The Doctors who Face Death
I didn’t imagine I’d end up working in the ICU (Intensive Care Unit) when I first studied medicine. I was thinking of going into surgery, because I love anatomy and I don’t mind the blood. But there was one time when I visited my uncle working in a hospital, and he introduced me to a doctor who showed me around the department. I loved it—the adrenaline, the challenge of the patients, the sudden shifts in tempo. A patient can come through from ER at any moment while the nurse is shouting she needs something five minutes ago, and you have to move immediately. I realized I like this environment a lot, working with acute patients.
I started my residency in a hospital near my home. It was tough. The first thing I realized is that I knew nothing about medicine. After seven years in medical school, I had all the theory, and the grades—but when you see your first patient, you just think… what do I do now? That’s when you realize you have to start to understand medicine again. Because the patient hasn’t read the books. The patient presents with symptoms—“I have a headache, a fever, my back is painful…” You have to figure out what’s going on. The books just say “this disease comes with these kinds of symptoms”, but seeing a patient is a whole different thing. The patient cries, gets annoyed, is a good person or a bad person, may have had the symptoms for a while and been very uncomfortable, but doesn’t know what it is or when it started. That’s the human contact side of medicine, and it is difficult to teach and understand. Many residents quit within the first three months.
But ICU is a special area of medicine, because for a patient to be admitted to ICU, there must be a chance that the patient will die. That is more or less the condition of entry. We live constantly in the ICU with this kind of thing, and death is very common; it is very normal.
When I was a supervisor, I had a first year resident (who after this became a great doctor) but on that first day, after we finished the doctors’ meeting, I assigned her first patient, who was in a very serious condition. Everyone knew this patient was going to die. But we know that this is part of ICU. Five days later, the patient died, in the morning, and I saw her crying. So I sat her down and asked, “What’s going on?” She said, “Oh, I miss my patient, I worked so hard with him, I thought he was going to make it…” So I had a really tough talk with her. I told her, “This happens, this is ICU. The patients die. All the patients here on these beds have a chance of dying. It could be 50%, 20%, 80%, 90%—but any of them could die. Suddenly or not. You are constantly living with that. You have to talk to the family about that. But you can’t be too involved.”
It’s the first lesson you learn in ICU. You can’t be too involved with the patients.
I once read an article about we Latin American people. We have a problem as humans, with death. We know that all of us are going to die at some moment. We buried our fathers, our fathers buried their fathers, our sons will bury us, this is life. Death is the only 100% certainty. The article showed that Latin American people have a problem living with that. When we doctors say, yes, your father, your son, your mother, your uncle, your friend will probably die, it could take a few hours or days, but it’s impossible to do anything because the damage is too severe. We have a problem accepting that.
In Latin America we don’t accept euthanasia. It’s a crime. Because we can’t tolerate death; it’s overwhelming for us. We always hope a miracle will happen, to change the facts of the situation. Sometimes it’s very difficult.
In the ICU, we often have very young patients who have suffered a car or motorbike accident that destroyed their brain, themselves, and died.
We humans can die in two ways. Our heart stops, or our brain stops working. But the brain dead have a problem if their heart is still beating. The body is warm, you look at the monitor and you have the pulse, everything. That is very complicated for the family to understand. What is lying on that bed is a thing, it’s not a person. The person is gone. We can sustain that situation, but there is no way back. That’s the only thing in medicine that is 100% certain. But even so, it can still be difficult to understand.
The problem sometimes is not that the patient survives, it’s how the patient survives. Which person you give back to the family. Sometimes the patient is not the same. The brain can have contusion, hemorrhage, damage. You do a lot of work with the patient, the patient improves, the patient is still alive—but not the same. If the person is lying in bed, in a coma, or opens their eyes but without consciousness, we give that patient to the family and say, “This is your son, 22 years old, but more like a plant, a vegetable.” And that is the worst part because in the beginning the family says to you, “I want my son to live…” But sometimes, what is life? If I give you the same person before the accident with a couple of scars, nothing else, that’s one thing. But if I give you a person who can barely open their eyes, without a part of their skull, lying in bed… that’s another thing entirely. Some families have the resources to keep their sons, their siblings alive with all the comforts at home, and perhaps they will. But others do not have those resources. It’s very expensive to keep a person living. You even need a nurse to change their pants—and again, is that your son?
One of the treatments we can offer is comfort. At the end of the day, we are not gods, and the human body has its limits, medicine has its limits, and we doctors have our limits too. Sometimes the only thing we can offer the family, for the patient, is comfort. They don’t have to have pain, they don’t have to suffer at all. Because believe me, nobody dies easy, nobody dies in a good way. This is from the movies. People only die sadly, and it’s a very traumatic moment. And the only thing you can offer the family is to say OK, he or she won’t suffer anything, feel nothing, never realize what’s going on. There are drugs we can use to put the patient in a coma. They are anaesthetics, hypnotics, used to decrease consciousness. We use drugs that are 80 times stronger than morphine, and in higher doses, to ensure the patient doesn’t feel anything. After that, it depends on what you want to believe. But for sure, the patient won’t suffer their death. That is the best we can offer for the last time, for the family, for the patient.
In the ICU, I have become used to death; I have seen people from 15 years to 99 years old pass away. Over time, it still affects you. Some doctors burn out and have to go back, see other kinds of patients, stay in another part of medicine. It’s worse when the doctors in ICU start not to care. I’ve seen doctors burn out, and become—not a butcher, that’s a very strong word—but they start not to care whether the patients live or die. It’s just another bed. “OK, the patient in bed number 4 died, great, we need that bed.”
Or even worse—they start to feel like a god. You decide if the patient lives or dies. That is when you are overwhelmed by the power of this position, because with the patient, the ventilation, the drugs, all the monitors, if the patient needs those things to live, you are the person who can shut it down and say “OK, the patient has died.”
The only way is to protect yourself from this kind of burn-out is to always remind yourself, “I am human, I can make mistakes.” Sometimes we doctors start to think, “I’m a god, I can manage this without any problem, it’s easy for me…” and when we make a mistake we realize, “this is not so easy, I’m human.”
You can imagine facing the family after making a mistake with a patient. It’s very tough. That is why the most important thing about being a doctor is humility. I am a doctor, nothing less; I am not God, not perfect, I am human. This is a profession, it’s work. We like to be doctors, to be with patients, treat the challenges, fight disease. But always the best doctors are those with the greatest humility.
Dr. Julián Alberto Strati - ICU, Family Medical Practice HCMC