Steve Server // The residents of the Cardio-Thoracic Intensive Care Unit (CT/ICU) work in a cluttered, white box. The walls are bare, blindingly white, except for the decorations which hung for a few days celebrating some unknown individual’s retirement. None of us had any idea who would soon leave “The Unit,” but as soon as the decorations had been hung late one night, they began to drop off the wall, announcing their descent with a quiet whoosh, a slight plop, and a slow skittering across the gleaming, white linoleum floor.
There was one central table on which we were to set up our laptops. But any free space on it was strewn with stacks of sterile-packaged materials necessary to fend off critical illness. Naso-gastric tubes, endotracheal tubes, Foley catheters, Swan-Ganz catheters: like scientific specimens, they came in a remarkable array of shapes and colors, all resting perfectly and inertly and timelessly behind hermetic, yet transparent, barriers.
In the one empty corner stood the telemetry monitor, its colored lines tracing pulse, blood pressure, respiratory rate, and other vital signs for all the patients on the unit. Telemetry served a dual function for us. The screen gave us minute-to-minute information regarding the physiology of our very ill patients. But it was also the only device in that white box which gave those of us working in The Unit any sense that we were creatures in time at all. No windows to let in sun- or moonlight. No clock on the wall. We had only the throb of human life to anchor our circadian rhythms. Every morning, we got the report of which of our patients did not make it through the night. Then we would have Rounds, interrupted by a code situation. Back to Rounds. Break to join the Cardiac surgeon on his rounds. A bronchoscopy. Another code situation. A lecture. A naso-gastric tube placement. Removal of a femoral arterial line. Indeed, the last procedure was a particularly good lesson in time-keeping on the unit: femoral arterial lines, when removed, require the medical student to maintain intense, direct pressure with the index, middle, and ring fingers on the removal site for twenty minutes. When you lost sensation in your fingers, your job was likely complete.
Critical care is about the passage of time, not one’s place in it. We had patients on The Unit who had been in our care for a month: pages on the calendar slowly drifted to the ground like leaves or snowflakes; we were still watching as the red line blip, blip, blipped along. “This critical care tempo,” as Drs. Hall, Schmidt, and Kress write in The Principles of Critical Care, “differs from the time-honored rounding and prescription practiced by most internists and primary care physicians” (Hall et al). Since at least the mid-nineteenth century, clinicians have recognized that the needs of critically ill patients required a break with the normal temporal patterns of medical care. Arguably, the initial inspiration for close moment-to-moment monitoring of critically ill patients is attributable to Florence Nightingale, who advocated placing gravely injured soldiers closer to Nurse Stations in Crimean War-era hospitals for superior observation. This clinical goal became easier to accomplish as technology expanded physicians’ capacity to monitor patients’ physiology.
Indeed, by the mid-twentieth century, a patient’s vital signs were not only tracked but also supported and augmented on a beat-to-beat basis. The first proof of concept came during a 1952 outbreak of polio in Denmark. The disease had robbed many of their ability to ventilate their lungs on their own, due to paralysis of muscles of respiration. The prognosis for these patients was grim because the Blegdam Hospital for communicable diseases had only seven respirators for the 316 patients admitted. Dr. Bjorn Ibsen, a Copenhagen anesthesiologist, offered a solution: positive airway pressure as used in the operating room. A tracheostomy—an incision in the neck to open the trachea—could be made, rubber tubing fed into the hole, and air pumped in via a hand-compressed rubber bag. It took a small army of about 250 medical students in several shifts constantly manually ventilating patients in order to bridge the crisis. Mortality fell from 80% to 40% (Kelly et al, “Intensive Care”). The use of positive airway pressure in the setting of polio was not new (first recognized in 1950), but Dr. Ibsen’s lasting contribution lay in the understanding that positive airway pressure ventilation could be mobilized for a variety of disease states beyond the polio crisis, making critical care as a broader clinical practice possible (Reisner-Sénélar, “The birth”). This discovery served as a critical impetus for the emergence of ICUs across the world. In the early 1960s, Dr. Max Harry Weil opened a four-bed unit for shock patients at LA County-USC Hospital, and other hospitals followed suit (Vincent, “Critical Care”). The trend spread, a marriage of assiduous management of vitals and the audacious application of technology.
Today, physicians have been able to preserve life through even more physiological states incompatible with life. A patient with left or right ventricular heart dysfunction, for example, can get a Ventricular Assist Device (VAD) placed, which supplements the intrinsic pumping ability of the heart with the continuous spinning of a forward-flow turbine. The VAD devices are typically considered a temporizing measure, to sustain a patient until they are ready for heart transplant. Those patients exist without a pulse. The only sound one hears when listening to their chest is the constant machine whir of artificial life.
The ICU is, by design, a place out of time, a place which exists in the twilight between life and death. And one does not cheat time forever without incurring the cost of taking a time-bound being out of its natural state. Indeed, temporal disturbance has its own deleterious effect. Delirium is a mental disorder characterized by rapidly fluctuating levels of awareness and attention, cognitive disturbance (in domains such as memory, disorientation, or perception), changes in psychomotor behaviors such as hyperactivity, agitation, or drowsiness, impaired sleep, and “variable emotional disturbances, including fear, depression, euphoria, or perplexity” (Frances and Young, “Delirium”). Often, patients experience “sundowning,” a transient increase in agitation when night falls, as though the darkness and concomitant quietude further un-tether the patient from the time-bound world outside their ICU window.
To assess for delirium, nurses and clinicians use the Confusion Assessment Method for the ICU or CAM-ICU tool. It involves asking patients logically obvious questions (“Are there fish in the sea?”) to assess for disorganized thinking, and to squeeze a clinician’s hand any time they hear the letter A, while the clinician spells “SAVEAHAART”, to assess for attentional fluctuation (Khan et al). If a patient is unable to respond with a pulse in response to stimulus, a prompt throb, they could be considered to be lost in time.
And if our patients are lost, how are we to ground ourselves as providers?
Every evening when I’d get off from work, I’d attempt to rejoin the world where clocks and dates mattered. Trying to rush to the theater to make a 7:30 pm movie was somehow impossible. I found that my mind drifted back to the ICU, to its shiny floors and glittering timelessness, and to the patients whose hearts were keeping the time that I was used to. On one of my last mornings in the ICU, during lecture, the attending physician reached down and put out his hand to pantomime the SAVEAHAART procedure. I reflexively put out my hand to meet his. Everyone began to laugh. It took me a second to realize the attending wasn’t actually going to take my hand to examine my own mental state. I said to the room, “Hey, at this point, I’m not sure that I’m not delirious myself.” Everyone chuckled. I wasn’t wholly kidding.
Header image courtesy of Wellcome Collection. Apparatus for administration of oxygen, designed by H.W. Davies and A.R. Gilchrist, 1925, in use. https://wellcomecollection.org/works/xtmchkrs
Frances, Joseph and G Bryan Young. “Diagnosis of delirium and confusional states.” UpToDate. https://www.uptodate.com/contents/diagnosis-of-delirium-and-confusional-states.
Hall, Jesse B., Gregory A. Schmidt, and John P. Kress. Principles of Critical Care. 4th ed. New York, N.Y.: McGraw-Hill Education LLC., 2015.
Kelly, Fiona et al. “Intensive care medicine is 60 years old: the history and future of the intensive care unit.” Clin Med (2014) vol. 14 no. 4 376-379. doi: 10.7861/clinmedicine.14-4-376.
Khan BA, Perkins AJ, Gao S, et al. “The Confusion Assessment Method for the ICU-7 Delirium Severity Scale: A Novel Delirium Severity Instrument for Use in the ICU.” Crit Care Med. 2017;45(5):851–857. doi:10.1097/CCM.0000000000002368.
Reisner-Sénélar, Louise. “The birth of intensive care medicine: Björn Ibsen’s records,” Intensive Care Med (2011) 37:1084–1086 doi: 10.1007/s00134-011-2235-z.
Vincent, Jean-Louis. “Critical care – where have we been and where are we going?” Critical Care (2013) vol. 17: S2. doi: 10.1186/cc11500.