“MICU rounds are like a gas: they expand to fill their container, and when pressure is applied, they perform more Work.” -Walter O’Donnell, M.D.
We began each day with morning rounds on the floor of the medical intensive care unit at Massachusetts General Hospital, where the twenty-or-so patients were divided among two ICU teams: red and blue. I was assigned to the Red team, which never had fewer than seven patients, though our team was able to stabilize and transfer four patients to less urgent floors in the week I was there.
Our team consisted of roughly five junior residents, one senior resident, who took lead, a fellow, pharmacist (PhD.), and an attending physician, whom I was shadowing.
New patients were always addressed first, but all patients were approached in the same way: methodically, and with great precision. The resident on night shift meticulously described the patient’s current condition, how the patient came to enter the ICU,known medical history, and the course of treatment that had been started in order to best stabilize the patient throughout the night. The attending then led the team in the complete examination of the patient starting at the feet and then working his way up to the head and back: checking the feet for signs of swelling, contusions, abrasions, checking for fluid in the legs, comparing each side, examining the abdomen for tenderness, rigidity, abnormality, then the hands for signs of clubbing (where the nail plate becomes thicker thereby indicating poor perfusion, and serving as a sign for more serious illnesses including lung and heart disease); and finally the chest: the keeper of more serious afflictions, where he and the other physicians spent their time auscultating the chest and back, listening for adequate lung sounds, comparing each side. The attending physician was sure to instill in his students the importance in always performing a complete exam, “to simply listen to the patient’s chest, is to listen to only twenty percent of the patient’s lungs,” which is why the team would always work together to assist the patient in sitting forward, and then calmly described their actions to the patient as they continued their examination of the patient’s chest and back, even if the patient was intubated and sedated — a state of being where one would assume the patient to be completely unresponsive — it didn’t matter. There was never a moment where any patient was treated any less than the autonomous individual they were, regardless of their current state. Then, if the patient’s family was present, or if the patient was awake, the plan and course of treatment would be discussed so that the patient was sure never to feel disconnected from their care — they gave their patient a voice, they empowered their patient always, and made them involved in their course of treatment.
Once finished with the examination, the team would reconvene outside of the patient’s room and enter the shop-talk portion of treatment, where I could all-but-try to follow along and remain informed. This portion of rounds was mechanical in the way it was presented — intentionally, so as to ensure that all issues were addressed. First, the patient’s nurse joined the team and read off all vitals and trends: Maximum/current temperature, blood pressure range, pulse range, respiratory rate, change in medications, inputs (including fluids and medications) outputs (solid and liquid excretions), and current accesses. One of the residents would then take over by listing all current medical problems from most important, to least. The Plan would follow, where each previously-addressed problem was assigned a medical course of action. Followed by an extensive evaluation of the patient’s medications–what needed to stop, and what needed to continue, or change). The lead resident would then summarize all concerns addressed; and that was the procedure for each and every patient until the methodology of rounds eventually became a type of reflex–a muscle memory–in order to ensure that nothing would be missed.
An important distinction to make in all of this is that, though methodical in approach, the ideas of each physician were always fresh, the approaches intelligent yet conservative, when needed–always keeping the patient’s best interests in mind. It was understood from the very beginning that the most expensive, exciting, and aggressive courses of treatment were hardly ever the chosen manner of approach. Often, the focus was simple: to make the patient comfortable. Frequently, the type of patients that were admitted into the ICU, were patients who were terminal, and had simply gone from bad to worse — like one of our patients who was losing her fight with metastatic breast cancer. Her only wish was to be well enough to go home for end-of-life care, and that became the primary goal of the ICU team, not to save her life, but to preserve the quality of the life she had left. By the time I saw her last, she was stable enough to be transferred from the ICU to an oncology floor, where they would continue her plan of care — one step closer to being home, the team had done what it set out to do, they completed their goal. Medicine at its core isn’t simply a battle against illness, in fact, it is rarely about the illness. Medicine is the acknowledgement of the person that once was, absent of judgement — the mother who raised the three beautiful children who now stand at her bedside as she lays in pain, the husband, barely thirty and just two-weeks married, laying in his bed, yellow and bloated as he waits for a new liver, the woman of known substance abuse, now on a ventilator after inadvertently poisoning herself from a cotton-born toxin left on the cloth she used to filter her latest dose of heroin — and works to bridge the gap between the person as they are, and the person they wish to become.
There was never a moment during my time shadowing in the MICU, where I did not feel like part of the team, where I felt out of place. From my first to last day at MGH, the team was incredibly accommodating, welcoming, and open to my onslaught of questions about the conditions of each patient as well as their plans of care. Not only has this week served as an incredibly humbling experience, but it has also cleared me of whatever doubts I might have had in wanting to pursue medicine. There is not a doubt in my mind that I am on the right path, and there is nothing that I want more in this world than to become a physician.