Crowbarrens, chest tubes, and death on the ICU

People die on the ICU.

This is just a fact of life: we can’t save everybody. Bodies fall apart if enough bad things happen to them. Sometimes we can keep part of the body alive, but not the rest; sometimes we can support consciousness even when the body is doomed, although eventually even consciousness will fade. More often, we can keep the body running even while the brain is completely dead.

You’ll notice that, with other organ systems, we use different terms than with the brain. If your kidneys have some working tissue, but aren’t strong enough to get your blood really clean, you have renal failure. If your kidneys are so fucked up they shrivel into black raisins and you never pee again and you depend on a dialysis machine to clear out all your nitrogen waste products forever, we call it end stage renal failure, not renal death.

If your liver is a huge lumpy pile of scar tissue and blood can’t flow through it at all, you aren’t experiencing liver death (although you will soon die unless you get a new liver), you’re in end stage liver failure. If your lungs are full of gross shit and require mechanical assistance to get oxygen and carbon dioxide in and out of your blood, you are in respiratory failure; if your lungs are filled with scar tissue and nodules and all the cilia are burned out and every breath uses up more oxygen than it gains, you are in end stage respiratory failure. All of these things lead directly to death, although we’ve learned to cheat them a little better over time, but they are not death.

We also talk about heart failure, in which the heart can’t move blood well enough to maintain equilibrium without medical help. We even talk about end stage heart failure sometimes, although this mostly means this person is about to be dead. The true end stage of heart failure is cardiac death.

We call it death, because for a very long time, the lack of a pulse was death. There was no way to get it back. Once you crossed that line, you were gone.

But we’ve learned to cheat even that death, sometimes, if we’re lucky. We can, if we’re willing to break ribs and insert tubes and flood the body with toxins, restart the heart. We can even support a fatally wrecked heart for a while with ventricular assist devices. What was once death is now closer to failure.

So if we’ve blurred the line between life and death, what’s left? Is there anything that can be so damaged that we can’t compensate for it? Is there anything that truly goes beyond failure into death?

Lucy, Ed, and Carl Hamilton Park

First impressions, outside the hospital, are predictable. Height, weight, color of skin, expression; handshake, attention span, first and last name. Maybe you find out what their laugh sounds like, or you notice how everyone else in the room watches them with wary admiration, or you discover that they spit when they pronounce their sibilants.

Inside the hospital, first impressions are just as predictable, but in different ways. Every shift begins and ends with report, and every report follows the same structure, a whole unit reciting the history and status of each patient every eight to twelve hours, in unison.

This is an anxious fifty-year-old woman, the night nurse told me, patient of Dr. Ling, here for hyperkalemia and possible sepsis secondary to C.diff superinfection. Here is her entire medical history: bowel cancer, diarrhea, multiple intestinal fistulae to both internal and external abdomen, repeated surgical revisions, perineal remodeling with multiple additional fistulae, urinary tract infections, incontinence. Here, look at these reports: learn all about her rectum, her vagina, her most private processes.

Here is a picture of her chest, a scan of her abdomen. Look at her body, right down to the bones. Look inside her. Here are all the molecules we’ve found in her blood, in their rightful and wrongful proportions. Here is a transcription of her heartbeat from twelve separate axes.

Oh, her name is Lucita. She goes by Lucy. Want to go in and meet her now?