a half ago. Mask ventilate. Then the fourth try, and the tube is in. The tube is in, but the balloon is busted, so the other staff comes, threads a guidewire and then another tube. Stable on the vent. That got our own adrenaline going, but the patient was okay -we felt she was safer. Yes, this was better. "That was a close call" said the others. Someone started to go on about what they would have done differently -easy for them to say, but I know it's not the same when you're there. I had been there, with that baby -I could at least appreciate that it could happen to any of us, so cut them some slack.

And then a good, long lull. We went for lunch. I had some Mediterranean vegetable and cheese streudel and a Cott Black Cherry. Laughed, vented, talked shop and life. Walked back to the unit. Still nothing. The residents had sorted who would be presenting at Morbidity & Mortality (M&M) Rounds the next day. We still had a lot of empty beds. It was just hitting on 1 pm. The fellow and I sat at the desk, wondering what to do next.

"Code Blue. Code Blue."

The ICU nurses had already run upstairs. The code team was huge -ER docs, Medicine docs, nurses... we didn't think we'd be needed so much, but we walked up briskly anyway. One year ago, it would have all been a blurr. But I wasn't shocked or frightened this time. I listened, I stood back and out of the way. Surgeons spoke with the nurses, who spoke with the medicine residents and fellows. Our team hung back for a moment. I caught bits and pieces of the patient's history. She had been on the ward a while, a complicated post-op cancer patient, with multiple other illnesses -the standard poor old lady. Stable this morning and then suddenly, vomited massive amounts of blood and just wouldn't stop. And then somebody said "Anesthesia?" and our team member disappeared into the room to help intubate the patient. The morning's episode turned out to be a 'dry run' for this afternoon crisis. They pumped fluids, pressors, unit after unit of packed red blood cells, platelets and clotting factors and still the patient bled and was unstable.

And then on one side, stood the third year medical student, shocked in a daze, running frantically to get things that the doctors inside asked for, but always returning after someone else had already acquired what was needed. That was me last year, with my jolly, Greek patient, who was always "fine", teased me regularly, but always said "Thank you Doctor". And then one day, the day before he was meant to be discharged home, he had vomited blood. So much blood. He had lost consciousness. My seniors had pumped him up with the goods, just like the more experienced residents, fellows and staff were doing for this poor old lady now. My patient had spent a week in the ICU where they finally managed to control the bleed. But he almost died.

Here now, this girl, only one year my junior, her patient was almost dying the exact same way. Nobody was with her, nobody was explaining anything, understandably, given the circumstances. I went over and asked her to tell me more about the patient's history -afterall, she was the one who followed this poor old lady every single day. I nodded, sometimes asked a question, mainly just listened to the story. A pause. And then she added, "You know, I really liked this patient a lot -she was one of my favourites."

"Yes, I know. I had a patient like her once."

"She would joke with me a lot about how she was going to eat pizza once she left the hospital. Oh, and juice. She really likes juice and was looking forward to being able to have some again."

"Okay. Once she is stable in the ICU, I will give her your regards and let her know you would have really liked to bring her some pizza."

"Okay."

"Also, feel free to come visit her when she's in the ICU -she'll appreciate the familiar face and you'll have the continuity of care, if you would like. Now do you want me to explain what's going on in that room?"

"Yes!" replied the other medical student, with that yearning for understanding, for knowledge, and a way to cope. And though I am not that knowledgable, I have learned a thing or two through my experiences as a medical student and now, during this ICU rotation.

So I explained that when a patient has massive bleeding, the main concern is that they are losing volume. So we give lots of fluids and fast, and then we give lots of blood, and then once we give lots of blood, we have to also replace platelets and factors, and when we give lots of those we also need to give calcium since the preservative in blood products will bind the calcium in a patient's blood, so in very large quantities, this matters more and we have to replace it at some point. I explained that it is important to keep the patient's blood pressure high enough to perfuse / oxygenate their organs well, so we also give pressor medications to help with that, and I specified which ones we usually give.

And then, still standing back, we watched the dynamic scene before us. I was struck by how much I was moved by the whole endeavour, in the middle of seemingly organized-chaos. Yes, the Canadian medical system is so imperfect on so many levels, but acute care management is not one of them. There in front of us, it was plain as day that the hospital and the whole system was designed for this very moment. Here it was that cherished cliché: doctors saving lives. We watched them, the whole fleet of 10, 15, 20 residents, fellows, staff physicians and nurses, so many nurses, called from almost every corner of the hospital -general surgery, ENT, anesthesia, internal medicine, ICU -pumping, poking, loading, watching, organizing, moving, down to the ICU from the ward, down to angiography from the ICU and finally, to the operating room. Her red face, blood-stained cheeks, sheets and lines, her empty blue eyes. But not dead yet. An army of medical personnel for a whole half day and evening to save one life.

It is the greatest blessing we have in this country, and an honour to witness it. That we can value one life so very much -that one life is so precious that a team of 20 or 30 health care professionals will drop everything they are doing for their other patients, to go save that one life. It is moving to witness that. It reminds us why we went into medicine. And while it is true that in the hospital, we mobilize so many resources -blood, people, drugs, technology, time, money -to save that one life, and yet, people in the community die everyday from poverty, homelessness, and other, less costly social ills, the point is, that this single act within the hospital, represents the most beautiful aspects of our humanity. The love of life, no matter whose life it is, if they are a Level 1 (i.e. they want their life saved at all costs), that person will not be allowed to die without a fight.

I have no illusions about the reality of medicine. We try to do the best we can by our patients. We can help, but we're usually not drastically changing outcomes on a regular basis. Patients are resilient, tremendously so -it's actually amazing. So often, they live despite us, not because of us.

But the spirit of the true physician, who wants so much to help and serve and save their patients, spare them from suffering... it is an honour to witness their passion and love for life and their patients in action. This institution and this profession may be flawed, but it is still inspiring.

And for me, on just another day where I couldn't do much more than watch -just another medical student -I felt I had played my own part in the process, taking on the role of little teacher. I will never know everything, but a big part of being a doctor is in fact, teaching others -colleagues, juniors, even patients and their families. We impart whatever little knowledge we have, but also, we can impart the spirit of this profession. We can validate feelings, we can provide emotional support, we can teach each other to be the kind of doctor we want to see more of in this world, and we can lead by example. I learned something by watching my seniors go through the code and I taught by guiding my junior through her first one. That was a profound lesson for me today. Perhaps it was an early initiation into the role of teacher that I will play for the rest of my medical career, and especially, as I start my obstetrics & gynecology residency in just a few months time, on that far away rock they call 'Newfoundland'.