We recently had a patient who arrived on our service in the intensive care unit after a complicated surgery. The surgery left him close to dying, and he was immediately put on life support and given heavy sedatives.
He had monitors attached on and inside him. At any moment, we knew exactly how many liters of blood filled and left his heart chambers. Multiple times each day, we counted how many immune cells were circulating in his body, how much urine his kidneys produced and how much stool he produced. Every hour, dozens of data points were recorded by a nurse who was waiting attentively at his bedside.
And yet, no one on our team had ever spoken a word to him since he came into our care. How we can know our patients so well and yet know them barely at all? We could keep track of nearly every single detail of his physiology. Yet the distance between a patient and his doctors was perhaps never greater than when the patient is at his sickest.
Part of this gap is intentional on our part. We break down our patients into cold numbers and trends because their diseases become easier to manage. Patients turn into , and it’s an effective and safe strategy. Checklists make sure every aspect of the body is functioning and they’ve been shown to reduce complications. Is the blood pressure too high? Let’s give him a beta blocker. Is his heart not putting out enough blood? Let’s start a drug that enhances his heart muscles. Is he not making any stool or urine? Let’s give him a laxative and a diuretic.
But the patient’s body is not synonymous with the patient. I once had an attending during my first year of medical school who liked to repeat oft-quoted aphorism to never lose track of the forest for the trees. In the ICU, when all your patients are on the cusp of crashing and require continuous careful monitoring, it’s too easy and tempting to get lost looking at each “tree” we are tracking. It’s easy to forget that our patients are more than the sum of their cells and organs and tissues.
We also put up this partition because we need some semblance of a win when we take care of these sick patients. On rounds, we like to say our patients are doing better because their “numbers” are improving. With our patient, we finally raised his cardiac function. He started making urine. His blood pressures stabilized. His white blood count was going down. We took it as a victory, no matter how contrived.
But was he actually better? Sure, if we looked only at his numbers in isolation. To his family, though, he wasn’t. To them, he was still lost under the tangles of the IV drips and ventilator tubes. He was as much as on the cusp of dying as ever regardless of how proud our team was of his “numbers.”
I had another patient who made a quick recovery and was eventually stable enough to leave the ICU. On his last day in the unit, I told the wife that her husband was making strides in his recovery — his breathing volume had finally normalized, his serum electrolytes were balanced, his blood pressure had finally risen enough that we didn’t need to monitor continuously. The physical therapists gave him clearance to walk, if he so wanted, and could even finally be discharged from the hospital that same week.
Most of what I told her flew past her ears. She didn’t care about any his pristine lab results, the ones that gave me reason to grin in the mornings. I might as well have been speaking to her in a foreign language. In fact, the only detail that hooked her attention was the fact that he could walk — that they could finally go home and go on with their lives.
There are many definitions of “better” in health care. For doctors, it’s easy to choose the one that makes us feel better, the one that convinces us that whatever we’re doing is working. But ultimately, the one that our patients and their families choose is the one that matters.
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